On 20 July 2017, I attended the Positive Birth Conference at City University in London. I just love being around birthing professionals and feeding off their knowledge and enthusiasm, and this conference was no disappointment.
There was a stellar line-up of speakers, including:
- Cathy Warwick, Chief Executive, Royal College of Midwives
- Professor Susan Ayers, Professor of Maternal Child Health, City, University of London
- Octavia Wiseman, REACH
- Ellinor Olander, Senior Lecturer, City, University of London
- Milli Hill, Positive Birth Movement
The themes of the day centred very much on what women are looking for when it comes to their birth experience and how to potentially give them a better birth experience.
This was approached from many angles, including continuity of care. The presentations and discussions challenged where the line for this currently stops and where more could be done to improve this.
So what are women looking for?
- to have a safe birth
- to be able to choose the care that is right for them
- to have care that wraps around them with no pressure to make choices that simply fit with service provisions
- to be listened to and not categorised
- to be taken seriously with honest discussions about risks, if they arise
- to receive continuous and consistent high-quality communication
Where to give birth
Choices regarding her place of birth have been identified as an area for improvement. Not all women report having made a choice – and the decision that women make is not neutral. Many factors can influence a woman’s decision. The crux of it is; choices are constrained by reality (e.g. choice of place of birth is not available, classification of mothers (low risk/high risk) may rule out the birth centre, for example).
The Better Birth initiative states that women should have three choices of place of birth, NICE – the National Institute for Health and Clinical Excellence – recommends four: Obstetric Unit (hospital), Alongside Maternity Unit (birth centre within a hospital0, Freestanding Maternity Unit (standalone birth centre), Home. Regardless of where women are in the country, they should be able to make a choice from all offerings.
Midwives are advised not to just accept women asking for what they want but to ask them to explain why they have made that choice. The midwife should then ensure that the benefits and potential risks of that choice are understood, as well as making certain that all other choices have been explained in the same way. This allows the woman to make choices in an informed way and that she has the full scope of options first. The she can reaffirm her final decision on where to birth.
Continuity of Care
Some areas of the UK are criticised for lack of continuity in antenatal care, though this is starting to be addressed in some Trusts with the reintroduction of case-loading (seeing the same midwife/small team of midwives throughout a woman’s pregnancy). However it felt that more could be done to ensure a woman is given the right care during pregnancy and a smoother handover from the midwives to the health visitors, so that upon the first appointment with a health visitor they are already aware of the woman’s pregnancy and birth experience.
Ellinor Olander spoke about this theme and her study identified factors that women said we/weren’t important to them:
- Location of appointments: meeting their caregivers in the same location for antenatal appointment was not important to them; however home visits after birth is appreciated.
- Staff: When considering the transition from midwife to health visitor, face-to-face contact with health visitor in pregnancy is not needed. An introduction via post or email would be welcome. New mums would appreciate not having to repeat their medical history to the health visitor and would appreciate a better hand over from the midwife. Some said it would be helpful to the first meeting with both professionals together – especially for women have had traumatic experiences.
- Most respondents had a named midwife, this was not important to all of them.
- Most had met with more than one health visitor
- Information: Most women wanted to receive consistent information from all the caregivers they came into contact with
Continuity of care is also especially important in women who have experienced some degree of trauma.
Birth Trauma: Risk and Resilience in Women was the theme of Professor Ayers presentation.
She shared her research on women who have suffered some degree of trauma during labour and birth and who have as a result experienced Post Traumatic Stress Disorder (PTSD). Evidence shows that 4% of women experience Post Traumatic Stress Disorder (PTSD) in pregnancy and a further 3-4% develop PTSD as a result of birth. However, most women who have a traumatic birth don’t go on to develop PTSD (55%). Risk and resilience factors have been identified during the study and medical professionals can use these findings to prevent PTSD and enhance positive outcomes.
The events that occur during pregnancy and birth are important, as these are what contribute to Post Traumatic Stress Disorder and Post Natal Depression. Although much of this is based on the individual’s subjective thoughts around the events, rather than the events in themselves (some women are more acute to situations than others and it may not be the event in isolation but a number of factors that have added to the woman’s life experiences).
Even though it has been cited that 3-4% of women can experience PTSD in pregnancy, this can be as high as 39% for those who have a history of abuse.
PTSD can result in:
- Preterm birth
- Low birth weight
Stress in pregnancy is known to carry over to baby. Evidence shows that these babies have an increased response to stress, which carries into their later lives.
We hear often about war veterans suffering from PTSD and ongoing drives to raise funds to support to these individuals. However, in terms of number of individuals, this perceived low percentage of women who suffer from PTSD is much, much higher than those of veterans. Resources need to be found in order to support these women better.
Ayers research has delved into analysing the care that women received after birth and what positive impact this has had. For those that have received support, a pattern that has emerged. Women who experience birth trauma and who receive support, find strength and resilience to move forward and give meaning to that event, which often sees the woman experience growth from that crisis.
So how can risk be reduced?
The most common responses were:
- Better communication (39%)
- Be listened to more (37%)
- Be supported more/better, both emotionally/practically (30%)
As a result of this study, a framework has been put together to identify those women who are potentially at risk in order to customise their care during, pregnancy, birth, postnatally, all of which needs to be fed back into the services to build up more expertise.
The conclusion was that with this new insight, we can develop personalised care when we have identified women at risk, and by offering them the correct support maternity services can enhance positive outcomes.
Octavia Wiseman, spoke to us about the REACH Pregnancy Programme, which is a five year study, currently about half way.
This study aims to identify women who may not usually seek full antenatal care, possibly due to one of the following factors:
- Socio economic, linguistic and cultural diversity
- Social issues
- Practical issues
- Demographic issues
- Cultural issues
- Health issues
The aim is to find these women living amongst us and offer them the antenatal care that they may otherwise miss out on.
The study is also trialling Pregnancy Circles, which brings together pregnant women who are at similar stages in pregnancy and who live near each other, for clinical care, information-sharing and social support. The Pregnancy Circles aim to provide a woman-friendly, community environment for antenatal care. These meetings are 2 hours long, rather than the 15 minute appointments expectant mums would normally receive. So far these meetings have been positively welcomed.
As a co-cost of Havering’s The Positive Movement, it was a personal delight to hear the final speaker of the day Milli Hill. It was great to hear how she has inspired so many women to take up her movement and bring women together to look at birth positively. She centred her presentation on Carl Jung’s Shadow Theory. Jung saw quite clearly that failure to recognise, acknowledge and deal with shadow elements is often the root of problems between individuals and within groups and organisations. Hill challenged us to consider the shadows in birth, midwifery and within ourselves.
It was a really interesting day and in the two years that I have been a part of this industry I continue to learn so much from my peers. My wish however, would be to see a maternity care that is stripped of the red tape, so that the midwives who go into the profession wanting to be with women, can dedicate their time caring for them throughout their journeys. Continuous care is not a new thing, better births is what we all strive for. These conferences help solidify our ambitions towards a positive birth experience, if only it could happen a little faster.