Our Big Hairy Audacious Goal

Fantastic ARM Study Day at Wigan on Midwifery Regulation (18th March 2017).  This is what I said in my bit.

We want to set up a new Council for the Regulation of Midwives based on strong values: beginning with the wellbeing of the mother and her family.  We want all mothers to feel supported throughout their maternal pathway and we believe that good quality evidence is at the centre of midwifery practice- for this is what public protection most properly means for maternity.

So my call to you at the end of this day as mothers and midwives of this generation is to set about making this happen for the benefit of the midwives and mothers to come.  It will take work and cunning and more work and political wheeling and dealing and a hell of alot of campaigning but it can be done and we can do it.  And this is what is called a BIG HAIRY AUDACIOUS GOAL.

A BIG HAIRY AUDACIOUS GOAL is based on vision but is not itself a vision – vision is about values such as the stuff I have just said.  A Big Hairy Audacious goal is what you want and what you are determine to achieve.  That all mothers are supported through the maternal pathway is our vision, that the centre of our practice is nurture and good evidence is a value, but  OUR BIG HAIRY AUDACIOUS GOAL – to achieve this vision and these values – is to set up a new Regulatory Council for Midwives.

It is AUDACIOUS: it makes one raise ones eyebrow, it makes others sit up and think, it may keep some of us awake at night wondering how the hell we are going to do it.  It is audacious but it is a concrete outcome and it is achievable so it is a goal.  And it is BIG and HAIRY because ALL Audacious Goals have to be Big and Hairy.  It is more fun that way.

And fun is a big part of this BHAG.  Because it is not much fun being a midwife with a regulatory body that does not have a practicing midwife on it, has a one day a week midwifery advisor to the CEO and does not know the difference between a private midwife and an independent one. It is not fun to lose your practise because your regulatory body can’t be bothered to go through your insurance policy in detail. Fragmentary factory care is not fun!  Coming off a 12 hour shift feeling like you have given your all but not met the needs of the women you have cared for is not fun.  It is not fun to find that supervision, the independent professional support for midwives and mothers has now been seceded in England to the employers – where we are already seeing conflicts of interest come into play.  It is not much fun if you have ever had the misfortune to be hauled infront of the NMC to be tried ( because that is what it is) by judges who do not know or understand your profession – or anything much about maternity.  It is not fun to pay more in regulatory fees than other better paid professions. It is not fun to watch what you hold precious in your profession de-valued so much that it is abolished as has happened with the midwifery code.  It is not right – that is for sure – but it takes all the FUN out of being a midwife.

So our BIG HAIRY AUDACIOUS GOAL is about putting the fun back into our profession.  And so I do suggest that whatever we do whilst achieving this goal, that we ensure that we have FUN whilst achieving it.  Some activists in the Netherlands recently spoke of working with ‘unrealistic optimism’ for the eradication of poverty and injustice.  And that is the attitude we must now have.  In the face of all challenges and setbacks we must work diligently with unrealistic optimism, because that is why we have a BIG HAIRY AUDACIOUS GOAL.

OK so how do we go about achieving our BIG HAIRY AUDACIOUS GOAL? That would be a 2 day course I think so some pointers.  We need a strategy and it needs to be simple and clear.  And then from it we have tasks – things we have to do to take the strategy forward.  A group of us have started working on a strategy and it is simple there are 3 initial key lines (more will emerge and other will fall back).

ONE

We need a research  group – These are our scouts who will find out, what happened last time, what has gone wrong now (digging into papers and minutes), what examples and models are there out there which we could use or partner with etc.  Lots of reading homework for those so inclined. Could do with a lawyer or two as well.  Also some formal meetings and networking work too – they may need to be different people as visiting people is not just about information it is about politics – its not just information we seek but a bond and a political position. We want to get all our ducks in a row all our evidence in place all our arguments formulated, the key people nobbled,before we go in there with our formal proposals

TWO

We need our campaign group to become a movement.  Currently it is small it can be ignored, laughed at and derided – this is currently the outward attitude of the NMC and the Government to the Save Independent Midwifery Campaign and this move against the NMC that has come out of it.  That is fine – they are behaving just as expected.  What we need to do now is make it so big, have so many stake holders in it that it cannot be ignored – this is when we will find the real opposition in and outside midwifery because this is when the fight really begins.

How do we build a movement?  By talking and educating everyone. So we set up meetings, we speak at meetings, we set up study days and conferences. We set up websites, and FB groups blogs and memes (notice the plural – let every flower bloom is my view).  We have meetings with our MPs and our counterparts in other professions.  We talk to consumer groups and parents.  We just talk to everyone who will listen – all the time.  I talk to drunk men coming home on the train from a foot ball match for God’s sake!  Never pass up an opportunity. Yes you become a regulatory bore but make it fun – it is BIG and HAIRY after all – unlike the guy on the train I might add.

Remember Caroline Flint talking about the vow to tell someone everyday about being a midwife and having a homebirth?  Well this is it!  That is how you make a campaign group into a movement – when everyone in the campaign starts telling someone anyone, who crosses their path that they want midwifery to be regulated by midwives and mums, and why. And we have social media which means you don’t even have to go out of your front door to do it.

THREE

The technical organiser in me says we will need to constitute a proper organisation at some point – just because this is going to be too big for any small group to hold.  Also we need buy in, leadership and input from a wide cross section of people.  An organisation will keep things relatively orderly when and where it matters which is when we approach funders, ministers, professional bodies and so on and so forth.  Don’t get me wrong the nature of movements is that there will be a happy and at times unhappy chaos.  But at the steely core there has to be a strong structure that can hold things together.  This will take a bit of time and effort but is not hard to do, but running this organisation will take over the lives of the people involved as the ARM has taken over the lives of some of the people involved and as Aquabirths took over my life.  But the group who do this will be making a difference and contributing a big chunk to the BIG HAIRY AUDACIOUS GOAL.

Now the next level down from the big strategy above is the detail – and I certainly aint boring you with that at this time of day!  Join the campaign group choose which bit of the strategy you want to go for and linking in with others get on with it is what I say. Except for one thing: One detail you could all help the campaign with TODAY, is to write a letter of support for a new regulatory body for midwifery.  We need letters of support – hundreds of them – so we must start now.  With you.  Like at school, I need you to write a short letter stating your support for new regulation for midwifery and why.  It does not have to be long – two paragraphs will do – one saying what you want and the other saying why.  Sign off with your role and position – eg Midwife and mother, Big cheese midwife, professor midwife with big hat, Baroness Nobody and mother etc etc  you get the idea anyway.  We can bank these and collect many more for when we need to demonstrate that there is a seriously big mandate for change.  Email to me for now: ruth@aquabirths.co.uk or message me:  ruth Aquabirths Weston – my colleagues who support me selling pools will go mad as they wade through  all the emails.  But hey  – the price of success.

Yes and the price of Success.  This BHAG/Project cannot and must not rest on the shoulders of one person or even of a small few.  And this is a warning to my lovely ARM colleagues here and also to myself.  This is a massive project – it could take years if the movement stays small and we get no money.  So we have to build structures into our movement that ensure that as one falls there is another to take her place.  Not because we are all going to drop off the peg but because we are all ordinary folk here – we have jobs, we have children, we have aging parents we have life in all its fullness.  We will all need to deal with stuff other than Midwifery Regulation and so to box clever we need to ensure that the whole thing rolls on without one particular person having to be there.

This is so important to the achievement of this goal and why constitution of an organisation is part of the initial strategy.  One suffragette who was also a mother and a mill worker said – ‘We fight with one hand tied behind our back because seldom has a cause been won between dinner and tea!’  The suffrage movement – and it became a movement with several organisations within it – was forced to organise in this way to achieve its BHAG.  And these are the women on whose shoulders we stand today.

If you need to learn some lessons on changing constitutions then go and read up on the suffrage movement, we have all their barriers: a profession dominated by another professions, a patriarchal culture still in existence within and outside maternity, our room for manoeuvre limited by our place in society and the expectations and decisions of others.  Do not underestimate the subtle and pernicious ways this affects us and our opponents in the achievement of our goal.  I am not saying this to get you down but to be realistic.  For instance one of the points made at our formative meeting was that midwives are so overworked and crushed by their working conditions they won’t want to know or do anything.  Yep that is so true – and has been true for other movements for change like suffrage – but it is a challenge to be overcome not an eternal barrier – so we must seek out fun ways to meet that challenge in our colleagues. In Peace and Justice circles it is called ‘empowerment’..

And just like this job isn’t just for one person or one group of people, so we cannot do everything at once and won’t achieve everything at once – so we must be focussed.  As a group and as individuals we must recognise what we can do now – choose our priorities and do those few things we can do, the next step will enable us to do more, and so will more people, but ultimately it is choosing our priorities doing what we can do and not worrying about what we cannot.  Really and truly this is how big changes happen.

Remember the cycling team success for the Olympics? – they decided their focus was to be fixing the small things that got in the way of achieving their BHAG and in fixing the small things by degrees they arrived at their BHAG and gold medals.

I remember learning my lesson as a University chaplain many years ago.  My senior colleague told me – there is so much work to be done here, you can only see 10% of it, and of that you can only do 2%.  You have to learn to live with this fact and not try to do everything but do your 2% well.  And he was right – do what you can well and don’t worry about the rest.  This still enabled me to run a national campaign on student poverty, it still enabled me to set up and facilitate a student housing group, that achieved a cross professions task group with council and university reps that ultimately set in place policies that are still in place today keeping students safe.  And I bailed out half way through to have a baby and then was made redundant. But I had facilitated the change from a campaign group to a movement and it did not need me anymore to make the change actually happen.

I despair when people give up on the small thing they could do because it won’t change anything – because I know and so do other change-makers that it is doing the small things everyday that changes EVERYTHING.  If everyone here does the small things they can do – I am telling you we will be well on our way.

Okay, so my time is up and we need to recap to remember.  What is a new regulatory body for midwifery?  A BIG HAIRY AUDACIOUS GOAL – it is big and hairy because it is fun, and it is big and audacious because it is a mighty challenge but it is a GOAL because it is achievable.  And we can and will achieve it.

We achieve it by having fun and having a strategy.  Our strategy is simple 123. 1 Build a movement – and the key action today is to tell everyone and any one – and all of us can do this, 2. Do our homework and get all our ducks in a row before heading down the M6 to march on Westminster, 3 make sure we have an organisational structure that will keep order and ensure no one person or persons becomes critical to the achievement of our GOAL

We know that we are human that we are women with LIFE and responsibilities but we know that other women before us have faced the challenge of change-making in the midst of life and faced greater discrimination that we do.  So we will be focussed and do what we can well, we will be focussed boxing clever with our priorities, we will be patient because this could take a long time, but we will be confident that change can happen – because this is our  BHAG and we are working stolidly to achieve it.

And today’s actions by this group are: 1. to write a letter of support for this big hairy audacious goal, 2. to make a personal vow to tell someone each day about this by whatever social means, and 3. to think about setting up a public or private meeting and inviting one or two of us to talk about it so we can grow our campaign through the maternity communities of our land.

No big deal then!  Small steps and Big Hairy Audacious Goal – I am looking forward to the fun – and I hope you are too!

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What you can do to save midwifery as an independent profession in the UK.

By Ruth Weston and Emma Ashworth

Independent Midwives are in the NMC firing line, and most of the campaigning that you might see is about this. However, the NMC (Nursing and Midwifery Council), which made this decision, did so without a practicing midwife on the board, and the ramifications of the decision affects every midwife in the UK.

For instance, the NMC have stated, “A registered midwife can only attend a woman during a birth if she has appropriate indemnity cover. The midwife cannot avoid this legal requirement by attending the birth in a ‘non-midwife’ capacity… The only exception to this is when a midwife attends a birth in a personal capacity to support a family member or close friend for whom they have not previously provided midwifery services”. “Services” includes emotional and physical support, meaning that midwives are being banned from attending the births of their grandchildren, or their own babies in the case of male or lesbian midwives if they’ve so much as listened in, or supported their partner through morning sickness.

The NMC is removing the midwifery committee, which advises the NMC on midwifery matters. Its replacement will have no budget and delegatory powers and it is unclear who will be on it and what its role will be within the NMC. As the NMC – the NURSING and Midwifery Council – has overwhelming numbers of nurses compared to midwives, and the way it is now being set up means midwives will be regulated by a completely different professional – one geared to nursing sick people rather than caring for healthy women -without their own voice being heard at all.

There is a huge risk that this will toll the death knell to midwifery as an independent and autonomous profession. becoming subsumed into the nursing profession as another branch of nursing.  This is certainly the way the NMC and the Government legislation is treating midwifery at present and would mean Midwives would lose the status of being THE professional experts in the normal maternal pathway and key care provider. This is not inevitable but as a profession and as parents we must rise up and clearly and strongly oppose  the removal of the midwifery code, the midwifery committee and lack of representation for mothers and midwives at the NMC. The profession has never been in more jeopardy, and never has the care of women and their babies been so much at risk since the formation of the profession of midwifery.  It falls to us to do something about it..

What can I do?
1) There have been several petitions. The writer of this one admits that if it had been less rushed it would be better worded, however, if we want Parliament to take note of the voices of women, midwives and their families then this is a good petition to start the ball rolling, so please do support it. https://petition.parliament.uk/petitions/178561

2) Share your story of how midwives have helped and supported you. What impact will the lack of access to IMs have on you?  Share on:

Facebook, Save Independent Midwifery page: https://www.facebook.com/groups/443681876022589/

Send to Birthplace Matters who is preparing stories and letters to the NMC through  birthplacematters at yahoo.co.uk

Send them to the saveourmidwvies.co.uk website.

Don’t forget to include permission to share.

3) Tweet!  Use the #savethemidwife hashtag with your messages about how this affects you. You can  tag Jackie Smith of the NMC using @JackieSmith_nmc, and BBC Watchdog (@BBCWatchdog)

4) Write to your MP. The website saveourmidwives.co.uk has important template letters which answer the cut-and-paste responses that most MPs are sending. Find your MP here: http://www.parliament.uk/mps-lords-and-offices/mps/

5) Join IMUK, the Independent Midwives’ professional body, as a supporting member. It only costs £20: http://www.imuk.org.uk/professionals/join-imuk/

6) Make a complaint to the NMC. E-mail complaints@nmc-uk.org. They have less than 20 working days to respond. It is important to mention that it’s a formal complaint to ensure that you go straight to Stage 2 of their complaints process. If you don’t like the reply, simply respond back, say you’re not satisfied, why, and then appeal the complaint response, escalating to Stage 3.

7) Many women and Midwives across the UK are using their passion, creativity and skills to support independent midwives and to challenge midwifery regulation to do its work better.  Do what you can with the people you can, and watch this space as more developments are in the pipeline.  Thank you!

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Of Priests, Bishops and Midwives

Today I am returned from the service of celebration of the 20th Anniversary of women being ordained at St Asaph Cathedral, Wales. To remind us that we are still radical we had a small picket of people calling upon us to adhere to the scriptures ‘that women should keep silence in churches’. We were there because we had been there 20 years ago when our good friend Kath Southerton was ordained as one of the first women priests in Wales. We took our 2 year old daughter who is photographed in the arms of the presiding Bishop Alwyn.

It is significant for me that we were there 20 years ago and it is significant that I was there today, because this is part of the struggle we face as women to be treated as of equal value with in the world including within our faiths. And misogyny and discrimination remain and most particularly in the two areas of my life I am most passionate about: the maternity system which deals exlusively with women birthing and in the Church whose starting point is God’s love for all regardless of gender and creed and status in life.

Bishop Rachel, first woman Bishop in England gave the sermon. She took as her readings the story of Ruth(!) and the resurrection story of Mary Magdalene in the garden. These were both women, she said, whose context was shaped by the decisions of others.

In the story of Ruth we have a woman whose context is shaped by the decisions beyond her control. A Family of two parents and their sons migrate for work to a neighbouring country. The sons grow up and marry two local girls. This is in a culture where marriages are financial and social contracts where women are commodity as much as people. Tragedy strikes and the Father and sons die leaving the women without the protection of a legally recognised (male) head of household and means of living. Naomi, the mother in law decides to return to her own people where she maybe able to afford some living and protection amongst family and tribes people. Her daughters she releases to return to their families where they would be married off (perhaps as second hand) to another man/family. Ruth looks at the choices she has – shaped by her context and the decisions of others. None of the choices are easy but she chooses to take the risk of going with Naomi, setting aside her own culture and nationality to, in effect, become a daughter of Naomi – her people, her God – taking the risks of an all female household. All ends well for Ruth as with some more courage (and the cunning and audacity of the two women) she marries a wealth relative of Naomi – Boaz – becoming one of the very few women to be named as an ancestor of Jesus in Matthews Gospel. Rachel said that this was a woman taking life changing chances in a context limited by the decisions of others – this is the context of all – men women and children – but very much so for children and women.

Bishop Rachel is the first woman Bishop, but over the last 20-25 years since women were ordained priests in the British Anglican Church there have been many women as clever, as wise as suited to the role of Bishop who have not been ordained due to the ongoing discrimination of the Anglican Church. This will continue to be the case for many years until Women Bishops are the norm. The context of women priests is framed by the decisions of others’, individual women priests face this truth as they follow the path of their vocation.

And so I want to say to my daughters and to my female friends out there. We operate in a context framed by the decisions of others. This can empower us (such as anti discrimination legislation, some maternity laws and the mentoring of women ahead of us) but the decisions can also be limiting – many women I know, myself included have injured ourselves against the glass ceiling – and historically this has often been the case. Our efforts are in the context of a millennia of patriarchy – if we think our steps forward are very small we have to set them in this context – the story of Ruth set in the second millennium BC reminds us of this.

And sisters and daughters, if you have worked hard, you are talented and qualified but you don’t achieve what you should, do not blame yourself (as we so often do!), look at the context shaped as it is by the decisions of others. If you seek to bring about change to benefit women – and I think here of the midwives, birth workers, maternity activists and mothers themselves and you fail ( as I have) or your victories are not great and soon eroded, or you burnout ( as I have), then do not blame yourselves, remind yourself that you have been taking life enhancing action, taking life changing risks in a context that is shaped by the decisions of others.

Today we celebrated 20 years for the women who made it to ordination in the Welsh Anglican Church, whilst remembering the many more who worked, campaigned who suffered much and received little in the years before and since. Today we celebrated with the first woman Anglican Bishop of England celebrating in a few days the consecration of the first woman bishop in Wales, commemorating 20 more years of missed opportunities for the gifts and talents of women in Wales.

Today I also remember the many women priests of birth, the midwives and the doulas, who have empowered and enabled women to make their own healthy choices for birth. I celebrate we who have campaigned so women can choose a birth at home, in water, in a midwifery led unit, with a midwife she knows and trusts, to have impartial information and support whatever her decision. Our successes and failure speak of courageous selfless women taking life changing risks in a context shaped by the decision of others. Sisters we do what we can, we do not blame ourselves for what we can’t and we call on our daughters to stand on our shoulders to take the work forward. Amen

Breastfeeding community building

A guest blog today from Lucy Sangster, who’s been reading up on the latest breastfeeding research for us.

New research shows how peer support for breastfeeding helps strengthen local communities. While existing research on breastfeeding support shows that it is effective and valued, work on how it fits into social cohesion has been missing, according to the authors of a new study: Gill Thomson, Marie-Clare Balaam and Kirsty Hymers.

Reading their work on Blackpool’s breastfeeding peer support, the value of the research is that, at a time when provision is at risk, proving wider benefits for breastfeeding support may well help groups argue for funding and gather more allies for breastfeeding support in their own areas.

The full report is packed with stories, quotes and evidence of what is working in Blackpool, here’s a summary of some of their findings.

There are really determined efforts to remove barriers to breastfeeding in Blackpool:

  • A crèche is provided at meetings
  • A peer will meet someone new before a meeting so there is a familiar face for them
  • They get to know women before the birth
  • They involve peers from some of their minority communities
  • They go out to people who are less likely to get in contact: at young parent groups and at a supported accommodation centre for homeless families
  • They involve partners, families and grandparents, so that they understand and can support breastfeeding
  • They raise the profile of breastfeeding in Blackpool with events, local media, work in schools, and wearing their ‘uniform’ t-shirts around town
  • They’ve made breastfeeding feel more normal through local businesses displaying a sticker ‘breastfeeding friendly business’ so a less confident woman doesn’t need to worry about whether it’s ok to breastfeed.
  • They work hard to get the support of health professionals in the area with communication, feedback when a referral takes place, concentrating on shared goals and support.

Because the study has used an existing model for social cohesion (made popular by Ted Cantle nearly 15 years ago) they are able to look at several different impacts of peer support. They show that peer support breastfeeding can help women create bonds with other similar women that last beyond breastfeeding; it can also create bridges between people with little else in common and form links between mothers and people with more power.

The inherent tensions between professionals and volunteers are given space within the report and anyone who has worked in a system including both professionals and volunteers would recognise that when working well, everyone wins… but it can be hard to keep it working.

The study shows that clear communication with professionals and proving how peers support them helps the peers maintain good relations with health professionals.

‘“I think at first the health visitors were the hardest but now they’re great. Because it’s showing them how you can help them as well, that you’re there to support them, that’s what it’s about.”’

The main sources of tension were when there was a lack of communication, conflicting advice, feeling there was no common agenda or negotiating hard cases such as a baby losing weight.

Previous research suggests that peer support for breastfeeding can do harm as well as good, particularly by inducing guilt or imposing pressure, so the feedback that the peers in Blackpool were non-judgemental and approachable is valuable, to indicate that they’re avoiding some of the pitfalls.

In the full report you can read more about how the service was set up, how they changed it and how they made the peer role flexible so that people with caring responsibilities are included. There are also details in the references to the recent Cochrane review on the effectiveness of skilled support on increasing the duration of breastfeeding and other research on the subject.

What makes a birth centre?

I’ve been privileged to talk to two women who were central to making the Bradford Birth Centre so successful. Alison Brown has recently retired as consultant midwife in normality and Deborah Hughes was project lead in setting up the birth centre. They’ve both moved on and would like to share their experience of enabling natural birth within the NHS in the kind of “alongside midwife unit” encouraged in the new NICE guidelines on low risk birth.

The Bradford Birth Centre now deals with a third of Bradford’s births – around 2000 every year – and offers an environment for a genuinely woman-centred natural birth. It’s taken hard work and a lot of determination after decades of only having an obstetric led unit. But it can work and it does work, so here is the journey that these pioneers took Bradford on.

More than procurement

Both midwives were clear that you need more than the right equipment. As Alison says, “Before the birth centre, we had a pool and it was part of the wider maternity ward but we had a terrible struggle getting midwives to use it… Once it was part of the centre you couldn’t stop them.”

We’ve got a great idea!

At the start, finding allies was key. Who can stand up for the aim of woman-centred birth through the organisation? Deborah says that “having other people keeping an eye on it and championing it” helps an idea grow.

One key ally was Ruth Weston, then Chair of the MSLC, who was able to deal with stumbling blocks and maintain pressure by writing letters and asking questions in a public forum like the Trust AGM.

Even now, the centre benefits from having allies, as community midwives spread the word about the centre, the benefits of their approach and how best to access it.

Creating a confident team

Midwives who were used to labour ward practices benefited from training on natural birth, traditional midwifery skills, alternative pain relief like hot compresses and the role of Oxytocin. They looked again at the language they could use to encourage natural birth. Gradually a group of people committed to a new way of working and a different culture of birth emerged.

Culture is a word that Deborah and Alison keep coming back to. And of course with staff changes, building that culture isn’t a one time job. New midwives work closely with experienced staff. One new midwife told Alison that she felt anxious using water: ‘I can’t see the baby’s head coming out and I don’t want to pass my anxiety onto the mum’. She felt able to tell someone and wanted to deal with her anxiety rather than restrict the options of the women she was working with. That’s the power of a new culture. That midwife received training and even paid for it herself.

A kind culture

Deborah praises Birth Centre Manager Carol Dyson for working on the idea that a different culture meant staff being accessible, kind and warm hearted. Kindness, as Deborah calls it “the gentle stuff”, works right through their practices. Birthing women and staff mingle together, with the whole space open and mixed.

That attention to mood helps women to feel safe and trust the staff. In an age where women often doubt their ability to birth and presume they’ll need a lot of intervention, it takes trust to believe someone saying that rather than having an epidural straight away, try the pool first.

“It’s really sad,” says Alison. “They presume that having a baby is such a risky thing that they’d never be able to do it without lots of intervention and help. We need to give women the confidence that they can have a baby.” And yet, “if you get them in the pool they take a sigh of relief, it lowers the stress in the whole room. You can see the birth hormones kick in and they let things go a little. It relaxes everyone. It’s amazing when you see it.”

Using the space as a whole

As the centre was a small space – seven rooms off a main corridor – one of the key decisions that made it work was using the space as a whole rather than keeping rooms and women separated.

Deborah used her experience from working in Calderdale. Using the space in this way means that the pools can be in constant use and more women can access the centre. “Women can move around and use it how they wish rather than being stuck in one space. Wanting one space tends to be a safety issue and when women feel the space belongs to them and is safe, they don’t mind moving around the whole unit.” A woman moving from a pool to a bed to a sofa is a normal part of birth in the centre.

It meant that while there are only two pools in place, 30 per cent of women give birth in them, with many more moving in and out during their time there.

Policies that stick

Policies take a long time to agree and can be a frustrating part of the process, but both Deborah and Alison emphasise how important they are. Deborah said, “It took over a year. It was very important that everyone knew from the beginning what was going to happen. There were things that we were willing to be flexible on that we had to define so that other people were comfortable.”

They talk about three key steps:

Firstly you need to set out your goal. For the birth centre, the goal was creating the right environment for woman centred natural birth. Everything else was judged against that goal.

Secondly there’s no way to dodge difficult decisions. The team in Bradford decided that women who transferred to the labour ward wouldn’t have continuity of care – the midwife wouldn’t move across with them – because losing staff would make the centre unviable and would stop another woman from taking her place. Continuity of care is rightly important, but they had to consider the hard case of whether it had priority over their main goal.

They couldn’t get agreement to allow access for women who wanted a vaginal birth after a C-section (VBAC). Deborah said “You don’t want any mistakes, heroics or drama”: it felt more important to get agreement and then revisit policies when they could.

Thirdly, there are other parts of the organisation with concerns and the ability to stall progress. In Bradford, after the concerns of the Estates team had been worked through, there was a long running issue with the Moving and Handling Team who insisted on the centre using hoists when getting in and out of the pool. Alison said “We even had people just coming in saying that they’ve come to measure for a hoist! We’ve had to bar the door! We set up a plan for anyone who did collapse in the pool, it works well and we don’t need a hoist. However it’s just part of the problem that the NHS organisation just does not get water birth. We’ve had a similar battle with infection control”.

Who’s the gatekeeper?

The team fought a long time for the principle that women should judge when to access the centre. Deborah says that experience from past work suggested that this was vital to meet their goal. Usually a triage team responds to women asking to be admitted and therefore they effectively get to say when labour’s started and whether the woman is ‘allowed’ to come in.

Instead Bradford Birth Centre ensured that women contact them directly. Women get to choose when they want to access the centre and if there isn’t yet space but they want to sit in the soft seating area and have a hot drink that’s fine with the centre staff.

Despite worries that the centre would get ‘bunged up’, it worked well. Instead of a judgement from triage, first contact is the centre’s way to establish relationships and trust in the staff.

However this is sadly an ongoing battle and it’s an example that even with success, you have to keep arguing your case to avoid sliding back.

Separate and different

What may surprise is how strongly both midwives felt about being separate. The way of working and the environment is so different in the centre that the larger organisational culture is quick to take over again. Whether that’s doctors walking through and imposing decisions, midwives picking back up labour ward ways of working because they get ‘taken off’ their centre work for other priorities or triage deciding when labour starts, separation is key to the goal of enabling woman centred natural birth. Just moving to another part of the building from the labour ward has a big impact.

The future

Separation is important right now, but Alison has spent time finding ways to support higher risk women in the labour ward to achieve the same experience as you’d find in the birth centre. “From the woman’s perspective, it doesn’t matter how many complications or risks you have, women still want a nice environment to birth in. The reason they don’t get that is really complicated though. The ward should be recognised for their high rate of vaginal births. But it feels to staff as though they can’t look after people and have them in the pool.”

Despite working through case studies, buying high tech monitoring equipment and having pools in place, the ward isn’t embracing natural birth yet. Can you recreate that birth centre culture in a labour ward? Alison hopes that her successors keep trying.

Alison finishes by saying, “Changing the culture takes time and is a challenge, we had people trying to tell us that women in Bradford won’t want to use a pool! But when they know it’s there they beat the door down, they start to realise that it will work for them and be a great thing for their birth.” With 2000 women passing through each year, that’s a huge impact on women finding out what a good birth can be like.

Birth is a human rights issue

Birth is a human rights issue! 

Here is the powerpoint presentation I am going to deliver to the 3rd year midwifery students at the end of my seminar on women-centred care tomorrow, Friday 17th January 2014.

Be part of making change happen, help us to change the way the wind blows!

Birth as Human Rights Issue

Because it is not an ideal world . . . .

This week I have had a lot of ‘in an ideal world . . ‘ comments from people talking about midwifery staffing and one to one care.

And I want to say I am fed up of it, I want it to stop and it needs to challenged!

To say that in ideal world we want gold standard one to one midwifery care, is to consign that notion to impossibility.  One to one care IS happening on the NHS now in Liverpool (the Wirral) and elsewhere.  Small puddles in the desert they may be but nevertheless demonstrations of the concept of real world gold standard care.

Yesterday I was at a meeting about where things went badly wrong in maternity service, and the report states that staffing had been an issue on the night and it was clear there was big lack of continuity of care – but it was deemed unchangeable – in comparison to changing the policy to ensure many more women will have a medical birth to ‘save’ this happening again.

In an ideal world was the medical directors comment, and I said “No, its not about an ideal world its about saving women’s lives’

Sisters brothers, comrades in arms, one to one midwifery care, gold standard continuity of carer that provides dignity and time and respect to every woman, saves women’s health, sanity, and their lives.  This kind of midwifery ensures baby gets mothers milk and fathers get support and guidance, this kind of support is called social care and it makes a big difference to families and communities.  And its not for an ideal world because in an ideal world we would not need it – gold standard midwifery care is for the real world because we need it to meet the challenges of healthy birthing and parenting.

Our mantra should be ‘Its not an ideal world  – that’s why we need gold standard one to one midwifery care!

Calling all campaigners: how parliament works

 Stroppy Mums of the UK – here is a good opportunity to get some free training on how to be effective in lobbying Parliament.  Or at least how Parliament works so you can be effective in lobbying.  I went to one, it was excellent and will blog my report when I have a chance to write it up.  YOu can email the contact to find the workshops closest to you.

Midwives and independent Midwives need our support.  And Mums need the lobbying support of midwives.

Lots of love

Get Involved – In Legislation

 

The Houses of Parliament’s Outreach Service & Involve Yorkshire and Humber are running four workshops in July on how Parliament scrutinises and passes proposed legislation – and the opportunities for groups and individuals to get involved!

 

The workshops will cover:

  • · The Queens Speech 2012
  • · Parliament’s process for passing a law
  • · Different types of Bill (proposed laws)
  • · How you can track the progress of Bills
  • · Opportunities to get involved in the parliamentary process

 

They will take place at:

 

Scarborough 3rd July, 10.30am to 1pm – Allat House Annex, West Parade Road, Scarborough, YO12 5ED

Beverley 3rd July, 6.00pm to 8.30pm – Seminar Room 1, Bishop Burton College, York Road, Beverley, HU17 8QG

Huddersfield 4th July, 10.30am to 1pm– Venue to be confirmed

Barnsley 4th July, 6pm to 8.30pm – Voluntary Action Barnsley, The Core, County Way, Barnsley, S70 2JW

 

To book a place and for more information, contact Ed Poulter at Involve Yorkshire and Humber on ed.poulter@yorkshirehumber.org.uk or 0113 394 2300

Places are limited so book early to avoid disappointment!

 

 

Daniel Wood

Outreach Officer – North East, Yorkshire and the Humber

Houses of Parliament Outreach Service | wooddan@parliament.uk | 07917 488839 |www.parliament.uk/outreach

 

 

Bradford’s Birthplace Conference Notes Re-posted

The new draft NICE guidance on birth place has caused a stir and some controversy.  Below I have re-posted the conference notes from the northern launch of the Birthplace survey which was the evidence behind the new draft guidelines.  It is a reminder that these guidelines are based on strong clinical evidence regarding safety, outcome, satisfaction and cost.   This evidence now needs to be implemented, the draft guidelines have to be confirmed and put into practice by CCG commissioning.  To comment on the guidelines you need to do so through a participating organization like http://www.aims.org.uk.

The Birthplace Conference at the Bradford Royal Infirmary was a wake up call for birth and midwifery. It was absolutely clear what women require for a normal natural birth – and it is not an Obstetric Unit! It was also clear that the myths of the higher cost of midwfery led units and safety fears, were all just that –  myths – well not even myths because myths require an element of truth.

I rarely take notes these days but once the conference had ended I wish I had!!!!! So I asked my friend and fellow Airedale Mum, Sally Watson, Student NCT Antenatal Teacher and all round good guy – if I could borrow her notes and publish them on my blog. She kindly consented and so here they are.

BRI 10 February 2012

Mary Stuart; Birth Place Study (see on SDO website, BMJ or NHS choices website)
All research on birth place has its limitations. The focus of this particular study was on outcomes for actual place of birth – rather than planned place of birth, this inevitably skews the data.
This research looked at 4 different places of birth, obstetric unit, freestanding midwifery unit, attached midwifery unit and home birth, comparing 65000 women
Primary aim of the study to compare intrapartum and early neonatal mortality and morbidity – by planned place of birth at the start of care in labour.
A disproportionate number of complications occur in obstetric units – this must be talked about!
Characteristics of those who choose homebirth – white, middle class, affluent, have a partner.
In all places there is a low risk of an adverse outcome (4.3/1000) where the mother is low risk.
Adverse outcomes included; stillbirth (14 in total), early neonatal death (18), neonatal encephalopathy (114), meconium aspiration (75), bronchial plexus injury (20), fractured humorous or clavicle (2)
Statistically significantly higher for first time mums (1 compared with 1.75)
Event rate is higher for homebirth than obstetric unit (3.5 compared with 9.5) the researchers were not able to say why this was, but said that the majority of the adverse outcomes were neonatal encephalopathy and meconium aspiration – there is no way of knowing the long term impact of these outcomes. Much was made of the infamous daily mail headline – the authors stressed that their reporting of the study was simply not true http://www.dailymail.co.uk/health/article-2065928/First-time-mothers-opt-home-birth-face-triple-risk-death-brain-damage-child.html the number of still births/ neonatal deaths were so small that it is of no statistical use to analyse these.
For nulliparous women there was a 45% transfer rate from home to hospital, for multiparous women this reduced to 12%
Birth outcomes;
C/S rate – 11.1% Obstetric Unit, 2.8% HB
Spontaneous vertex – 74% Obst Unit, 93% HB
Normal birth – 58% Obst Unit, 88% HB, 83% FMU, 76% AMU
Definition of normal birth – labour spontaneous, without episiotomy, forceps or ventouse (can include ARM, Syntometrine, pethadine).

Juliet Rayment (research assistant at city university of London, she focused on case studies Juliet.rayment.1@city.ac.uk)
She found that women were limited on where to give birth by the distance. Their choices really came from within the community – women talked about their friends, sisters, family etc. The more information they had, the more choices they had. Women wanted to birth close to home – don’t want to travel distance.
Also found that the leadership of an organisation/ unit set the tone for learning and accountability rather than blame, when things went wrong.
Women felt that their concerns about their health or the health of their babies was not always heard.
The study raised questions – are women receiving optimal care from Obstetric Units? The findings would suggest not – there is a need to find out what’s going on?
Cost according to place of birth (irrespective of outcome)
Obstetric unit – £1631
AMU – £1461
FMU – £1435
Home – £1063 (included with that are the staffing costs – yet home birth is still cheaper)
Look on BMJ website for full report.
Should advise low risk women to give birth outside of an obstetric unit, their outcomes are likely to be more positive, also much better obstetric health for subsequent babies.
One quote from obstetrician in the study “keep women away from us…we meddle”!

Mary Newburn (NCT)
Talked about the birth centre research study, found that physical environment led to psychological safety. For the women in the study it was important for them to see the place/ the atmosphere, once there, they felt compelled to birth there.
Why women chose to give birth in birth centre (some of the reasons they gave); they heard about it, being allowed, all natural, comfortable, calm and appealing, it made sense of how labour works, husband can stay, could ‘see myself there’, midwives get to know you, holistic approach, feel safe/ confident.
The midwives in the birth centre have a different mentality
– a belief in normal birth (not the conveyor belt production that Dennis Walsh talks about)
– Connection with a woman
– Understanding birth physiology
– Inspiring confidence in women
Midwives who worked in a birth centre from an obstetric unit talked about ‘pushing boundaries’, forget instincts and what you feel/sense in the room.
Parents talked about how it was like “going into another world”, the midwives provide continuous care, a firm support.
One of the fathers used the analogy of labour as like going to the gym ‘two more bounces on the birthing ball, then we’ll get you into the shower…then we’ll move somewhere else’
Midwives talked about “walking the line” between competing pressures and demands.
Knowledge and resourcefulness of early labour – a lot more needs to bedone on how to support dads/ birth partners support women in early labour. Mary Nolan has undertaken recent research into dads involvement – in Midwifery journal in past month.
Recommendations from the report; need a consistent welcome in the birth centre, and quiet time (unit was not always quiet), there was a heavy focus on the birth and lots of privacy post birth – but not so much support – couples tended to be left alone, yet there is a need for BF support, there is huge disparities in respect of who accesses the unit – still groups of the community who are not using the birth centres. There followed a general discussion with midwives from birth centres in different areas – all talked of referrals coming from the same midwives – with other community midwives not referring – it was felt that this was because they didn’t believe in natural birth.

Jane Munro (RCM) campaign for normal birth July – August 2010
They had 1000 returned surveys from 24 units (46% response rate which is pretty good)
67% Obstetric Units
1% Home births
32% Midwifery led unit
Found a link between instrumental delivery and semi-recumbent position. Although the majority of women in the study laboured upright, 49% birthed on the bed
RCM produce cards with different birthing positions on for midwives – include 22 images
Home births;
52% reported HB training in their initial training, 71% had experience of a homebirth in the last 12 months, 58% didn’t have any CPD on home births since qualifying
57.6% of the respondents said that their area always offered a home birth service
Confidence in attending a HB – 50.4% said very confident, 37.1 confident (slide went away before I could take the rest down)
There was some discussion about taking beds out of the rooms in birth centres – one midwife said that in her unit the bed flips out of the wall. A woman can use chairs/ sofa and the bed is only pulled out if particularly long labour and she wants to sleep – or afterwards. Other midwives talked about sitting on the bed or raising the bed so women can’t get on!

Chris Warren – Yorkshire storks
Talked about her statistics.
In 48 deliveries since 2005; 25 homebirths, 2 PPH, 6 forceps/Ventouse, 12 CS, 1 Elective CS, the rest hospital births.
They have had no emergency transfers to hospital (blue lights), their transfer rate is 10% (more for primips).
Women do not choose bad options when it comes to place of birth – they are scarred into it.
Look at evidence based guidelines for midwifery led care May 2008 (unsure of reference – might be RCM!)

Evidence is not enough to keep a Birthcentre open

The freestanding Jubilee Birthcentre in Hull is to close. IN the light of the birthplace evidence this is bad news and short sighted, the cost benefit anaysis given in the Birthplace study makes it difficult to see how it is justified. Government and regional health authroities should have policies of building birthcentres rather than shutting them, and making them default places for low risk women to attend, rather than the curent system where the default even for healthy women with no issues is an obstetric unit.

Here is the link to the news. Below that, is an insightful comment by Professor Lesley Page,  responding to the disappointment of local midwves in this region.

http://www.rcm.org.uk/midwives/news/midwife-led-birthing-centre-to-close/?utm_source=Adestra&utm_medium=email&utm_term=

Lesley Page says: I think we need to re frame this. First it is definitely short sighted when birth centres are closed, particularly given the current problem with our low normal birth rate and high intervention rate. I am always so sorry to hear about these closures. The financial arguments for closing rarely take into account the reduced costs of interventions financially and on women themselves ( and their families).Often the staffing could be made more cost effective. But, although we should be realistic it is important not to be pessimistic. What we have to do is alter the view point-we are in the beginning of a paradigm shift, and although some birth centres are closing there are more, I believe, than a few years ago. We are all leaders and here is what we have to do-really talk to women and their partners about why out of hospital birth should be considered seriously, tell them about the hormones and effects they have.tell them about the risks of unnecessary intervention. For the development of midwifery we need to have confident midwives support those who need to increase confidence. Make birth centres as cost effective as possible. This by: possibly creating caseload practices around them,and making them development areas for midwives to learn from each other, skills, tips, latest research, how to stay competent and confident. Birth centres should be part of the rotation for new midwives and all midwives should be encouraged to work in them for a while. Lets make the culture in them buzzy and dynamic where midwives and others talk to each other about and evaluate how we make birth normal and safe, and how we can make midwifery fulfilling for us midwives. Evaluate methods such as hypno birthing in the birth centres. The future is too important to be pessimistic-and I sense there is a change-it wont happen overnight-so lets hold onto that future.  www.lesleypage.net

 

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