Maternity Experience

Women’s Voices in #MatExp – your Sonographer

I was asked to do a talk to student midwives at Salford University last month on the topic of “Women’s Voices” in maternity care.  As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience.  “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.

So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the fourth of those.  Unlike the others, this one is anonymous.  You can read the other blogs in the series here:

Your Midwife

Your Doula

Your Breastfeeding Supporter

And yes, I will be doing a “Men’s Voices in #MatExp” series too.  Because this campaign is about all voices.

Helen.x

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Ultrasound

I have been a sonographer for 13 years, and I’ve asked to be anonymous because I want to be honest, and I don’t think my managers would appreciate every aspect of this.

I’ve worked in a few different NHS trusts over the years, and now work in a small, rural hospital.

I do both pregnancy and non-pregnancy scans, and enjoy the variety in my work. There are more complaints around pregnancy scans, but my overwhelming impression of pregnancy scans is that it can be very hard to meet parents expectations in the NHS.

For routine, screening scans parents generally expect the reassurance that all is well, without necessarily fully considering that the scan findings may be devastating. I have a moment with the notes (hopefully, if the mum remembered them) to quickly obtain a bit of history which may give me an indication that the parents may actually be extremely anxious- but some things aren’t written down, and I struggle to determine the body language differences between anxiety, or that I’m interrupting an argument between the parents, or there is worry about something unrelated to the scan, all while the mum may have a desperately full bladder.

Once the parents are in the room, its usually only a minute or so before the lights are dimmed, if they were ever turned up in the beginning. Myself, and older colleagues have noted how our eyes adjust more slowly to sudden darkness- I used to have no trouble going from bright light to darkness in a scan room, but now I’m older I can’t see very well when the lights go off- not very helpful for the scan, but keeping the room dim all the time adds more barriers to communication.

I have been scanning a number of years, but I only learned a couple of years ago the importance of eye contact in those first seconds of the scan. I think if I’d learned that sooner, I could have easily made more clients feel more welcome. Right at the beginning is when I’m usually checking I’ve got the right patient on the computer screen or paper details, probably staring at a screen, and I expect I really came across rushed or off-hand, before I knew better. I have asked for customer skills training, but the training I have had has been more about dealing with challenging behaviour, and when I asked for training around breaking bad news I ended up on a course which was more about end of life conversations, which was interesting, but geared to spending a lot more time setting the scene for breaking end of life news without interruptions, rather than sonographers specific task of breaking bad news very quickly, with little warning.

Something that comes up time and again, is how rude sonographers are, prodding bellies and saying how fat our clients are. I’m sure a lot of us could gain from some training in customer service, but there is a reason behind the hurtful words. A scan can be uncomfortable- pressing on a full bladder isn’t great at the best of times, but sonographers end up pressing harder on larger tummies trying to see the detail that is required for that scan. We try not to, not only because we don’t intend to hurt our clients, but most sonographers are in physical pain scanning and pressing harder makes it worse. We are our own worst enemies at times though, because we concentrate so hard on what we are looking at on the ultrasound screen. So, brains may not be fully engaged on saying tactful comments, we may not realise how hard we are pressing (I rarely notice the pain I am in until I finish up the scan, and realise I shouldn’t have pressed so hard).

At the end of the scan, the other vital part of our job is communicating the findings, which usually involves giving a copy of the report to the parents in their notes.

We have to explain what limitations there are on the scan- have I seen everything perfectly like the text books? Usually not, and then we have to explain why. I’m not aware of too many people feeling insulted when its baby’s position that is a limitation, but the various ways we say we lost detail because the sound waves were travelling further (which happens if there is a layer of fat in the way) can be perceived as insulting. I know in my trust the midwives try to mention this to larger ladies before they come for any scans, and I feel that being forwarned helps when the sonographers then are repeating something already said. It doesn’t seem too shocking if I’m trying to explain the extra layers around where I’ve been scanning have limited what I can see, if its already been mentioned, hopefully by someone they trust. Sometimes that hasn’t happened, or the parents haven’t taken it on board, and some of us sonographers manage to say things quite badly. Probably in fear of saying it badly, some of us don’t mention it all, and leave it to the midwife to explain the terms on the report, which can be just as upsetting.

Sonographers sometimes across as grumpy, and one possible reason is that we are usually rushed. My day in obstetrics is divided into 15 minute slots- with double slot for first trimester screening and the 20 week anatomy / anomaly scan (different places give it slightly different names), and a bit extra for twins. In that time we really need to allow about 5-7 minutes for trying to document the findings accurately, and producing a copy for the parents to keep in the notes (IT technical issues can easily double this, and are a regular problem where I work now).

Some scans take longer than the allotted time, and sometimes in that short time interval I have to give devastating news, try to be supportive but also find another health care professional to handle the initial grief and arrange what happens next. With no time to reflect I must carry on and scan a lady who might have been kept waiting longer, with a desperately full bladder. I try hard, but part of me is probably still processing the blow I dealt the previous lady, and hoping that while distracted/upset I am doing my job well enough for both clients, and I really hope the lady who has been kept waiting is kind, because I can’t tell her any of this.

The 15 minute break slot I get each list is rarely a break, but just a little leeway so I can try to take a minute or two extra with with each lady I meet without running too late by the end. My lunch break is officially 30 minutes, where I’d love to step outside and enjoy the beautiful grounds my hospital is in, but many days in obstetrics I barely have time to eat in the scan room, before washing my hands and continuing to run late.

I’d love to spend longer, explaining each part of the report, going into the parents particular concerns and signposting them to the appropriate person if I am not the one who can help.

Officially I need to work on my time management. I take too long, I must scan too slow or talk too much. My rescan rate is too high (at the 20 week scan, if we can’t see everything in one visit we are allowed to offer one rescan, which where I worked previously wasn’t ever counted or limited, but now I use that option too freely apparently and I must have less than 10% rescan rate), but that means I must scan for longer to see everything- it is unthinkable that I would say I had seen something when I hadn’t, but I do wonder what will happen when sonographers who aren’t as honest as I am, or feel more pressured than I do, get to this point.

I have been specifically told to talk less to parents before the first trimester screening test, because after a conversation, some mums decided against it. In my old trust we were told, as Band 7 staff in the process and the person about to do the test, that we had to be sure the ladies really wanted it- and check they have heard the potential outcomes including that the diagnostic test, with a risk of miscarriage, may be offered. Where I work now I may ask if they’ve discussed the test with their midwives, have they seen the booklet, but I must not ask enough for me to be confident about the information they have, because their community midwife takes responsibility for this.

Screening tests are an option, not compulsory part of pregnancy. Many women I meet wouldn’t dream of having a pregnancy without a scan, but its not an informed choice if the mum gets in the scan room before she realises the scan is optional-this is something that happened last week.

My personal choices around scans have changed over the years, going from wanting everything going first time around, to having none with my third. I found the anatomy scan with my second child a hugely anxious time, knowing the potential conditions that could be diagnosed, and the huge number of abnormal but unexplained things that might be seen, and of course the range of conditions that a scan would never detect.

A dear friend had a devastating diagnosis at a 20 week scan before my third pregnancy, which meant baby needed delivering at a specialist centre for the best chance of survival, and I was hugely affected by how the family were affected by the diagnosis and the stress throughout the final 20 weeks of pregnancy. Their experience and my attempts to support them made me evaluate exactly what I would gain or lose from scans in my third pregnancy, and, for me, at that time, the decision was not to have scans. The same events affected other people differently, and they tell me they wouldn’t dream of not having a scan after being involved with such a tough experience, which I can completely understand, appreciate and support. I’m not planning more children, but if I did I would have to consider it all very carefully- I don’t know if I would opt for scans or not.

In the first trimester screening scan, sometimes called the NT scan, sonographers are audited in a few different ways. Where I work we have one 30 minute appointment, and if we can’t obtain measurements that meet the national screening committees criteria, then we must offer the quad test. So, we get audited on how many ladies end up being offered the quad. We are audited that our images meet standard criteria. We are audited that our measurements fit a national expected scale- and steps are taken if we don’t meet all these criteria. It isn’t too hard to meet these criteria in a baby that is lying in the perfect position, but the position of baby is one thing outside of our control.

I imagine this scan will be around for a while yet, though I am glad to know non-invasive prenatal screening has been around in private practices a while and hopefully will become more widespread in the NHS in years to come – this blood test is a much more sensitive and specific screening tool, but it is currently quite expensive.

Something else sonographers do that causes conflict is limit the number of people in the scan room, and warn that noisy or disruptive children may need to leave. If there is an accompanying adult then they miss the scan by having to leave with the child, or the scan may be abandoned if the mum is the only adult with unsettled children. I have tried to continue to scan while a child was working very hard to stick their fingers in the fan, run around, screamed constantly, but these are situations where I have to stop before I make a mistake.

It is also very difficult to concentrate when an excited parent/grandparent has someone extra to talk to. The rare time I break the rules and allow someone extra in, I have usually regretted it. I must need further training in being politely assertive to obtain the quite atmosphere I absolutely need to concentrate on seeing all the structures I need – in the given time.

If I scan in silence, I am complained about for being too serious- so I try to keep a light hearted, pleasant line of conversation going while I stare at the screen intently concentrating, looking for potentially life threatening problems with baby. Its a situation perfect for misunderstandings.

Keeping the chatting going is much harder on those days I have a bit of a headache, or my 3 year old has had a bad night, or my 7 year old had a nightmare. I suppose I might call in sick for not being on top form, but the team I work with is so small so I know parents may turn up for long-awaited appointments and be forced to rebook, or my colleagues might try to squash extra scans in an already full list- with all the usual pressures still standing for making it a pleasant scan, not rebooking, etc. And of course, like any business, sickness records are kept and if you take sick time too often, then steps are taken.

I’m struggling at the moment. Concentrating non-stop, knowing mistakes mean huge potential consequences for families, doing it all against the clock and targets is draining me. By the end of my working week I usually feel too exhausted to cuddle my kids before I crawl into bed, unable to cook or eat tea, straight from work, hoping I can take time out of family life to recover from my week. My head hurts, I keep going faint, but the GP says there’s nothing to worry about. My sickness record is something else to worry about. I can’t cut my hours- I think I could probably cope if I were doing it less. If I could have some time for catching up at the end of my lists, I think I could do a better job.I work with a good team, but the managers don’t seem to get the pressure they are putting on us. But then, I don’t know what pressure they are under. I suspect my manager is struggling, but trying to keep it private. She is taking unpaid leave to try to keep going, but scheduling it has been almost impossible. The needs of the service come first.

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Why Your MSLC Matters

Maternity Service Liaison Committees (MSLCs) provide a means of ensuring the needs of women and professionals are listened to and we saw how effective they could be when properly supported and led.”

National Maternity Review February 2016

“I urge you to play your part in creating the maternity services you want for your family and your community. Voice your opinions, just as you have during this review, and challenge those providing the services to meet your expectations.” (Julia Cumberlege, Chair of the Review Team, 2016)

These quotes really illustrate why MSLCs matter. They sum up why I am so passionate about maintaining and sustaining our wonderful Maternity Services Liaison Committee and helping others maintain theirs.

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Because I have seen the difference a dynamic, properly supported, MSLC can make to a hospital Trust. Bromley MSLC, like its counterparts throughout the country, is a mix of individuals including commissioners, service users, midwives, doctors and other professionals coming together to monitor and improve local maternity services. The respect that everyone has for each other is evident in our meetings and some of the lightbulb ideas that arise are extraordinarily exciting. I tend to come away from meetings with my head reeling, but also tremendously grateful that we have this group of extraordinary passionate, dedicated people working and living in our area.

MSLCs were first established in 1984, enabling women to be involved in shaping the maternity care provided for them. The Department of Health suggests there should be an MSLC for each Trust in England and Wales. The Health and Social Care Act of 2012 states that health services at every level need to actively engage with service users:

  • Participating in planning and making decisions about their care
  • Enabling effective participation of the public in the commissioning process itself
  • So that services reflect the needs of local people.

Recommendation 13 from the 2015 Kirkup report into the Morecombe Bay Investigation also highlighted the importance of MSLCs.

MSLCs matter because…..

  • They are the only multi-disciplinary committee of its kind in maternity, bringing together commissioners, NHS Trust staff AND the women for whom the service is designed. One third of the committee is made up of service users, including a service user rep chair and vice chair.
  • They are independent NHS working groups that advise on commissioning and service development
  • They should include service users from all parts of the community, ensuring that all women’s voices are heard.
  • They promote collaboration and involvement
  • They plan, oversee and monitor maternity services in a local area and make recommendations for improvements where necessary.

They are one of the few examples in maternity where there is true collaboration between healthcare professionals and service users on equal terms at a local level. This leads to a much greater understanding between both parties of the challenges that are faced and the issues that really matter to local women.

The National Maternity Review also highlights the consensus among health professionals to change things for the better. Nowhere is this more evident than on an MSLC!

MSLCs1

MSLCs can achieve amazing things:

They plan…..together with the commissioners, service users have the unique opportunity to help shape the future of the maternity services in the local area. For example, because of user testimonials provided by our MSLC to the clinical executive, a new perinatal mental pathway is being developed in our local area by the CCG, which will greatly benefit thousands of women.

They oversee……our MSLC is involved in one off projects designed to improve maternity experiences for local women. We have designed information posters, are having an input into a “Welcome to the Ward” postnatal pack and have helped improve the birth environment on the Labour Ward. We also make tours of the wards, bringing a service user perspective and a fresh pair of eyes to the environment.

They monitor……our MSLC gains feedback from women through surveys, questionnaires and Walk the Patch both in the hospital and more recently in children centre health clinics in the community. That feedback is given directly to the lead health professionals of the Trust as well as the commissioners, who listen and act on our recommendations. Those improvements are then fed back to the service users, via social media and other means, so that we close the loop.

This type of work is not just being done by our MSLC. I know of countless other committees which are tirelessly working to improve services in their local area too. Our brilliant vice chair Michelle Quashie is planning a Women’s Voices conference in October and has asked me to present the achievements of our MSLC and others around the country, demonstrating how effective collaborative working can be. I am looking forward to showcasing just what has been and can be achieved then.

At our recent Whose Shoes event pledges were made at the end of the workshop about something that the delegates would do differently as a result of that day. These pledges have formed the workplan for our MSLC for 2016 and we will check to ensure that they have been carried out. MSLCs are true examples of #MatExp in action at a local level.

MSLCs2

We were also really pleased to see the importance of MSLCs highlighted on our beautiful graphic courtesy of New Possibilities.

For this blog I asked members of other MSLCs for their thoughts on why MSLCs matter. Responses included:

MSLCs4

MSLCs6

MSLCs3

MSLCs5

Catherine Williams has written a lot about the importance of MSLCs in her blog https://birthandbiology.wordpress.com/

And from our MSLC Leaders Facebook group:

MSLCs7

MSLCs8

And this from our vice-chair Michelle Quashie:

“MSLCs matter because it is gives all that are passionate about a Women’s Maternity experience a chance to join forces and make their hopes for better birthing world a reality.  It enables all members to be involved in ensuring this happens. It allows true collaborative working and keeps service users involved in decisions made about women’s maternity care and that of their family. It’s a safe place where women’s voices are heard, valued and respected. A Women’s experience is its driving force for that reason I am proud to be part of such a dynamic committee.

Initiatives like ‘Walk the Patch’ enable all women’s voices to be heard regarding the maternity care they are receiving. These voices from the community can then be filtered back to senior levels and actions are derived to improve the service as a result. WTP also gives the chance for those HCP that are providing truly women entered care the recognition they deserve.

I joined the MSLC after feeling very let down buy my personal maternity care. I knew I had to help change things for other women. Being part of the MSLC has enabled me to do that from the inside out. The work we have done and the wonderful HPs I have worked with has helped to restore my faith and feel empowered by being part of making change happen for others.

I hope that MSLCs get the recognition and support for the amazing work we are doing across the country. All that give up their time, do so because they are passionate and dedicated. MSLC’s should be mediatory for all trusts. How else can you ensure a woman centred service is given without women voices being heard in order to influence that service?”

Refreshed guidelines from NHS England, due for imminent publication, call for MSLCs to be run, maintained and funded by the CCGs. This is much needed, because in the current economic climate many MSLCs are fighting for modest but essential funding to continue the collaborative work they are doing. In addition, due to the unique nature of these committees it can be difficult for the commissioners to work out a mechanism for funding.

It is against this background, while MSLCs are struggling, that Julia Cumberlege, chair of the National Maternity Review, urges women in her introduction, “play your part…for your family and community … voice your opinions” as quoted at the top of this blog. MSLCs provide an ideal forum for service users to do just that. They are the ‘best practice model’ for shaping the future of our maternity services.

A petition has been started to emphasise the need for MSLCs in all areas. Please consider signing and sharing this petition so that MSLCs can continue the vital collaborative work they are doing at a local level, with volunteers’ expenses paid and commissioners everywhere listening and learning. https://petition.parliament.uk/petitions/121772

If you are not already involved with a local maternity group that feeds into an MSLC – or the MSLC itself, search online to see what you can find out about local provision. Contact your local CCG, your head of midwifery, local Healthwatch, or any pregnancy and parenting groups, such as the NCT and find out what’s happening. You can find out more about MSLCs at https://www.nct.org.uk/professional/mslcs

Laura James

Chair, Bromley MSLC

2016

Facebook: http://www.facebook.com/bromleymslc

Twitter: @BromleyMSLC

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Musings on the 2015 CQC Maternity Survey

Flo

I have been mulling over a few thoughts about the CQC Maternity Services Survey 2015.

With the launch this week of #YourMaternityCare campaign by the Care Quality Commission (CQC) encouraging women to share their maternity experiences now seems as good a time as any to share some of my thinking and importantly ask some questions.

To be clear I am not going to talk scientific methodology, survey design or validity, I am simply going to share some personal ideas as an obstetrician and a member of the #MatExp gang and question if we could use the survey to challenge ourselves in a more creative way.

What sort of impact does this sort of survey have on the care women receive?

The answer to this may depend on how you view the results. It can be examined at a national level looking at care across the country and comparing with previous years to look at trends and themes.

Undoubtedly this survey showed better experiences overall than in previous years and this is good news. An excellent example is the increase in the number of women receiving care before 10 weeks of pregnancy, with a big potential impact on eventual outcome. It is important to take time to give ourselves a collective pat on the back and celebrate those improvements as it can be so easy to focus only on the negatives.

For a great visual overview, take a look at the infographic produced by Picker.

On a regional level the 2013 Maternity survey and the negative results of some London Trusts was actually one of the sparks that led to the London Maternity Strategic Clinical network focusing on ‘Patient experience’. Therefore it directly led to the ‘birth’ of #MatExp and our collaboration with Gill Phillips to produce a maternity version of her Whose Shoes game and development of a workshop toolkit & examples of best practice.

So that’s another positive: the resulting #MatExp change platform and community of people interested in improving maternity experience therefore could be said to be a direct result of the 2013 survey.

We can examine hospital level data and see how a maternity service changes over time, and how women respond on specific questions. This can help us identify a particular area that needs improvement, such as continuity or postnatal care, as well as giving positive feedback about what is working well. It can help us benchmark our services against others locally or nationally. It is undoubtedly a valuable data point even if it has limitations and exclusions however it is only one of many ways we should be looking at feedback.

Most Trusts will have an effective governance system meaning that the results will be reviewed and circulated, an action plan devised and those actions systematically ticked off when completed.

We need to be cautious as it can become all about process and tick boxes if we are not careful, held at management level and a little detached from both those in daily practice and our service users.

I wonder how many Trusts have worked proactively with their Maternity Service Liaison Committee (MSLC), staff and service users since they received their individual 2015 reports to identify what improvements would have the biggest impact for their women and to look at how their survey results correlate with other methods of feedback they use?

Moving on to some specifics now, the very first sentence in the recently published CQC response to the survey results is a shock There are almost 700,000 live births each year in England. Having a baby is the most common reason for a hospital admission.’  

Why is this?

According to the National Tariff benchmark data 65% of women are ‘standard’ i.e. do not have a complicated antenatal period and therefore are ‘healthy’ pregnant women.

Therefore, the first challenge from the results is why are so many of these births happening in hospital. It probably has something to do with the fact that the survey showed 63% of women who have given birth previously were definitely given enough information about where to have their baby, falling to 53% of women giving birth for the first time. This presumably means large numbers of women are not getting adequate information.

I’m not going to recap NICE Intrapartum care 190, but we know it provides evidence that for healthy pregnant women who have had a baby before we should be explaining birth at home or in a midwifery led unit is likely to have less intervention and the same outcome as delivery in a hospital.

Across the survey results first time mothers seem to be getting a worse experience with consistently lower results than women who have given birth previously. Is this because we are doing something different for first time mothers, is this because we should be doing something different or is it simply that the different groups of women have different expectations? Do first time mothers have higher expectations and are then disappointed whereas mothers who have given birth previously have lower expectations as they know what it was like last time?

In amongst some good improvement scores remain worrying minorities. 89% of women said that during their antenatal care they were “always” spoken to in a way they could understand – up by 7 percentage points since 2007 (82%). However, this means that 11% were not “always” spoken in this way.  87% of women reported that they were always treated with dignity and respect during labour and birth compared to 85% in 2013, but what about the 13% that were not? Surely these are the fundamental basics of care and should be true for every single woman. What are we doing about these women? Can we identify who they are, are there specific groups we are not catering for or not understanding what they need?

Don’t even get me started on lithotomy: ‘The proportion of women being in a position of lying with legs in stirrups whilst having a normal vaginal delivery has seen a steady increase over the past few years going from 17% in 2010, to 19% in 2013 and 22% in 2015’. What on earth is this all about? In 2015 I undertook a lithotomy challenge on NHS Change day and you can read about my experience in the blog I subsequently wrote.

Postnatal experience is clearly lagging behind antenatal and labour care with much lower figures sitting in the approx. 50% region on all aspects of care including physical and emotional wellbeing. Collectively we need urgent action to address this? But the need for collective action raises a problem. Within the NHS we now have this terrible dilemma collaboration versus competition.

The CQC Response to the survey results clearly highlights Trust who have performed better or worse than expected in the last two surveys. If we accept that these results are valid and not a difference in expectations or different for other reasons, then as a simple solution we could potentially buddy up good performing Trusts with poor performers.

However, Trusts are individual organisations. The strategic clinical networks and NHS England can influence, but there is no obligation for Trusts to help others. If we work at a good Trust what is the incentive to share what works? Pure altruism goes some way, but when you face difficult budget choices and competing demands collaboration can be an easy casualty, and as health care professionals what responsibility do we have to try and improve quality outside our own immediate practice?

I certainly don’t have all the answers. For me #MatExp is some attempt at trying to improve and discuss many of these issues on a broader scale, ignite a lively conversation about maternity care and to encourage others to think that they can influence positive change however big or small.

Florence Wilcock

2016

If you are interested in joining the conversation or taking action on improving maternity experience in anyway jump in and join us on Twitter (find tweets tagged #MatExp), join our group on Facebook, or send us a message.

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What Does #MatExp Mean To You?

I had the privilege of hosting one of the weekly #MatExpHour Twitter chats last night, on the topic of “What Does #MatExp Mean To You?”  We had already received some thoughts on this topic via the #MatExp Facebook group, and I couldn’t wait to hear what answers we had from the gang on Twitter. I was not disappointed.  This campaign that Gill and Flo started has become something more than I think any of us could have imagined.  It is with much delight that I share with you what #MatExp means to those involved.

Those who couldn’t make the chat were keen to get in their thoughts in advance:

Helen Green

Sheena

STARFISH

Emma Jane Sasaru: “To me it embodies what I believe can happen when everyone works together to support families. It means that while many say we cannot improve things we really can. Helen Calvert and I always refer to the starfish story because if we all just make small changes they add up to big change. Always believe you can make a difference because you can.
Personally #MatExp has helped me so much. As many of you know I had PTSD from a terrible birth experience and poor care. #MatExp has given me hope that we can prevent this happening and we can make sure that families are treated with our ‘heart values’. It has helped in my healing, enabled me to meet some amazing people, make changes in my local trust and also further my work to raise awareness around perinatal mental health.
What I love is the passion, the genuine want to improve things for families and the fact that it comes from the heart. Any of you that know Gill and Flo will know this is be true. Thank you everyone and remember you can be the change you want to see.”

Gill Phillips

Gill was worried about the limitations of Twitter when it came to explaining what #MatExp means to her, but started by sharing this article from The Edge.  You don’t have to ask for permission to make change!

Flo

Cathy Brewster: “What I love about #MatExp is the coming together of people from diverse backgrounds. As a parent I have been able to directly talk to midwives, obstetricians, commissioners, researchers, MSLCs etc. about homebirth and have gained unique perspective and insights from them all. And I hope they may have gained something useful from me too. #MatExp certainly made it easy for me to get our homebirth posters out there and it is wonderful to see them being used all over the place. The other thing I love about #MatExp is that it’s a platform for learning. It has opened my eyes to so many new maternity issues that I knew nothing about. So a big thank you from me to #MatExp”

Sue

Flo2

Action

Jeannie

Jude

Surbiton

Susanne

I had shared some wonderful blogs in advance of the chat, this one from Emma Jane Sasaru “Why The Wonderful #MatExp Has Given Me Hope”, and this from Victoria Morgan “Reflecting on #MatExp and the Impact it is Having”.

A bit more from Facebook:

Georgie

Lucy Ruddle: “I found it really useful when I was pregnant, to discuss the choices I had and why certain things were offered / what various hasty discussions with HCPs actually meant etc. So pretty much, a really useful source of good information.

Gill Skene

Anna

Anna2

Bronwen

Gill Stellar

Read Gill’s Stellar story here!

Sarah

Louise

Bronwen2

Surbiton2

Susan Parker: “Even though I haven’t been involved for the longest time, for me it’s about parents being able to share their stories and for HCPs to be able to listen and reflect. It’s about sharing information and collaborating. And at times it’s about having a bit of a debate about a certain topic – which is of course a great thing to listen to a different viewpoint that you may not have considered.
On my radar were things like compassionate care, mental health and a mother’s choice. But my eyes have been opened to way more than that because I hadn’t previously experienced those issues, but I can talk to women who have and learn from them. I feel a blog post coming on (but maybe at some point in the future!) would love to do more with #MatExp.”

heart

Edie

Mandy

Sally

Michelle

Michelle’s wonderful blog post about what the Bromley MSLC #WhoseShoes event meant to her can be found here. And Bromley MSLC had got their thoughts in ahead of time:

Bromley

MSLC

Greenwich

Susanne3

CofC

Lemons

What is is about lemons?!  Find out here.

Flo4

Have you seen Flo’s amazing Lithotomy Challenge? Read about it here. Amazing to see the people who got involved!

Digity

Natalie Finn: “For me it’s knowledge, understanding, support and passion. As an aspiring midwife, I want to extend & broaden my knowledge and there truly is a wealth here. As a mother of 4, I have knowledge of pregnancy/labour/birth, but simply from my perspective and reading others experiences, feedback and action taken interests me immensely. To be a well rounded midwife, I feel I need to see things from all aspects and perspectives, the mothers/families most importantly. Equally my entire maternity experience has been wonderfully positive largely down to having the same wonderful midwife for 6 pregnancies, 2 losses and 4 births over the span of 8 years!! I’m passionate about normalizing birth as a whole as well as home birth, breastfeeding (despite being a reluctant bottle feeding mum!), continuity of care. I also value the level of passion and support shown in this group. No question is too difficult, the cup of #MatExp runs over with understanding and it’s rare to find a community such as this that just so NICE!

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Look what happens when you JFDI! I didn’t ask permission to do the #MatExp Survey!

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Gill Phillips made this wonderful film which also demonstrates what #MatExp means to her.

At the end of the day it’s all about women and families.

Rita

Because some things never change.

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What does #MatExp mean to you?

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Women’s Voices in #MatExp – your Breastfeeding Supporter

I was asked to do a talk to student midwives at Salford University last month on the topic of “Women’s Voices” in maternity care.  As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience.  “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.

So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the third of those.  This is El Molloy’s experience of supporting breastfeeding.  Thank you so much to El for agreeing to write for us.

You can read the first two blogs in the series here and here.  And yes, I will be doing a “Men’s Voices in #MatExp” series too.  Because this campaign is about all voices.

Helen.x

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I am an NCT Breastfeeding Counsellor in Coventry, and a Peer Supporter on the Infant Feeding Team (run by Coventry City Council).  I sit on our local MSLC (Coventry and Rugby CCG) and was a member of the Coventry Breastfeeding Strategy Group.  I am also a Babywearing Peer Supporter for Coventry Slings, and am about to do my Consultancy through Slingababy at some point this year. Probably after I finish the dissertation for my MSc in Child Health (through University of Warwick). I also help to facilitate the Coventry NCT Birth Choices (after caesarean or traumatic birth) Group after it was set up and run successfully by one of our amazing local Antenatal Teachers.

El Molloy

This is supposed to be a blog about Breastfeeding Support. Which means it also has to be about being a Peer Supporter – and being a Breastfeeding Counsellor. And now I don’t know who knows what those roles entail, or what we do in either of them. Is there a difference? Can parents tell the difference? Do they care? To be a Peer Supporter, or a Breastfeeding Counsellor – that is the question…I think?

I make a damned good cup of tea (and coffee – because I drink a *lot* of coffee). And at a push I can do cake, but usually I have biscuits. However this is all the icing on the cake or at least bribery, to encourage new mums to come to our groups, have a drink, have a biscuit, and stay a while. Let us listen to your story. And I carry tissues in my bag – always.

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As a peer supporter I have had UNICEF training in breastfeeding support (for most projects this is between 6 and 10, 2-hour sessions, delivered by someone who may be the local Infant Feeding Lead Health Visitor or Midwife/IBCLC/NCT Peer Support Trainer). I am a mother who has breastfed her own children. If you want to get technical I *am* a peer supporter – I am still breastfeeding my youngest. I can walk alongside you in your journey, I can tell you that things were and are occasionally tough for me – that despite the official badge and t-shirt (purple this time round, blue before – I declined the hot pink – it clashes with my hair!) I am not an “expert”. I don’t know all the answers – and I’ve yet to meet anyone who does. But as a peer supporter I can tell you what ‘normal’ breastfeeding should look like. I can tell you that there are no rights or wrongs, except what works for you and your baby. With the caveat that baby is happy and you are not in pain. And I can offer you information about what you need to look for in your babies feeding patterns so you can feel confident things are going well.

Does Peer Support make a difference? I’d like to think so – and I can see locally that overwhelmingly most families find us useful. There are always the other stories, the one about the PS who said to use baby rice at 4 months, but that’s no different to the story about the Midwife who said baby should sleep for 4 hours between feeds, or the Health Visitor who suggested controlled crying… One poor piece of information shouldn’t tarnish a whole section of support. This is something we are seeing every day on #MatExp. There is a world of difference between midwives and *this* midwife; between Peer Supporters and *this* Peer Supporter. And the supporters are only ever as good as their training and ongoing Continuing Professional Development (CPD) and supervision.

And this Peer Supporter is also a Breastfeeding Counsellor. Specifically, I am an NCT breastfeeding counsellor. This means, for the uninitiated, that I am trained in person-centred counselling skills, that I am a sign-poster to other information, other options, other Health Care Professionals. But that always the mother is front and centre. This too means that I have breastfed my own children (for a minimum of 6 months – though extenuating circumstances may apply for others). It means that rather than the UNICEF training, I have spent 3 years distance learning through a University accredited course, writing essays, going on weekend workshops. Debriefing my feeding experiences; embedding my counselling skills in practice as well as theory, understanding and training in group facilitation (for both antenatal sessions on courses, and in running breastfeeding groups). Parents aren’t interested in the Diploma that I have, or the ongoing CPD that I have to fulfil, including regular supervision, or the fact that my CPD is specific to each of my roles within NCT. Parents just want to know what I can advise – what I can do to ‘help’. The honest answer is “nothing”. Because in either of my roles, that is not part of my job description. Advising would indicate that, again, I know best – and I do for me, but not for you. I have being trained as a reflective practitioner, and I have recently realised that I have moments of conscious and unconscious competence – I am, as we all are, a work in progress.

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If I am visiting you, or welcoming you at our group, I will sit and listen to you talk about your options, and maybe offer suggestions. We might talk about how you feel about what you’re being asked to do, until you come up with a plan that is going to work. Reading the previous blog by Maddie, some of her descriptions about working with parents in labour – asking – what do they want to do, how do they feel… This too is how we work. And the general mistrust by other HCPs feels all too real.

As a peer supporter. I might come to your house on day 1, or day 2 after your discharge. Maybe you called, maybe your midwife referred you because she thinks you need a bit more time, someone to sit while you feed, time that she just hasn’t got because her caseload is so much higher. I fill in forms, I offer to register your child with your local Children’s Centre. I will ask you how your birth was (because this might affect feeding). Maybe your Health Visitor has referred you because you are 12 days in and feeding still isn’t ‘right’ for you. Perhaps your baby still isn’t back to birth weight. We have time. I have time to stay to the end of the feed and see how your baby slips down because the cushion could be in a better place…

As a Breastfeeding Counsellor I also have time to sit and listen to your worries about how feeding didn’t work well with your older child. You might have called me because I facilitated your antenatal session; or maybe you’ve been searching on the internet. You might have called the national line, and they have given you my details. Maybe you have come to the Drop In that I run with another colleague. I might visit you at home, where you apologise for going round in circles about whatever is worrying you – but I sit and listen, and reflect your words to you, or maybe ask the one question, or make the observation, that triggers the understanding in you that your worries are not all feeding related, that you’re concerned about your relationship with your partner.

I too go home and worry; did I say enough, not enough. Did I miss a subtext. I am all too aware of the responsibilities that the midwives and health visitors have. The understaffing, overstretching. We will refer in parents who are struggling. “If you are still concerned talk to your midwife, is this something you feel you can ask your Health Visitor about…”. We will make the phone calls where we are concerned about parents mental health, those feelings where things just feel slightly ‘off’. We trust that you will support families, and we ask that you trust us to do the same. Trust that we have the experience with breastfeeding, that we can and do support mothers long after they stop attending baby weighing clinics, long after their regular assessments – all still breastfeeding. We support them to continue, and to stop when that’s right for them. At 2 months, or 2 years, or even longer.

I want (I want?) I can say it in this context… I want all women to have confidence in their decisions, and to have the right information for them to make the decisions that work for their family. Whether that is because they understand that breastfeeding past 9 months isn’t tantamount to child abuse (yep, that old chestnut); or whether it’s because I signposted her to the information they needed about their anti-depressants which meant they had confidence in continuing to feed even when she felt her world was falling apart. Whether that’s because we worked on positioning until she finally hit that sweet spot and it finally clicked that no, breastfeeding does *not* have to be painful; or whether after seeing 6 other HCPs and being told that she had ‘forgotten’ how painful feeding was, I mentioned tongue tie as another possibility, and lo and behold division did result in huge improvements. We have time, I tell the women I see, don’t worry (often as I’m glancing at the clock, thinking, I’m going to be late to my last visit, and I know that’s 20 minutes away, and it’s already 4.45pm on Friday, and I finish in 30 minutes). When baby won’t latch, or has just fed before I arrived and won’t be woken. “How have things been?” “What have you tried?” “Some parents find…” I joke that all babies sleep for me, except my own. We talk about previous miscarriages, we talk about the joy in feeding her firstborn, and the fear that it won’t work this time. That she’s been told it’s just a “small” tongue tie, but she’s worried about him swallowing blood; we talk about how to deal with engorgement, and how can she ease the cramps that accompany her let down. How can her partner bond with baby, so when can she start expressing; we talk about shared bath times, and babywearing. And how will she cope when he goes back to work. We have such a fluid society that we don’t often live close to our mothers, and can’t learn from them the way we used to. My visits span the world, from South Africa to Vietnam, to Latvia, Canada or Scotland. The accents change but the worries and fears are all the same.

It gets easier, you can do this. And particularly in the light of the media frenzy unleashed by the Breastfeeding Series published by the Lancet. We can do this. Together we can change the world.

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A message for GPs: when a breastfeeding mother walks through your door…

This post first appeared on Emma Pickett’s own website.  Emma is a Lactation Consultant supporting families in North London, and Chair of the Association of Breastfeeding Mothers. She has kindly agreed to let us share this excellent post on #MatExp.

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You may have seen the Lancet series on breastfeeding that was published last week [1] and you may have seen the headlines that announced the UK was the “world’s worst at breastfeeding” [2].

It’s a time when those of us in breastfeeding support feel both energised by the Lancet’s affirmation that breastfeeding matters in all countries: “Our systematic reviews emphasise how important breastfeeding is for all women and children irrespective of where they live and of whether they are rich or poor”. [3] And also disappointed that the media’s emphasis was on UK ‘failure’ and it quickly turned to the ‘failure’ of individual women. [4]

As Dr Rollins stated at the launch of the Lancet papers, we need a different focus: “This is not about individual mothers either succeeding or failing. This is not about one lobby group winning over another; it´s not about our individual comfort zone or fashion; it´s about the survival and health of women and children today and in future generations” [5].

These are big issues and they require big thinking and money. At a time when money is hard to find. Health visiting and community breastfeeding support have moved to local authority funding from NHS England and these are the same people looking to save significant chunks from their budgets. There is a local authority in London threatening to decommission health visiting services in 2017. Peer support services are being slashed – even the ones run by volunteers [6]. Children centres are closing and the few groups run by volunteers are struggling to find places to meet [7] Infant feeding coordinator positions are being lost. There is no breastfeeding lead or national committee on breastfeeding in England and the post of Welsh lead has just been cut.

Things are about to get very real for GPs in the world of breasts. Imagine a mum giving birth and being discharged by the community midwife (already stretched and unable to give sufficient time to breastfeeding support) and then when breastfeeding goes pear-shaped after 10 days, the GP is her only port of call. If I had a pot of money to spend on breastfeeding support in the UK right now, I would spend it on talking to GPs about breastfeeding. In a country where the infant feeding survey is cancelled, helplines running on a shoestring, health care professionals being trained by formula companies [8], I’d still spend it on talking to GPs. If I had unlimited time too, I would buy every GP a coffee and say, ‘Can I just have five minutes of your time to tell you a handful of things that will change lives?’

Health care professional bashing is a national pastime. Right after the breath where we say how proud of the NHS we are. But please don’t imagine that those in breastfeeding support don’t get how hard this is. You have ten minutes to talk a mother who is presenting with complex issues wrapped up in emotions and sleeplessness with a chaser of internet research. You have to be a generalist and the lactation bit really wasn’t a focus in your training. We understand that and we’d like to correct that but now you are in your surgery and working a day that doesn’t give you time to go to the toilet, we get that ship might have sailed.

Before you move onto your next webpage, please skim this one. I am an IBCLC, International Board Certified Lactation Consultant. That means I took two 3 hour exams after a thousand hours of supporting breastfeeding mothers. And I recertify every 5 years after a further 75 hours of education in lactation. I am chair of a national charity (http://www.abm.me.uk) that helps to run the National Breastfeeding Helpline and have spoken to more than 3000 mothers myself on that helpline. I run three drop-in groups in North London and have done for seven years. I visit mums in their home and spend all day texting, emailing and phoning to discuss breastfeeding issues. I don’t know everything but I do know what is likely to walk through your surgery door and what will be helpful for you to say to them.

Mothers need help with medication. They want to continue breastfeeding and treat their other conditions. They don’t want to stop breastfeeding for even a day. That’s like asking them not to be a mother when breastfeeding really matters to them. It is hard to get reliable information on the compatibility of breastfeeding and medication as manufacturers will have rarely paid for the necessary licensing for breastfeeding mums and the responsibility is pushed back on to you. Luckily in the UK, we have other people who will take that responsibility. The Breastfeeding Network runs the Drugs in Breastmilk helpline: https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/.

The factsheets on this site give a summary of the main medications for a range of conditions. The compatibility of anti-depressants and breastfeeding may be especially relevant to some of the new mums you see: https://www.breastfeedingnetwork.org.uk/wp-content/dibm/anti-depressants-oct14.pdf.

Research has shown that ending breastfeeding can increase risk of postnatal depression so supporting mums to use medication that is compatible is an important role of the GP [9]. As well as using the factsheets, you or the mother can contact the helpline directly to speak to a specialist pharmacist. The ‘Breastfeeding and Medication’ page can also be found on Facebook:https://www.facebook.com/breastfeedingandmedication/info?tab=page_info. Messages are answered by trained volunteers

Mums walk in the door with mastitis. Let’s just check first it’s not a blocked duct that can be resolved with good self-help measures. A blocked duct means firmness and even tenderness in the breast but the mother feels generally well and there is no pyrexia. This can be resolved with increased drainage of the breast, warm compresses on the firm area and massage. An electric toothbrush is handy for massaging the affected area. The mother may benefit from using different positions to help with draining the breast effectively or pumping after a feed if there is concern the baby is not feeding well. If infective mastitis is suspected, antibiotics should be accompanied by increased drainage and the massage and warm compresses. If a mother does not continue to breastfeed frequently, it is more likely she will go onto to develop an abscess. Obviously antibiotics should be a last resort for a number of reasons, not least because the dyad may go onto develop nipple and breast thrush as a consequence. https://www.breastfeedingnetwork.org.uk/wp-content/pdfs/BFN_Mastitis.pdf 

​Mums will walk in with sore and damaged nipples. This may sometimes be the entry point for the staph aureus which is the common cause of mastitis. The most common cause of nipple damage will be positioning and attachment issues. Of course, in the ideal world, you’ll be referring a mother to a breastfeeding support group, a lactation consultant or a trained health visitor. However there are things that take less than three minutes to point out that could make all the difference. Is the mum leaning forward to ‘put’ the breast in the baby’s mouth or moving the breast unnaturally (so then inside the baby’s mouth it springs back into its natural position and gets trapped against the baby’s hard palate)? Damage is likely to be caused by nipple abrasion against the hard palate usually because the baby does not have enough breast tissue in its mouth. The baby’s gape is important. And when the baby gapes, we want to maximise the space of their tongue on the breast. Their chin should be making close contact, the baby’s body close, the baby not likely to drift if mum’s arms get tired. We want the baby to take a large mouthful of areola below the nipple. This lactation consultant explains how simply leaning back can make all the difference and the fact we falsely believe a mother should sit bolt upright is often the problem:

“In the commonly used cradle, cross-cradle, and football/rugby holds, mothers and babies must fight the effects of gravity to get babies to breast level and keep their fronts touching. If gaps form between them (which can happen easily with gravity pulling baby’s body down and away), this disorients baby, which can lead to latching struggles. The pull of gravity makes it impossible for a newborn to use his inborn responses to get to his food source and feed…In these positions, gravity can transform the same inborn feeding responses that should be helping babies into barriers to breastfeeding. Head bobbing becomes head butting. Arm and leg movements meant to move babies to the breast become pushing and kicking. Mothers struggling to manage their babies’ arms and legs in these upright breastfeeding holds have often told me: “I don’t think I have enough hands to breastfeed.”
http://www.mothering.com/articles/natural-breastfeeding/
These videos shows a powerful alternative:
http://www.nancymohrbacher.com/videos/And this image from Nancy Mohrbacher may help

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​Latching issues can also cause vasospasm and blanching of the nipple. It can also be responsible for neuralgia deeper in the breast. A mother with Raynaud’s syndrome may experience nipple pain when breastfeeding is otherwise going well. She may find applying warm dry compresses after a feed helpful and in severe cases nifedipine can be prescribed:http://www.raynauds.org/2011/02/08/help-for-pregnant-breastfeeding-moms/

If it’s not an issue of latching, you may be prescribing topical antibiotic cream or considering treatment for thrush: https://www.breastfeedingnetwork.org.uk/wp-content/dibm/thrush-oct14.pdf

Thrush will usually develop after a period of pain-free breastfeeding. If a mother is getting misshapen nipples after a feed and the nipples appear to show mechanical damage, latching will remain the primary focus. Even in the absence of symptoms, both members of the dyad will need thrush treatment if one is suffering. Miconazole oral gel is not licensed under four months due to a risk of choking but mums can be taught to apply the gel safely and it is shown to be more effective than nystatin suspension. Deeper breast pain is often connected to neuralgia but ductal thrush is a possibility. The pain will develop as the breast empties and peak shortly after a feed (or pumping session) has finished. Fluconazole is not licensed for breastfeeding mothers. However it’s worth noting that the amount that gets through in milk is 0.6mg/kg/day. The amount that can be given to a baby within the license is 6mg/kg/day (Dr Thomas Hale).

A mum experiencing constant nipple pain and damage despite support with positioning and attachment and may also have a baby who struggles to stay attached, feeds for excessively long and may feed frequently, isn’t putting on weight adequately, could have a baby with ankyloglossia (tongue tie).  An overview here: http://www.cwgenna.com/ttidentify.html. Posterior sub-mucosal tongue ties can be particularly difficult to identify on first look. You should have a referral pathway that gives you access to a tongue tie clinic locally:http://www.unicef.org.uk/BabyFriendly/Parents/Problems/Tongue-Tie/Tongue-Tie—Information-for-health-professionals/.​

A Mother may come for help when they suspect they have low milk supply. Is there anything you can do? It is worth noting that many mother lack confidence and perceive themselves to have low milk supply when they are experiencing normal breastfeeding:  http://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/low-milk-supply-101

If a mother’s breasts are feeling softer, if they no longer leak, if their baby is not sleeping for extended periods, if their baby is cluster feeding – all that can be normal. As can a mum whose body does not respond to a breast pump and they find it hard to trick their bodies in achieving the surge of oxytocin needed for the milk ejection reflex when a plastic pump is all that’s there to stimulate it.

However if a mother is showing further signs and her baby is experiencing faltering growth, she may be asking you to help. Has she already received good quality breastfeeding support? Has her baby’s positioning and attachment been checked? Is she feeding regularly and not switching sides too quickly (but also not staying on one side beyond the point the baby is transferring milk because someone has mistakenly told her a baby MUST feed for 30 minutes). Could she benefit from hiring a double hospital grade pump to help boost supply? Is she in the process of reducing her use of formula and giving her milk production a chance to develop?

What else could be happening?

The impact of thyroid dysfunction on low supply can be devastating and a significant minority of mothers experience thyroid issues post-partum: http://www.lalecheleague.org/ba/feb06.html.

Some mothers, perhaps those with insufficient glandular tissue, may be asking you for a prescription of domperidone. This is an off-label use of the drug and there have been some concerns with using it for lactation in the last few years. Some research indicated a link between domperidone and cardiac issues. However the issues were among patients over 60 who had cardiac problems, who were taking other medication which caused arrhythmia or were taking a dose of domperidone greater than 10mg three times a day.https://www.breastfeedingnetwork.org.uk/wp-content/dibm/BfN%20statement%20on%20domperidone%20as%20a%20galactogogue.pdf
Research has shown that domperidone causes a steady increase in milk supply over a placebo. As the Breastfeeding Network specialist pharmacist notes, “We do not have research suggesting that domperidone causes risks to otherwise healthy, young women who are breastfeeding.”

Metoclopramide is sometimes prescribed as an alternative prolactin-booster but we need to be aware this is known to increase risk of depression and should only be given for short periods.

Breastfeeding doesn’t feel like a ‘choice’ for many of the women seeking your help.For lots of mums, it is a choice and it might be a choice that they decide not to go for.  That is of course up to them and their families. But for many of the desperate women in pain and struggling, this is one of the most important things they will ever do in their lives. To discuss moving to formula instead of looking at the root of their problems or to discuss your personal views about formula feeding is a waste of precious minutes. You may have struggled with breastfeeding yourself, or watched your partner struggle. It can be difficult to empathise with the woman sitting in front of you who appears to prioritise breastfeeding beyond what you consider logical. It may make you feel uncomfortable about your own choices. Other healthcare professionals may get a chance to debrief their own breastfeeding experience but you rarely do.

Do not doubt that there are women who seek your help who would literally have a toe amputated if it meant that they could solve their breastfeeding problems. And they’d be happy for you to do it right there and then. And that’s about the level of pain they are experiencing right now, but still they persevere. ‘Why don’t you give up?’ is what they are already being told by mothers-in-law and friends and sometimes partners when they cry at 3am. They are asking for your help because that isn’t the way they want to go. When their nine month old is on a nursing strike and is suddenly refusing the breast, they want you to check for an ear infection before you talk about formula. They get it’s an option. Ending breastfeeding and using formula really isn’t a secret. If you don’t know the answers, then it’s valuable to have a sense of what is available to you locally in terms of signposting. Your local health visiting team should have information available on local support groups and drop-ins. What leaflets does the local post-natal ward give out? There are four charities in the UK that offer breastfeeding support: the NCT, the Breastfeeding Network, the Association of Breastfeeding Mothers and La Leche League. Is there a local La Leche League meeting near you?

If you aren’t familiar with local drop-ins, mums can also speak to breastfeeding counsellors through the National Breastfeeding Helpline: 9.30-9.30 365 days a year on 0300 100 0212. All the charities have their own separate helpline too.

If a mum needs more specialist care, a lactation consultant may be useful. An IBCLC may be attached to the local hospital or they can find one at http://www.lcgb.org

They may also be women breastfeeding past 12 months and even 2 years and 3 years. They are doing that because they are meeting their child’s needs and their knowledge of the constituents of breastmilk and its continuing immunological benefits may possibly supersede yours. If you are personally uncomfortable with it, it’s not a conversation you need to have. Do you believe that breastmilk ‘loses its benefits’ as time goes on? What is your evidence-base for that belief? Can you find its source?It looks as though the role of GPs in lactation support is likely to become even more significant in the coming years. There are places where you can access more training. UNICEF have an e-learning package that you may find useful:http://www.unicef.org.uk/BabyFriendly/Resources/Training-resources/E-learning-for-GPs/

Or here from BMJ learning: http://learning.bmj.com/learning/module-intro/breast-feeding.html?moduleId=5003232 
You can also find free videos here: http://www.health-e-learning.com/resources/free-lectures?lang=en
Shadowing a lactation consultant or a breastfeeding counsellor at a support group will also be a valuable way to spend some time.As the Lancet series says, ‘breastfeeding is generally thought to be an individual’s decision and the sole responsibility of a woman to succeed, ignoring the role of society in its support and protection.’ [10]. Those of us who talk to breastfeeding women every day know we cannot underestimate the impact of just 10 minutes of contact with a well-informed GP. The effect is felt in her immediate relief as she walk away from the surgery and in the lifelong impact on her and her baby’s health.Notes:
[1] http://www.thelancet.com/series/breastfeeding
[2] http://www.bbc.co.uk/news/health-35438049
[3]Victora, C.G. et al (2016) Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475–90.
[4] https://heartmummy1980.wordpress.com/2016/02/03/are-you-strong-enough-to-change-the-world/
[5] https://www.facebook.com/DrJackNewman/
[6] http://www.essexchronicle.co.uk/Essex-County-Council-cut-support-breastfeeding/story-28078350-detail/story.html
[7] http://www.bbc.co.uk/news/uk-england-wiltshire-34983055
[8] http://www.babymilkaction.org/archives/7167
[9] http://www.cam.ac.uk/research/news/breastfeeding-linked-to-lower-risk-of-postnatal-depression, http://www.ncbi.nlm.nih.gov/pubmed/25138629
[10]
Rollins, N.C. et al (2016).  Why invest, and what it will take to improve breastfeeding practices? Lancet 2016; 387: 491-504.

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Women’s Voices in #MatExp – Your Doula

I was asked to do a talk to student midwives at Salford University this month on the topic of “Women’s Voices” in maternity care.  As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience.  “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.

So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the second of those.  This is Maddie McMahon’s experience of being a doula.  Thank you so much to Maddie for agreeing to write for us.

You can read the first blog in the series here.  And yes, I will be doing a “Men’s Voices in #MatExp” series too.  Because this campaign is about all voices.

Helen.x

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Maddie McMahon is a doula, doula mentor, doula course leader and breastfeeding counsellor in Cambridge. She is also a member of the board of Doula UK. She supports women using the same hospital she, herself, gave birth in and has been a staunch supporter of that hospital ever since, sitting on the MSLC since 2004.

She is author of ‘Why Doulas Matter’, published by Pinter & Martin in 2015.

Find out more about doulas at http://www.doula.org.uk

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I have been a doula for 13 years and have supported hundreds of women, either before their birthing, during their labours or afterwards. I have been facilitating an initial doula preparation course since 2008 and have been mentoring doulas and intimately involved in the evolution of the doula community in Britain since early on in the history of Doula UK.

In all those years I have learned more about what a doula is not, than what a doula is. Every time I think I might have got a handle on the ‘definition of a doula’, my understanding and perception shifts again. The definitions that do the rounds on the internet can be shallow, to say the least and, at best, undermining and dismissive of the incredible talents and abilities that women bring to this role.

I see all sorts of women being called to serve the mothers of their communities. There are women, like me, who felt a gaping hole or a contrast in how the time of transition into motherhood can feel so very different with and without psycho-social support.

There are women who feel betrayed and let down by their health professionals. They may be fighting birth trauma or PTSD or just a deep sadness.

But there are also mothers joining the community now who have been supported by a doula themselves, feel ecstatic about their birth experience and have been inspired to pay it forward.

There are women who, despite all their protestations of loyalty to their careers, found that motherhood remade them, in a fundamental way, bringing them to a realisation that ‘work’ needs to fit around children, nurture our souls and service our communities if it is to be truly worthwhile.

Some come to the role from an academic direction. They are incredibly bright PhD students or researchers, for example. They are interested in motherhood from a sociological, anthropological, political, psychological or philosophical standpoint. They may be activists or campaigners.

Then there are the Human Rights doulas, the ones interested in things like consent, maternal rights and responsibilities. They may have worked in sex and relationship education, or in women’s advocacy or legal settings.

Related, are the doulas who come to the work through their work with social services, or other support of vulnerable or hard-to-reach groups. I know many doulas who started off working with Birth Companions, working with women in prison, or as Homestart volunteers, in teenage pregnancy units, or are Maternity Support Workers..

And there are those who see birth as merely one step on a female journey, all of which deserve emotional and practical support. They support their community of women through menarche, marriage and divorce, abortion and baby loss, birth, breastfeeding and beyond, right up to menopause and sometimes doula families through the last and ultimate transition – death.. They are the white witches, the humanists and the pagans, the searchers for and creators of ritual and ceremony, the red tent facilitators, the women’s circle founders…

The ‘breastfeeding doulas’, through their voluntary work as breastfeeding counsellors, come to see that the challenges women face initiating and maintaining breastfeeding are often down to wider social and familial pressures. They begin to see these pressures and understand that, much as we can suggest to women to go home, sit and enjoy nursing their newborn, it doesn’t magically get the washing up done. The hour they can spend with women in the breastfeeding clinic doesn’t give them the space and time to explore the social attitudes that invisibly pressurise them to supplement with formula, or sleep train, or help their partner take a more active interest in the baby.

Related are the ‘babywearing doulas’ and the nanny and childminder doulas who, again, have come to the work through close contact with new mothers…who have seen close up that mothers of newborns need a particular type of peer support that the doula ethos perfectly encompasses – that time, and space we can give. That unconditional listening ear. That ability to help a mother access and trust her own mothering instincts. The way a doula supports a mother to do the mothering, and supports the partner/father too to step up and find his skills and abilities as a parent. The doula way of somehow ‘de-medicalising’ motherhood.

And lastly, but certainly not least there are the midwives. Some are retiring. Some have been out of the midwifery loop for a while and are choosing between a return to practice course or the doula route. Others are, quite literally and very sadly, at the end of their tether with the NHS and the constraints it places on midwives and mothers. They often feel like they can’t practice in the way they would so love to; supporting women through the whole journey. Continuity of care, pressure to follow guidelines and management that pays mere lip service to issues like individualised care, consent and compassionate care, have driven them to throw in the towel.

doula

As you can see, many of these women might be bringing baggage to the role. They may well have conscious or unconscious axes to to grind. It is through doing a doula course that we aim to create a safe space to process and contain this baggage, to become conscious of our worldview and how it might create the version we see of the world. We begin to practice ways to bring ourselves back to the women and families we serve, to see the world through their eyes and to therefore support them unconditionally and without judgement. Because it is this lack of an agenda, a lack of micro-managing guidelines and regulations that allow families to relax into our presence and for doulas to become a trusted part of the family.

All experienced doulas know that we are, in some respects, extremely lucky. We revel in the luxury of not having to follow guidelines, merely supported by the philosophy and Code of Conduct that our community has created for itself. We are free to build deep and abiding relationships with women, their partners and their children. We get to listen to her deepest fears and anxieties, support her to find solutions to her practical challenges and gain a deep understanding of her desires for this birth and beyond. We never, ever make the mistake of assuming that women might hold the experience of childbirth above the safety of themselves and their babies. Every working day teaches us that this idea is ludicrous. We see the birth trauma, the family dynamics, the physical and mental challenges that explain a woman’s choices. Really, really close up, it all, always, makes sense.

So, we have this deep, vital knowledge of a woman and why she wants what she wants. We have seen her do her research, read studies, talk to professionals, lay/peer supporters, friends and family. She has worked it through in her mind and her heart. She understands the risks and benefits of the choices she is making. We walk with her on this journey, every step of the way. So, when that journey gets to the point where we might be sharing a space with midwives or obstetricians, we have to seamlessly move from being a team of 2 or 3 and move aside in a loving way to bring these professionals into the circle so that we can create a loving circle around the woman.

That dance can go in a number of different directions, depending on the circumstances. There are some common challenges that can prevent good relations between doulas and staff in the birth room. One of them is possessiveness on the part of the doula. It’s wrong, and egotistical and something that shrivels as she gets more experienced, but I do think we can be forgiven, just a little bit, for thinking that we know better than the maternity staff what the woman wants and needs. It can make us a little defensive when they appear not to have read her birth wishes. It can make us a little grumpy when someone comes into an atmosphere that we have set up according to her wishes and switch on the lights and start talking loudly.

Perhaps we aren’t always super-skilled at handling those kinds of interactions. And perhaps there is more going in underneath those interactions than we doulas are sometimes aware of. If I ask if it’s possible for us to find a floor mat for a labouring woman, and that midwife has just been having a conversation with a colleague about doulas and how we have a ‘natural birth and all costs’ agenda, she may read more into my request than I intended.

If a VBAC couple ask a doula to tell the midwife they don’t want continuous monitoring, how can that be handled? The midwife may not know that they have done their research antenatally and made an informed decision. She may wonder who the hell this doula is, who appears to be talking for the couple. How does a midwife know that these parents aren’t being coerced or persuaded into a course of action without understanding all the possible ramifications? How does that midwife know she will be supported by her colleagues to support this ‘off-piste’ decision?

Cloud 2

Sometimes we are aware that there is an underlying atmosphere in the room based on these myths and misunderstandings about a doula’s role. Most of us have realised that it’s common for midwives to think that all doulas are frustrated, wanna-be midwives. Some think we meet the clients for the first time when they are in labour. Many think we are making an inordinate amount of money. Some see the intimate connection we have with the couple and are forced to contemplate why they, themselves were drawn to birthwork in the first place and how it hasn’t quite turned out the way they longed for.

Other times, when a member of the obstetric staff is in the room, the presence of a doula can wrong-foot and confuddle them no end. They are talking to a couple, counselling them through their options, and they suddenly turn to the anonymous, unnoticed woman in the corner, and ask her what she thinks. Even more confusingly, sometimes she asks a question that sounds surprisingly knowledgeable, or asks the couple if they need anymore information about the risks and benefits, or wonders whether there is an option to do nothing at all. She may suggest a few minutes of alone time to think and usher everyone out of the room. The woman they assumed to be Auntie Doris, is suddenly orchestrating the situation somewhat. Unsettling to say the least. Worrying, perhaps, and possibly anger-inducing.

After the baby is born and a community midwife or Health Visitor visits, it can be hard for her, in the time allowed for the visit, to get a real handle on who this woman is who appears to know her way around the kitchen and hangs around in the same room for the duration of the visit. Can the mother talk freely in front of her? Is the doula giving out of date or wrong baby care or breastfeeding advice? These concerns remain unsaid, but can prevent a real human connection.

We know that sometimes, both doulas and staff bring baggage, myths and ignorance of each other’s roles into the birth room. And most of the time, it is our communication skills, or lack on them, that prevent a deeper affinity and closer working practices developing.

All those talented women, with enormous hearts and the energy to support birth, whether they are clinical or lay, deserve to have the love and support of each other. We all have a massive amount to give.

Doula UK

Doulas are responsible for some of the most positive support networks in recent times: The Positive Birth Movement (PBM), Birthrights, the VBAC and Birth Choices support groups, social media support, breastfeeding support to name but a few. When those support networks work most beautifully is when lay women and midwives work together as equals, loving and respecting the complementary threads we each bring to the work. By working alongside each other, we both learn and grow, for the benefit of the mothers we support.

These communities we build, the rituals we rebirth – these are the special and truly valuable aspects of the doula movement. Perhaps now is the time to validate this grassroots work and build on the models we have set up, that are clearly spectacularly successful! 170 PBM groups in the UK alone. 40,000 followers of Dispelling Breastfeeding Myths on Facebook, 10,000 followers of Birthrights. Community support and advocacy is clearly needed – in fact women are hungry for it. And a lot of this community-building work is about supporting health professionals too. Many doulas work to provide community support to their local student midwives, or welcome community midwives to their mother-support groups. We raise money for our local hospitals, sit on MSLCs, try to raise awareness of the challenges facing maternity services, even march alongside them, with placards raised.

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From the Mandala Journey

We like to think of the mother, at the centre, as the sun, with her supporters orbiting around her in elliptical trajectories. Sometimes the midwife moves in closer, sometimes the doula or the doctor. We move further away to make space, to allow the mother room to make decisions and find her own answers. We move in closer when she needs physical or emotional support. We recognise each other’s skills and talents and make way for each gift to be bestowed with love and appropriacy.

When we all work more closely together, we see for ourselves how much the doula philosophy of information without agenda, unconditional emotional support and listening without giving advice have a tangible effect on outcomes – not just in birth statistics but on the mother’s state of mind and her emotional and physical ability to mother her infant.

Many doulas know that some of us could learn a little more humbleness from midwives and Obs and understand a little more quite how challenging, heart-breaking and downright soul destroying their work can be sometimes. And perhaps they could learn a little from us – about compassionate listening and keeping care woman-centred, tailored to her personality, preferences and anxieties. They could learn how our depth of relationship with a family may give us insights they don’t have, and not to feel defensive about that, or jealous.

So how can be build better understanding and cooperative working practices?

We see a lot of wonderful stuff going on already: doulas being asked to meet and speak with student midwives, so that they learn about our role from the beginning. It would be good if this were extended to student doctors too.

Some doula preparation courses will allow midwives and student midwives to sit in, for free – to get a taste of the doula community and an in-depth understanding of the many variations of the doula role.

Many doulas sit on MSLCs and Labour Ward Forums, which is a great way for us to share stories and client experiences and to learn more about the workings of the service and the challenges it faces. Mutual empathy is often very effectively built this way. It can work even better when the staff come out to sit in our forums – to visit our pregnancy support, breastfeeding and parenting support groups.

Social media is one way forward. The relationships and mutual respect between doulas and midwives has blossomed since we have begun to get to know each other on Facebook and twitter. We can really help each other – doulas helping the campaign to spread the knowledge of Optimal Cord Clamping springs to mind, or spreading understanding and therefore driving consumer demand for the ‘gentle’ or ‘woman-centred’ caesarean and ‘seeding the microbiome’. We are also able to provide each other with emotional support online and these friendships sometimes benefit mothers in very tangible, ‘I know exactly the right person for you to talk to’ kind of way.

We’d like to see us working together to create more models that provide psycho-social support for more vulnerable and hard-to-reach groups. That 14 year old girl may well have a wonderful specialist midwife to support her, and perhaps the young parents group at the local children’s centre to tap into. But wouldn’t it be wonderful to find out whether any of the local doulas have experience in this area or were young mothers themselves? Sometimes someone coming along who isn’t wearing a badge or a uniform, can make all the difference.

What about those women who ask for elective c-sections with no clinical indication? How many units have specialist counselling services for tokophobia or birth trauma? How many doctors or midwives suggest to women that a bit of peer support might help? Signposting to ‘patient support groups’ can make all the difference, as many women’s accounts of the effect of other mother’s positive stories attest.

There are doulas who have experience of working with women in prison, doulas who are also clinical psychologists, doulas who work exclusively with young mothers, or who work closely with Social Services or Homestart. There are doulas who have a lot of experience building rapport and trust with women who are suffering huge anxiety, and doulas who work with women with particular conditions, like Hyperemesis. There are doulas who specialise in breastfeeding support and who are also Breastfeeding Counsellors or IBCLCs.

Some of us receive direct referrals from maternity staff. Some don’t. Some hospitals have built formal, cooperative models that incorporate doulas, in a voluntary or paid capacity, into the system in some way. Sharing best practice, spreading ideas, building on the successes and working sustainability, mutual knowledge sharing and auditing into the processes seems to us to be the way forward.

Given that doula support appears to have a growing body of evidence to suggest we can increase normal birth rates, minimise cesarean sections and save the NHS money, it is surely time to begin to formalise our partnerships.

So if you are a health professional, why not resolve to find out about the doulas in your area? Perhaps invite them for a cup of tea – they’ll bring the cake.

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Women’s Voices in #MatExp – Your Midwife

I was asked to do a talk to student midwives at Salford University last week on the topic of “Women’s Voices” in maternity care.  As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience.  “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.

So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the first of those.  This is Dawn Stone’s experience of being a midwife in the NHS.  Thank you so much to Dawn for agreeing to write for us.

And yes, I will be doing a “Men’s Voices in #MatExp” series too.  Because this campaign is about all voices.

Helen.x

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Dawn Stone is a 27 year old midwife living and working in central London. Dawn qualified as a midwife in 2014, and is passionate about improving experiences for students, midwives and women.

Dawn Stone

It’s an insignificant Monday afternoon in SE London to many. It’s beautifully warm, people are rejoicing in beer gardens as they finish work, I hear the giggles and shrieks of laughter from a nearby park as I walk home. It’s an idyllic summers day; and yet somehow it feels cold to me.

I’m on my way to see my GP. I made the appointment last week, but it feels fortuitous to have this lifeline today. Because today, of all the 303 days I’ve been a midwife, it feels way too much to bear. And I need some help.

I’ve been here before. A few months ago the feelings on inadequacy, frustration and disappointment reared their ugly heads and I made the same journey to my GP, begging for help. She, to her credit, was wonderful but the medication she prescribed was not. I went back to work but felt like I was going through the motions. My appetite was reduced, I hadn’t slept a whole night in months, and I constantly had a knot of tension in my stomach whenever I thought about work.

What do I do? I’m a midwife. And it nearly knocked me off my feet completely.

I trained as a midwife in a busy central London hospital, which often felt like a baptism of fire and was definitely not what I was expecting. I was lucky to witness amazing births, incredible women, and unfortunately, at times, disappointing midwives. It seemed as though some had lost the ability to care about the women as well as for them; and so I qualified with a goal. Be the best midwife I can be, and never forget the power and importance of being kind. It sounds so simple when you write it down!

Upon qualifying, I moved to another busy central London hospital, and began working as a bona fide midwife, alongside a group of also newly qualified midwives who would become my lifeline. Together we jumped into this chaotic and intense career, and discovered that being a student midwife does NOT prepare you for being a midwife. Not at all. You have no idea as a student the enormity of every decision you make – that lochia is normal, that baby is not jaundiced, that baby is unwell and needs an urgent review. And on and on it goes; a hundred different decisions, all before lunchtime and all before you’ve had a drink or something to eat. And if you’re lucky, you’re figuring this all out in an environment which is supportive and conducive to learning, where you know you have more experienced midwives to lean on and ask ‘Does it get better?’

If you’re unlucky, you’re essentially told to suck it up and keep going. Never mind that you’re awake at 4am going over and over the shift from yesterday, thinking about each woman and baby, and what you handed over – did you forget something? You definitely did. Shut up mind, go to sleep. Except you definitely did forget something because you did a blood sugar on the baby in bed 9 before you left and you forgot to write it down. It was normal, thankfully, but should I ring? No. It’s 4am and it’s your day off. Go back to sleep.

Working on a busy 50 bed AN/PN ward can feel like being on a carousel that’s spinning and spinning; there is no slowing down, only jumping on, and trying to stay upright and facing the right way.

When I arrive for my night shift, I look at my workload and I hope for an okay night. I have a mixture of 2 high risk AN women (for close monitoring of their severe PET), an IOL for post dates and 4 PN mums & babies – all of them are on obs overnight, 1 mum is also on IVABX for sepsis, and my colleague has just handed over that one of the babies hasn’t fed for 6 hours. I take a deep breath, try to quell the tide of worry that’s swirling in my stomach, and do the only thing I can do. I make a plan. I read the notes, I look at the blood results, and I try to prioritise what needs doing and when. I say hello to all 7 women, some of whom I know, and I begin to do what needs to be done.

And I’m sorry if I couldn’t sit with you longer during your breastfeed. I can see your baby is feeding well but as a first time Mum you need some support and guidance as you learn this new skill. I want to sit with you, and gently reassure and reaffirm you as you confidently latch your baby to your breast. But I can’t. Because I have 6 other women, and 3 other babies who need me. So I do what I can, and then ask a maternity support worker to step in, and do what I cannot.

I’m sorry my checking on you and baby felt like a list of questions, one after the other, relentlessly. I know this isn’t the best way to elicit how you feel about this huge shift to parenthood, and I may not ask the question you need me to, and so your niggling worries remain unchecked.

I’m sorry I have to wake you at 2am, and 6am, to check your blood pressure. The medication you’re on to manage it is very good but we need to ensure its effective, and the middle of the night BP is actually one of the most useful. I hate waking people up, and I know you don’t mean to swear at me as you grumble and sigh, before brandishing me your arm, but it still hurts to hear. Thankfully your blood pressure is normal, and I can tiptoe out & leave you to rest.

As I walk past the desk, I see my bottle of water, next to my colleagues. All untouched.

I’m sorry you’re in a mixed bay of women, and you can hear babies crying as your labour is starting, and it’s not dark or quiet as you need it to be. I’m sorry you’re quietly sobbing on the edge of the bed as you try to get through this contraction without making too much noise and waking the sleeping bay. I’m sorry I can’t be with you, talking you through your contractions and helping you to relax and reduce the fear/tension/pain cycle. I know that you need me, but I have obs to do on 2 of the babies in this bay, and I need to check on one of women with raised BP as she’s on the monitor and I hope it’s ok as I had to dash out of the room once it was on. I’m sorry I’m only half with you as I rub your back, as I’m juggling my outstanding jobs in my head. Thankfully, some codeine and a warm baths eases some of your pain, and you spend a few hours soaking in there, feeling much more relaxed.

I’m so relieved.

I’m so relieved that your labour didn’t progress rapidly, and your baby wasn’t born on the ward.

I’m so relieved all of your babies obs were normal, and they didn’t show signs of an infection.

I’m so relieved that the heavy bleeding you complained of turned out to be normal blood loss, and you’re not having a haemorrhage.

I’m so relieved your blood pressure was normal, and you’re not feeling any symptoms of pre eclampsia.

I’m so relieved when you come to me at 4am, as I sit at the desk gratefully drinking a coffee as I relish the middle of the night peace that’s descended, and tell me you latched your baby on yourself & it felt like a good feed.

I’m so relieved. I’m also hungry, and tired, and the water has remained untouched although I have slurped a coffee my colleague made for me.

This shift has been busy, and stressful, and required me to constantly assess, juggle and prioritise. But it’s not extraordinary. It’s a typical shift in a typical London hospital on any given day. The women are grateful, and I leave with a small sense of doing a good job.

Until I return the following night to be told I didn’t do a VTE risk assessment. And the dyad I helped with breastfeeding are now mixed feeding as she felt her baby wasn’t getting enough. And the mum who labour began during the night is still on the ward, awaiting a doctors review to formulate an ongoing plan. And we’re short staffed. And I can feel a headache coming on as I didn’t sleep well, worrying and replaying the previous shift over and over.

With such unrelenting pressure, is it any wonder I’m crying to my GP, telling her how unhappy I am, how tired, how morose? And is it any wonder she doesn’t bat an eyelid when I ask for antidepressants, and a sick note?

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 #MatExp is a campaign about ACTION!  So what can be done?  We have already written about how it is Time to Act for Midwives, but as this recent post on Sheena Byrom’s blog demonstrates, these issues are not isolated and they are not yet being taken seriously.

NHS Maternity Review

Sheena kindly commented on what Dawn had to say:

“Dawn’s reflection of her experience trying to do her work as a midwife is distressing, and tragically, Dawn is by no means alone. I receive regular emails from midwives and student midwives who feel desperate, unable to go on, and ready to leave our profession.

I sincerely hope the National Maternity Review report will kick start the much needed radical reform of maternity services. If we can’t support, care for and nurture maternity workers to provide safe, effective high quality maternity care, we have an unsustainable situation.”

A mile in my shoes

Community Outreach Midwife Wendy Warrington also commented on Dawn’s experiences:

“This could have been written by me and the majority of my midwifery colleagues as accurate, and to be honest been there themselves me included! I came back to work after nearly 3 weeks off and Monday morning I had a knot in my stomach when I turned on my work phone and strolled into the community office. Fortunately all was well, but that was due to in the run up to Christmas ny starting early working at home, finishing late and putting written plans in place. Four women on my caseload delivered and I have high risk caseload due to safeguarding concerns.

In terms of improving the situation there needs to be a shift from the blame and bullying culture that seems to be prevalent within the midwifery profession and the NHS as a whole. Senior management with their expectations bully staff below them and this continues down the pecking order. Midwifery sadly is still very hierarchical. Also the public perception and expectation has shifted from when I first started. There does not seem to be the respect from the public as in days gone by . The “where there’s a blame there’s a claim” culture. Cuts to funding, staff shortages and the media have not helped.

Sadly I am counting down the days until retirement as are many of my colleagues.

So how to improve the situation?  As colleagues we should nurture and support one another, and small pockets of us do. I personally have found my escape using Twitter and Facebook groups. Realising there were others out there who felt and thought like me and had not had the passion snuffed out of them really helped me, and gave me the courage to continue and believe that I can make a difference as a midwife.  But than in itself can cause problems: cyber bullying, we have seen that. The more your profile is raised the more you expose yourself to scrutiny. I was seconded to Project Manager for Early Years agenda for Greater Manchester and the knives were out . I was devastated when my Head of Midwifery said that this was par for the course: try to better yourself and jealousy kicks in.

There are health and well-being initiatives in some trusts which need promoting. While we are there to do our work the public should remember we have children, elderly parents and our own problems like them, and sometimes we can’t leave it at the door as much as we try to, so compassion and understanding comes from both sides. I do not know of any midwife who comes to work to upset, harm or distress any woman or her family.” 

So what do we need to do?  What are you doing? What is happening in your Trust that is helping?  Please share best practice and ideas – we are stronger when we work together.

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Top Ten Things NOT To Say To A Preemie Parent

Language is a huge theme for #MatExp, and one of our six Heart Values.  Francesca Tucker kindly agreed to write this post for us looking at people’s inadvertent language trip ups when talking to parents of premature babies.  Francesca is a part-time working Mum, who lives in the New Forest with her husband Murray, baby Harry and their three cats. Harry was born at 28 weeks, whilst his parents were on holiday in France. He’s now a happy, healthy 18 month old!

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As I sit and write this now, I can do it with a smile on my face.  But 18 months ago, if you’d said any of the following “Top 10” to me, my reaction would have been vastly different.  Depending on how my day had gone / how many Brady’s baby Harry had decided to scare us with / how much milk I’d managed to express etc., you may have had a response of tears, anger or stony silence. Because, quite frankly, there are just some things you don’t say to the parent of a premature baby!

Speaking on behalf of “The Premature Club” which no-one wants membership to, we understand that it’s difficult to know what to say.  The pure joy of the newborn news is tinged by the elephant in the room- “what if they don’t make it”?  We know that as our family, friends and loved ones you are thinking of us (we do appreciate it!) and you want to say the right thing, but we’re not expecting you to – there are no magic words that will break the spell and make everything better.  Just being there for us, letting us cry, shout, or just sit in silence helps.  And that silence can be golden – far better than the following “Top 10 Things not to say to a Preemie Parent”! (As compiled by myself and another Prem-Mum whilst we were in neonatal, both with boobs out, trying to get our babies to practice their breastfeeding!)…..

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1. You’re lucky!  You got to meet your baby early!

Yep, at this time, we’re feeling really lucky-said no-one EVER!  Last time I checked, there was no calendar hung in my uterus, so I’m pretty sure the baby had no concept of ETAs.

2. Your baby was just keen to meet you.

I was creating quite a nice little home in my womb which I was quite proud of- food on demand, good thermostat, nice sounds, and a lovely landlady who was providing everything.  I think my baby was quite happy to stay put for a while longer, and wasn’t that eager to meet me. He/she had heard me chatting enough already, so I’m pretty sure the baby knew me already!

3. Oooh, having such a small baby must have made labour easy!

Putting aside the obvious fact that childbirth is painful, what a lot of people forget is that Prems often arrive in emergency situations. This may involve tearing, C-sections, episiotomies as well as the wider delivery tool-kit of forceps, ventouse etc.  This is NOT easy! (And don’t even get me started on the emotional aspects of labour)

4. Lucky you!  You’ve got less baby weight to lose!

Why is it that when someone has a baby, everyone feels it’s acceptable to start commenting on your weight?!  It’s no-one else’s business that you weigh, it’s the last thing on your mind whilst listening to the endless beeping in neonatal. And chances are that with the stress of the situation, you’ll be losing weight anyway

5. Well, at least with the baby in hospital, you get a good night’s sleep!

Erm, no!!  At night, most Prem parents are trying to cram in a day’s work of general life into a couple of hours (unfortunately bills still need to be paid, housework done etc.), prepare supplies that need to go to the hospital the next day, express milk through the night to keep supply up, and are generally stressing.  A good night sleep is not anticipated for months!

6. With those nurses around, you’re getting far more support than most Mums.

Yes, the nurses are a fantastic support (they become your extended family!), and it’s a hard job to do, but they are by no means doing it single-handedly.  They encourage the parents to get involved wherever and whenever possible. I can’t think of many parents that have a baby just to hand them over to someone else to look after – you are the parents, and you want the job!  But also remember, the medical team is desperately needed- many Prems need a lot of medical support…surely no-one can begrudge a baby that?!

7. But tiny babies are so cute!

True, but would you swap your baby being dangerously small for “cute”?  I thought not.  And trying to find the “adorably small” premature outfits is tricky…and very expensive!

8. When will the baby be coming home?

We don’t know, and if we do, we often won’t want to say.  It is upsetting thinking you’re about to take your baby home, only for your child to take a downturn and your excitement turns to disappointment and fear.  Sometimes it’s easier for the parents to say nothing, rather than having to explain why the baby is remaining in hospital.  And when we finally take our little family home, we may well want a day or two to take it all in-it’s a long journey to get home!

9. How are you doing?

Mmmm, a tricky one.  Some days will be good, some days will be bad.  With 1001 thoughts and emotions running through a Prem parents head, it’ll probably take too long for them to give an honest answer- default option is option to be “Okay, thanks. You?”  A better thing to say if the offering of help for a specific thing e.g. “Would you like me to bring you a meal around, so you don’t need to cook?”

10 Will he/she be okay?

A very personal question, and again one that is completely dependent on individual circumstances.  Define “okay”?  The baby may have long-term health issues, but with the prospect of excellent quality of life, the outlook is overall positive.  Or the baby may be going through a serious complication, where the outcome is an unknown. No-one wants to answer “No, he/she is not okay”, as it’s upsetting for all concerned.  I personally think such questions are best avoided, and simply substituted by as much love and support as you can provide.

Harry

These are some of the favourite options I had for you from our early days of the neonatal journey.  Now, a favourite is “Isn’t he walking yet?” – nope! But bear in mind, his peers have a 3month developmental head-start!  Maybe I should do a Top 10 comments for the “Advancing Prem Baby”?!……….

But to anyone reading this, currently supporting a neonatal family – thank you.  Even though the family may not show it (they are probably too overwhelmed presently), having you present in their lives is helping them more than you’ll know.  And if you’re the parents of the little baby/babies lying in hospital- I welcome you to “The Premature Club”- it’s tough, and at times you may feel so wholly overwhelmed it can engulf you.  But remember, you are doing a great job and making the best of your situation. I send my love and support to you.

By Rosiepics
Francesca and Harry by Rosiepics

Francesca Tucker

2016

For more “What Not To Say” and other Preemie Top Tens please visit The Smallest Things website.

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WhoseShoes Confirmed That My Shoes Have Climbed A Mountain

This post is from Michelle Quashie, and originally appeared on her blog site Strong Since Birth.  Our thanks to Michelle for agreeing for it to be reposted here.

Michelle

The day had finally arrived! After contributing to #MatExp and interacting with many conversations surrounding ‘WhoseShoes’ throughout the year, I was finally going to experience the magic in real life.

Laura, the chair of our MSLC has written a fantastic post that captures the excitement of the day perfectly, you can read it here: When WhoseShoes Came To The PRUH

I was not disappointed, the day was everything I had dreamed of,  but for me it was so much more.

I was asked to open the event by sharing my Maternity Experience. I have spoke at several maternity training events in the past but my audience has always been Midwives. I was aware that this was a multi discipline training event and it was to be the first time I would share my story in such detail with Obstetricians and everyone else involved in Maternity. The thought made me feel anxious but I knew how important this opportunity was.

I had planned to stay in control and not let the emotions attached to my experience be displayed in the form of tears. It was so important to me to remain composed and in control.

My heart pounded through the showing of the MatExp film, this film moves me every time. It is so powerful and very thought provoking. Sadly I can resonate with many of the situations displayed in the film. I knew I was about to be discussing some of those memories any minute with all those surrounding me.

My name was called and I made my way to the front with my heart pounding. I decided to be honest and share how I was feeling with the room.

‘Please bare with me, I am feeling very nervous. I’m sure once I start talking I will warm up and I will be fine!’

Automatically I felt more relaxed and felt more able to share my story without the anxiety overruling my thoughts.

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It’s amazing how every time I share my experience it comes out slightly different, or I find myself saying things that I hadn’t thought of before? I had missed a couple of important bits out but neither the less I was very happy with the way I had presented and gauging by the feeling of emotion in the room I had touched the hearts of nearly everyone around me. For the first time I was able to keep my tears to myself even though I had noted that tears were shed by many in response. The room fell silent but the atmosphere spoke volumes.

I wasn’t aware of the tweets that were being circulated on social media but looking at them them later along with the emails I had received It confirmed that my talk was a positive part of the day.

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“Also a massive well done to Michelle for her heartfelt and emotional story, I could see it touched many people as there were certainly a few tears in the room. That took huge courage to stand there in front of so many people and share such a personal experience and to tell it so well. Huge WELL DONE Michelle.”

We began to play the the game and interesting discussions were had in response to the thought provoking questions that are key to the WhoseShoes success.

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Some of the discussions that stick in my mind were:

  1. A woman wanted a home birth but her husband wasn’t convinced. We had discussed that there wasn’t enough support or information given during antenatal care to ensure that the couple felt safe,supported and empowered to fulfil the woman’s birth choice.
  2. Consultant Obstetricians are normally addressed by other members of their team using their title i.e., Sir, Mr, Mrs or Miss as a mark of respect. I may be wrong but it feels hierarchical, unlike the power slogan and barrier breaker behind WhoseShoes and #MatExp ‘No Hierarchy, just ordinary people’.
  3. It was also discussed that consultants were on site until 9 pm, after that they are on call for emergency situations only. Now I understand why during my appointment to discuss my VBAC, the registrar said ‘ I mean, we don’t know when you will go into labour or who will be on duty should you rupture’. I now understand that my birth choices were  influenced by staffing levels at the hospital.
  4. Other key themes were Empathy, Language, supporting and facilitating informed decision making and just how important it was for everyone to be cared for individually based on their individual situation and needs.
  5. Midwives are able to have time to build a relationship with women whereas doctors are often called for the emergency situation and do their best to resolve the medical issue as it arises. This can sometimes make it hard for them to be able to connect with the woman that they are caring for and are not always able to fully appreciate the long lasting effects the experience can have on a woman.

The day was coming to an end and Anna gave us fabulous evaluation of our morning using the comments that came from the discussion at each table. It was fabulous to visualise the discussion using the graphic that Anna had been working on through out the morning.

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We each made an individual pledges. Here is my pledge:

“To provide a platform for women to share their Maternity experience.  I would like to ensure that women’s voices are heard as part of training and development.”

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I am currently planning a conference called ‘Women’s Voices’. More details will be available soon.

As the morning came to an end and people were leaving someone tapped me on my shoulder. I turned round and my tummy flipped. The face before me took me straight to a place of feeling vulnerable, feeling panicky.

‘Michelle it was me wasn’t it?’

Stood before me was the registrar that I had my consultation for my vba2c with. Unbeknown to my self and the organisers we had shared the morning. I had shared an experience that changed my life but had also been a time that left me feeling scared, vulnerable, isolated and questioning my mental health. The person that was responsible for those feelings was standing here in front of me, for a moment the feelings came flooding back, I battled to keep them contained.

Michelle6

She apologised for the way she had cared for me. She admitted that she had been wrong and has since ensured that she was fully aware of her professional guidance. She was now fully supportive of  women’s choice regarding their birth and ensured me that since having to write a statement in response to my complaint, she is fully aware of the impact of the care she provides a woman.

She actually thanked me for highlighting the error of her ways promising me it had changed her attitudes. I could see that she was overwhelmed with emotion and had spoke to me honestly. She asked if she could hug me and we both held each other for comfort.

I told her that I admired her for taking the time to come a talk to me and for apologising. I also explained that I was aware that she was not entirely to blame for the care I had received and I now understood that her response to me wanting a vaginal birth after two caesareans was due to the cultural belief of the trust she worked in.

It was clear that my birth wishes would not be supported and neither would anyone wanting to support me at that time. I know this because many attempts were made to provide me with the support I needed and no one stepped out of their comfort zone to provide me with the support I needed with regards me birth choices. As a result I had no choice but to transfer my care.

She empathised and promised me that as a result of my experience things were changing.

We said our goodbyes and I was trying very hard to contain my emotion that the meeting had evoked.

A consultant midwife that has walked by my side through this maternity experience and others and who has been a pillar of support to me came to see me. ‘Are you OK Michelle?’

The flood gates open and I broke down. I couldn’t talk at that moment. I was just overwhelmed with emotion. I couldn’t make sense of it at the time but now I think I can.

That meeting with the registrar brought some closure. I admire her ability to acknowledge the error of her ways.

The meeting took me back and reminded me of the scared women I once was sitting in her office, trying to persuade her that I could give birth, pleading with them to allow me. Feeling so horrible when it was highlighted that I had never given birth and they wasn’t sure if I could. I was subjected to a number of negative comments that effected my mental well being and left me questioning my sanity. Comments that left my family feeling unable to support my decisions in fear of my safety. it was a meeting that left me feeling isolated.

Here I sat after coming full circle with the same women but this time I was a different woman. I am a now a woman who has had the most amazing journey and have achieved some incredible things;

I gave birth, not only did I give birth but I bloody rocked that labour ward!

I came back and I told the story, I sang it from the rooftops!

I learnt to believe in me and my abilities.

I joined their MSLC and contributed to so many fantastic improvements within the Maternity service.

I have spoke at training events within maternity with an aim to improve maternity care for women.

I have written and had my views published here and in The Practising Midwife .

I have contributed to #MatExp campaign and connected with some fantastic people as a result.

I have met, received support and been inspired by many fantastic people. too many to mention.

The realisation that my shoes have climbed a mountain has happened!

I received the following email from a Consultant Obstetrician following the Whose Shoes event. It confirmed that this journey has been worth every little step:

“Dear Michelle,

I just wanted to reiterate how touched I was by your story and how impressed I was by the way you delivered it. You will be responsible for improving the practise of every obstetrician in that room today which in the end will improve the care of tens of thousands of women.

If anyone is amazing it is you!”

This is one of many mountains.

I hope to be climbing a mountain near you soon.

 

Michelle Quashie

2016

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