Maternity Experience

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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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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?

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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?

*********************

 #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.

MatExpblogbadge

 

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#OxyOct BOOM! What have we all made happen?

Leigh Kendall opened this month for #MatExp with a call to action for Oxytocin October. The campaign is always action focused and we are keen to hear from anyone who is doing something to improve maternity experience in the UK, be it something big or something small. Yet we had already put together a number of blog posts with calls to action, back in #FlamingJune. So I decided that my action for this month would be to revisit those blog posts and find out what progress has been made.

Flo Collage

The original blog posts were on these subjects (each subject links to the relevant post):

Having re-shared the posts on Facebook and Twitter I was delighted to see the responses coming in detailing what has changed, what has been started and what is continuing to be done. Take a look!

Perinatal Anxiety

Sarah McMullen of the NCT explained that she invited Emily Slater (MMHA Campaigns Manager) to speak and run a workshop at the NCT national conference – to raise awareness and inspire action. Sarah says that Emily’s plenary talk to 600+ staff, practitioners & volunteers “was incredibly powerful, and we’re meeting to discuss next steps for NCT”. Sarah added “We’ve also submitted two funding applications relating to mental health awareness (thanks to Rosey Wren for support), and have match-funded a PhD studentship with the wonderful Susan Ayres on Birth Trauma, and are supporting another PhD research project on group identity and PTSD”

Midwives on Twitter commented:

Anxiety capture Deirdre

Anxiety capture Jeannine

To read Jeannine and John’s blog post please click here.  “You matter. I care.”

Emotional Wellbeing

Birth Trauma Chat

#MatExp team member Emma Jane Sasaru has been incredibly active over the last few months.  She has launched Unfold Your Wings a place of information and support aiming to raise awareness of Perinatal PTSD, birth trauma, reduce stigma and give sufferers hope.  She has also launched a CoCreation Network community around perinatal mental health.  Emma has then collaborated with #MatExp team member Susanne Remic to bring about a weekly #BirthTraumaChat on Twitter run jointly from Unfold Your Wings and Maternity Matters.

Sue Henry

Also launched this month by West London Mental Health NHS Trust was this fantastic short film about perinatal mental health: https://vimeo.com/143359951 This film has already sparked many useful conversations.

PMH

Continuity of Care

I was speaking to a commissioner from Cheshire this month about the decision to commission OnetoOne Midwives. The company has this month posted an overview of their caseloading model: http://www.onetoonemidwives.org/_news/caseloading-midwifery-an-ever-evolving-model-of-care

In her talk at a recent National Maternity Review event, Baroness Julie Cumberlege made it very clear that the call for continuity of care is being heard by the review team up and down the country. Neighbourhood Midwives led a discussion at the review’s Birth Tank 2 event, and there were a couple of other discussions where options for continuity were also explored.

Support for Midwives

Poem from banksy midwife @JennytheM:

Midwives JennytheM

Midwife Deirdre Munro celebrated the launch of the new Global Village Midwives website this week. The movement is over a year old and Deirdre explains:

GVM capture

global village midwives

Infant Feeding

Lots of news about infant feeding from passionate individuals and voluntary organisations.  On our #MatExp Facebook group Zoe Woodman explained: “In May we got approval from NCT to run a branch funded feeding support group. Started in June with an NCT bfc attending who is also an IBCLC. We are on 3 boundaries in terms of commissioning services so no local peer to peer style support groups were running within 8miles. The only service is an HV clinic once a week and it’s one on one so you have to wait outside the room to be seen. It’s been on our branch aims at our AMM since I’ve been chair (4yrs!) so finally chuffed to see it in action and I will get to use it myself in January for no3! It’s running twice a month currently but hope we can get funding in the future to run weekly. It’s slowly building in terms of attendance. Feedback so far is great!”

Dorking NCT

Claire Czjakowska’s Breastfeeding Advert is coming together and is looking very exciting – watch this space!  Breastfeeding in Trafford launched its Twitter account this month so please follow for local breastfeeding news.  BfN Portsmouth tweeted:

Bf capture

Midwifery students at the University of Worcester have launched a petition around the questionable practices of infant formula companies – follow the hashtag #WeakenTheFormula for more information.

As if this wasn’t enough, this month has seen the launch of the World Breastfeeding Trend Initiative for the UK.  A committed group of individuals from the major breastfeeding voluntary organisations have come together to measure the country’s performance against the WHO Global Strategy for Infant and Young Child Feeding.  Please visit the website for more information on how this project is structured and the indicators against which the UK will be measured.  The project needs lots of input from families and professionals so please follow @wbtiuk on Twitter and find out how you can help.

WBTI capture

Tongue Tie

Doula Zoe Walsh updated us: “We held a North West tongue-tie workshop in Blackpool. It’s now going on the MSLC agenda for Blackpool so that we can discuss local provision and see if it’s meeting the needs of local families.”  

Breastfeeding and Medications

Friend of DIBM helpline

From a personal point of view, I finally got around to becoming a friend of the Drugs in Breastmilk Helpline this summer.  The helpline is absolutely vital for ensuring that women get the correct information about what medications they can use when breastfeeding.  The service is funded by the Breastfeeding Network and the charity once again asked supporters to do a #TeaBreakChallenge this month to help raise donations.

Teabreak challenge

A wonderful #MatExp collaboration has sprung up this month between Angelique Fox, Sarah Baker and Wendy Jones.  These two #MatExp mums who have never met in person have both volunteered to help Wendy to collect data and raise awareness with regards to drugs in breastmilk, particularly where dentists and podiatrists are concerned.  It was discussed on the #MatExp Facebook group that these two healthcare professions are often cited as not having up to date information about breastfeeding and medications so this collaborative project is aiming to tackle that.

Luisa Lyons, the Infant Feeding Coordinator who wrote our original post on this subject, gave us this fantastic update: “Been a busy couple of months. Infant feeding e-learning training for doctors up and running at my unit and both paeds and obstetricians encouraged to complete it. Great support from our obstetric consultant clinics director too. General paed nurses now doing mandatory infant feeding training every year. Been invited to teach general paed doctors face to face. Three GP’s have done the UNICEF 2 days bf management course with us and now writing bf training for GPs in Norfolk. Included info on bf and medications with scenarios to both student nurses and our midwives at keyworker training now, and incorporating into Mt for all maternity staff. Also off topic slightly am putting in a WHO code game to all the above which has generated lots of awareness with student midwives and maternity staff. Need to join DIBM as a friend which I had forgotten to do, so thanks for the heads up.”

Dads & Partners

Mark Williams, co-founder of Dads Matter UK, wrote this blog post for us for #OxyOct, detailing his work and campaigning: http://matexp.org.uk/matexp-and-me/dads-matter/

Men Love and Birth

Midwife Mark Harris launched his book this month, Men, Love and Birth, “the book about being present at birth that your lover wants you to read”.

A Manchester midwife reported positive outcomes around new rules enabling dads & partners to stay over on her unit:

Dads & Partners Mags

When asked how we can best support Dads & Partners, newly elected NCT president Seana Talbot tweeted:

Dads & Partners Seana

Community Outreach Midwife Wendy Warrington tweeted:

Dads & Partners Wendy

I asked Wendy about the work she does with regards to Dads & Partners and she explained “I talk about attachment and being with their baby, skin-to-skin touch. Antenatal and postnatal depression, and fathers’ role in supporting their partner in pregnancy, birth and beyond and how they can do this. I talk about baby cues and the impact of father’s involvement on child’s future emotional and cognitive development.  I have had excellent feedback from parents and when I see them after the birth they say they felt well prepared for feeling and emotions experienced post birth. They love the fact that I talked about it”

Collaboration between Midwives and Health Visitors

Health visitors on the #MatExp Facebook group told us:

My CPT & I have established 6 weekly meetings with the community midwife and the GP (whose special interest is pregnancy/neonates) to discuss cases”

“We already have that in my team we meet at least once a month with the midwife – it was weekly but we are very busy at the moment (both us and the midwife). She will just knock on our door though and share things – she really came on board with antenatal contacts telling parents to be and signposting those with small children with any worries to us.”

With excellent timing Sharon White, OBE, Professional Officer of the School & Public Health Nurses Association, then tweeted the updated pathway for health visiting and midwifery partnership.

partnership

And as a result of discussing all of this on Twitter, Sheena Byrom has invited me to lead a tweet chat with @WeMidwives and @WeHealthVisitor in November on the subject of midwife and health visitor collaboration.  Watch this space!

Birth Tank

And so much more has been happening in #OxyOct as well! #MatExp was well represented at the NHS Maternity Review’s Birth Tank 2 event in Birmingham – click here for Emma’s round up. I spoke at the launch of the Improving ME maternity review for Wirral, Merseyside, Warrington and West Lancashire – click here for my round up of the morning. Leigh Kendall and Florence Wilcock spread the word at the RCOG Conference on October 16th, and Leigh spoke at the Royal Society of Medicine event on October 20th.

RCOG

Leigh capture

Baby Loss Awareness Week took place this month and many important discussions were had around the subject of grief and loss, something which affects a number of #MatExp campaign members.  Leigh wrote movingly about Standing on the Periphery for #HugosLegacy.

BabyLoss

The RCM has this month launched its State of Maternity Services Report. Emma Jane Sasaru has written a series of three blogs about What Matters in Birth.  Susanne Remic has been raising awareness of IUGR. Michelle Quashie created fantastic word clouds for display in her local maternity unit.  We now have #MatExpHour every Friday created and launched by Louise Parry – click here for her round up of Week 2.  So much going on!

IUGR

I have no doubt there is much much more that I have missed from this round up. There is so much energy and passion in maternity services, and so much desire for change. Whatever it is you are trying to achieve, please join up with #MatExp via Twitter, Facebook or the website and get encouragement and input from like-minded people. Together we are stronger! Feel the Oxytocin flow!

 

Helen Calvert, 2015

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Dads Matter

As part of Oxytocin October (#OxyOct) I have been revisiting the first set of blog posts we put up calling for people to ACT in certain areas of maternity care. One of these was Time to Act for Dads & Partners, which included a mention of Mark Williams‘ work in this area.

Mark Williams is the founder of a new organisation called Dads Matter UK (Perinatal Mental Health for Fathers). He also founded Fathers Reaching Out, Youngness and Independent Mental Health Campaigners.

Father’s Reaching Out was set up in 2011 to raise awareness surrounding the detrimental impact that postnatal depression (PND) has on both fathers and equally families as a whole. Dads Matters UK aims to raise awareness of perinatal mental health, and educate every dad before the birth about birth trauma and PTSD for men.

We are delighted that Mark has written this blog post for #MatExp as part of #OxyOct.

______________________________________________

Mark Williams 4

Depression can hit up to around one in five fathers by the time the child reaches adolescence. In a published report in 2015, it states that at least 10% of fathers will suffer with postnatal depression, which can include the birth itself and up to a year after. Fathers can develop lots of complications in this period, and this can influence their daily lives as well as affect their role within their family unit. It can impact heavily on their relationships, financial stability alongside lifestyle and emotional states. Emotional problems and psychological health needs are crucial elements to postnatal depression in fathers and need to be addressed. Fathers tend to get forgotten at this important and life changing event of having a baby, with mother and child being the centre of care delivery and rightly so, but we must remember there is a father there too. Fathers often get pushed aside which can result in feelings of isolation, anxiety and confusion at a time when they to need help.

Dads Matter

Dads Matter UK is suggesting that the health service needs to develop a process for the screening and detecting of postnatal depression in fathers. As many fathers, the figures suggest, suffer with anxiety post birth of the child. The birth of a new baby can cause problems such as poor sleep, anxiety and stress. This can lead to problems within the relationship and fundamental communication processes within that relationship. After speaking to hundreds of fathers we are primarily concerned with the health of the father and their families. We feel that postnatal depression in fathers is equally significant and requires important consideration when implementing strategies and screening tools for postnatal depression. Fathers suffering with depression can feel increasingly pushed out and unsure of their role within the family thus affecting the bonding and attachment process between father and child.

Screening is important for men, as they are less likely to seek help and support. Particularly, in relation to their health problems. Due to the associated stigma towards mental health and its associated issues, young fathers are even more likely to be at risk and not seek the help they need. Men are often reluctant to admit that they may have an emotional problem or are unlikely to admit to feeling out of control. If this area of health is not addressed adequately this could lead to further breakdowns in the family structure and have long lasting devastating outcomes for our children.

Mark Williams 3

We must remember that fathers can also suffer from PTSD at the birth. Post-traumatic Stress Disorder can occur following a life-threatening event like military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. Most survivors of trauma return to normal given a little time. However, some people have stress reactions that don’t go away on their own, or may even get worse over time. These individuals may develop PTSD.

People who suffer from PTSD often suffer from nightmares, flashbacks, difficulty sleeping, and feeling emotionally numb. These symptoms can significantly impair a person’s daily life. As we know many suffer in silence and let post traumatic stress disorder effect all parts of their daily living. My own nightmares were what if my son had died and the thought of my wife being pregnant in the past did give me so much anxiety that at the time I didn’t know why.

PTSD is marked by clear physical and psychological symptoms. It often has symptoms like depression, substance abuse, problems of memory and cognition, and other physical and mental health problems. The disorder is also associated with difficulties in social or family life, including occupational instability, marital problems, family discord, and difficulties in parenting.

The “invisible wounds” of birth trauma-related PTSD affect not only the father or the family member, but also those around him or her. We must remember it effects everyone and education is needed to prepare the family for what may happen during and after the labour.

We run the risk of letting our fathers down at a time when we need to build strong families and communities for our future generations. Identifying the right support and providing improved health care in relation to Perinatal Mental Health is a top priority, so let’s ensure our health services have the right tools and services available to help and support fathers in relation to their partners’ postnatal depression. When screening fathers we must be mindful to remember that individuals are unique and have developed different styles of coping. It is important to respect the individual, involve them in their care and offer support to them as a person rather than just treat the illness.

Mark Williams, 2015.

What will

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#MatExp in Numbers and Pictures!

Our ‘small pilot’ MatExp has been going really well…!

Here are some quick facts, figures, and graphics:

  • Since the website was launched in June, we have had more than 7,000 hits!
  • There are more than 700 members of the #MatExp Facebook group, generating very constructive discussion
  • We had 24 action selfies for #FlamingJune
  • 16 posts added to our action linky during #FlamingJune

We tried to capture everything from #FlamingJune in a picture – there’s so much but we gave it a go!

  • #MatExp has seen more interaction on social media than ones about similar issues (not that it’s a competition, but what is so brilliant about #MatExp is that there is no limit to the number or type of people who can get involved because it’s by everyone, for everyone).

compare

This next stat is VERY exciting:

  • Since #MatExp started being used as a hashtag there have been – drumroll please…

numbers

Yes you read that right – more than 152 million!

(Impressions means that Tweets bearing the #MatExp hashtag would have been seen on that number of timelines)

Guys and St Thomas’ Hospital held a Whose Shoes workshop, and seems to have inspired everyone who went, with 100% of attendees saying it would impact on their practise!

Members of the #MatExp community have been busy putting into action improvements relevant to their own hospitals:

Being the language champion, I’ve been heartened to see so much chat about the issue with people from all sorts of professions and specialties taking on board the importance, value and impact of language.

I love this:

Other language – such as ‘allow’ and ‘fail’ can have a devastating, enduring effect on a woman.

Culture can take a while to transform, of course, but the fact that we are able to have such conversations, and so openly too is a very positive start indeed.

I was delighted to find this paragraph below on a site called lulubaby, which offers a range of courses to ‘prepare you for life with your baby’.

Words of common sense – “…you cannot sadly guarantee yourself a ‘natural birth’, even with the greatest willpower and determination…” fill my heart with joy. No mention of ‘low risk’ or ‘high risk’ either – let’s hope such common sense becomes much more common!

lulu

Never forget….

I am incredibly proud to have been named in the HSJ’s list of Patient Leaders, along with Ken Howard who designed our brilliant logo, and Alison Cameron, revolutionary extraordinaire.

Next week, I’m attending the listening event, the first of the National Maternity Review team’s activities. I’m going to be there as part of #HugosLegacy as well as #MatExp – I’ll be sharing my own experiences as well as thinking about how #MatExp can connect with the National Maternity Review team to make things happen. Flo and Gill are coming too – we spend so much time connecting on social media, it’s great to be able to catch up face-to-face sometimes too.

So! We’ve been rather busy. Which is why we have been seeking ways to create more hours in the day, such as getting a job lot of time-turners, like Harry Potter’s Hermione.

And we’re going to need them, because after the summer we have LOADS of exciting things going on, such as NHS Expo, and a #MatExp conference – watch this space! I’m looking forward to meeting even more of the #MatExp community, many of whom have become friends at these events.

All of the #MatExp community are busy doing something positive every day, of course. A huge THANK YOU to you all. IMG_20150526_190834These are for you for taking the time to get involved, share your stories and to make a difference to women, babies and their families. Forget-me-nots are very special flowers!

There is so much going on – Helen, Emma, and Susanne are also capturing as much as they can in their fab posts; it’s impossible to capture everything, but please know that every action and activity, whether big or small is greatly appreciated.

A couple of final thoughts…

You don’t need to ask for permission (besides the obvious!) – JFDI!CJAnPM5WUAEeFjI and always remember…

CJ5AgxgWIAACyso

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Time to Act for Continuity of Care

There have been some fantastic conversations taking place on the MatExp Facebook group, with lots of ACTION threads being posted to generate discussion. The aim of these discussions is to identify ways that we can ACT to improve maternity experiences. Big, long-term actions that might require system change or a change in culture. And small, immediate actions, that professionals and individuals can take today to improve the maternity experience of those around them.

Over the last six months two big themes have emerged from #MatExp for me. The first is WHY are so many age-old issues still a problem for maternity care in this country? The answer to me is the working environment midwives face, as discussed here. The second is HOW can we make a real difference to family’s maternity experiences? So many actions have come out of #MatExp but the one that stands head and shoulders above, in my opinion, is continuity of care.

I don’t mean Ed Milliband’s diluted version of “the same midwife throughout labour”. I mean the same midwife antenatally, during labour and postnatally, or the same team of two or three midwives for the whole of that period. Women who hire independent midwives or who have access to OnetoOne Midwives have this type of continuity antenatally and postnatally, but they only have those same midwives during labour if they give birth at home. IMs and OnetoOne are not insured to act as midwives in hospital settings, although they can accompany women to hospital as advocates. Doulas are also with women as advocates and support for the whole of their pregnancy, birth and postnatal period but they are not qualified to act as midwives.

Continuity

When I brought up continuity of care as an ACTION thread on Facebook, I asked the following questions:

  • What are the barriers to providing continuity of care on the NHS? Is it as simple as not enough midwives, or is there more to it than that?
  • As an anxious person I really prioritised continuity of care, so used an independent midwife in my first pregnancy and a OnetoOne midwife in my second. What would my options have been on the NHS, under what circumstances can women be put onto a one-to-one care pathway?
  • What ACTION can we take to make continuity of care a reality?
  • What ACTION can we take to build good relationships between women and their midwifery teams where continuity of care is NOT a reality?

The suggested actions from the discussion that followed were:

  • Demonstrate the benefits of caseloading to NHS midwives
  • Strong leaders at the helm of trusts who themselves understand how to implement and lead their midwives into wanting continuity of care
  • NHS trusts to talk to independent midwives and social enterprise midwives who are the knowledgeable ones when it comes to providing continuity
  • Think about options for a team approach. One group member directed us to look at the Streatham Valley midwife team: “They were part of a pilot scheme for community midwives where you saw the same midwife and often they came to you for booking in and later appointments. They also checked you at home when in labour to avoid wasted trips to hospital and they have an excellent home birth record. Out of my ante natal group of 5 first time mum’s none of us had anything stronger than gas and air we had one home birth and only one use of forceps. They are amazing.”
  • Understand the positive impact that continuity of carer can have on patient safety and infant mortality
  • Find ways to care for midwives and avoid the “burn out” that is often associated with a caseloading model of working
  • Women with more complex pregnancies to be caseloaded by a team expert in their complexities – in other words, being at a higher risk of complications should not exclude women from continuity of care, in fact if anything these women need it more
  • Consider personalised budgets ( i.e. the NHS would allocate a woman funding to choose the service they wish) and whether or not this concept could help in delivering continuity of care
  • If continuity is not available then note-keeping needs to be excellent so women don’t always have to repeat themselves (which can be particularly hard following baby loss), and so that plans can be discussed and followed up
  • Women who are vulnerable or at risk of perinatal mental health problems should be at the front of the queue for continuity of care
  • Ensure that families are aware of and understand any choices they do have when it comes to their maternity care team

One healthcare professional commented “The commonest refrain you hear from mothers these days is ‘I never saw the same midwife twice’; this is a great sadness to me as surely the greatest gift to mediate the stressful vocation that is midwifery, is the relationship you develop with your ladies.”

Another woman who had opted for independent midwifery care in her second pregnancy commented “I just needed to know that someone was going to know me personally and take my wishes/needs seriously.”

Continuity of care was the strongest theme in the feedback to the National Maternity Review provided by my private Facebook group. It comes up time and again in discussions – I was discussing it today with student midwives at Salford University and they agreed that many midwives want to work to a caseloading model as much as families do. It just has to be constructed in a way that makes it feasible for midwives, many of whom have young families themselves.

Campaign for Choice
Campaign for Choice

This is not news. The RCM’s Better Births campaign has continuity of care as one of its key themes. The demand for caseloading from families accounts for the popularity of OnetoOne midwives in the areas where they are commissioned. A group of mothers in Greater Manchester is campaigning for the local CCGs to make this service available to women, and as someone who has benefited from that company’s care I joined them on a demonstration in Manchester city centre. If continuity is not going to be available on the NHS then OnetoOne might be the best option for families, although as this post of mine shows not all women find that the various services work together. 

What I find striking is how much continuity of care would impact on other areas where the #MatExp campaign has asked for ACTION. Anxiety is reduced if women know their carers. Emotional well-being is improved as are infant feeding outcomes. Dads & partners have more chance of being involved and having their own struggles recognised if they are able to get to know the family’s care team. It will be far easier for midwives and health visitors to collaborate if it is clear who is looking after which families.

I was delighted when an insurance solution was found for independent midwifery in this country. I also have high praise for the model of care provided by OnetoOne. Support and advocacy from a doula can be invaluable. But continuity of care should not be on the periphery of the UK maternity experience. It should BE the UK maternity experience.

 

Helen Calvert

@heartmummy

2015

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Time to Act for Better Collaboration with Health Visitors

There have been some fantastic conversations taking place on the MatExp Facebook group, with lots of ACTION threads being posted to generate discussion. The aim of these discussions is to identify ways that we can ACT to improve maternity experiences. Big, long-term actions that might require system change or a change in culture. And small, immediate actions, that professionals and individuals can take today to improve the maternity experience of those around them.

As a result of the day to day experiences of the mums on my Facebook group, I have been in touch with a number of senior health visitors to discuss the service and how it can potentially be improved. I presented to a group of health visiting managers in Greater Manchester last week, thanks to an invitation from Jill Beswick, and have been asked to speak to the new health visiting students at MMU in the autumn. For some of my thoughts on health visiting please see these three posts on my personal blog:

Health Visiting: Quality and Quantity

Health Visiting: Tell Us About It

Health Visiting: Keeping Everyone Happy?

456 6Cs

Jenny Harmer has written this very useful blog post about what a health visitor’s role entails. In terms of a family’s maternity experience, it is the health visitor who is responsible for their care for the first five years of the child’s life, and they certainly focus on the 1001 Critical Days, or from conception to age 2. They are currently focused on transition to parenthood, breastfeeding, healthy weight and maternal mental health (as well as accident prevention and school readiness) – these are topics crucial to a family’s maternity experience and issues that crop up again and again when families discuss postnatal care.

So we would hope that health visitors are working closely with midwives and other birth professionals to ensure a smooth transition to parenthood and ongoing care and support. Unfortunately, this is not what parents are routinely reporting, as I mentioned in my blog post for Sheena Byrom’s series, What The National Maternity Review Team Needs To Know. When I introduced this topic on the #MatExp Facebook group I asked:

  1. Midwives – are you aware of the health visitor’s role, their 6 High Impact Areas and the ways in which they can help families? Are you aware that many now offer antenatal visits? How do you work with health visitors, hand over to them and so on?
  2. Health Visitors – those who are already doing antenatal visits, are these done in conjunction with communication with the family’s midwifery team? How do you work with midwives postnatally to ensure a smooth handover for families?
  3. Parents – how well did your midwifery and health visiting teams work together? Have you examples of best practice? Where are the gaps?
  4. Everyone – how can we ACT to make improvements in this area?

The actions suggested were:

  • Pathways to be put in place for communication and handover from midwives to health visitors
  • Close working relationships between midwives and HVs so that each team can phone the other to access additional support for families
  • Student midwives to go on visits with health visitors to understand why collaborative working is so important
  • Best practice is for HV teams to have monthly meetings with midwives and GPs, and for midwives to ring the HV team about every discharge so they have a full picture for postnatal contact
  • Joined up IT systems – HVs currently use different systems to the maternity units, so they have no chance to check through maternity notes and only receive basic demographic information about families
  • Continued and consistent support for mums re infant feeding during the first six weeks
  • 7 day a week health visiting service to truly meet the needs of families
  • NNU and other hospital departments to inform health visitors if babies have been born early or sick so that HV can offer support to the family
  • Websites with all of the local maternity information for families, including health visiting services; better signposting from all NHS teams to other groups and sources of support available to families
  • Midwives to inform mothers at booking and during pregnancy that they will be offered an antenatal visit from the health visitor, and that it’s a good opportunity to discuss pregnancy and feeding methods, alongside other parenting issues. If it was part of the schedule given it would become normal – antenatal appointments with HVs are now offered to all pregnant women and dads/partners are encouraged to be present – it’s a holistic assessment
  • Midwife @JennytheM commented “I was on a study day about supporting vulnerable families and the importance of contacting the Health Visitor in such cases was reiterated – an electronic discharge pings to a GP and I’m going to find out if that can also go to the Health Visitor = instant information about discharge – which would help prevent communication failures.”

NHS England (West Midlands) has launched a campaign to raise awareness of the role of health visitors: http://www.bcpft.nhs.uk/about-us/news-and-events/529-campaign-launches-to-raise-awareness-of-health-visitors-and-thier-five-key-visits I hope HV teams continue to clarify their role in this way, both to families and to other birth professionals.

Commissioning of health visiting services moved from NHS England to local authorities on 1st October 2015. It is important that the birth community and families alike recognise what HVs have to offer so that their services continue to be provided across the country. Health visiting teams are responsible for 100% of children born in the UK. It is a massive remit, and one that can have a significant impact on public health if used to its full capacity.

 

Helen Calvert

@heartmummy

2015

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#Matexp – Taking action on improving Tongue Tie services.

There have been some fantastic conversations taking place on the #MatExp Facebook group, with lots of ACTION threads being posted to generate discussion. The aim of these discussions is to identify ways that we can ACT to improve maternity experiences. Big, long-term actions that might require system change or a change in culture. And small, immediate actions, that professionals and individuals can take today to improve the maternity experience of those around them.

One of the discussed topics was Tongue Tie’s, the effect they can have on feeding, but also the struggle to access help and support. So what is a tongue tie? How does it affect a mother and her baby? What can we do to ensure families access the support they need?

“Tongue-tie (ankyloglossia) is when the string of tissue under your baby’s tongue called a frenulum, which attaches their tongue to the floor of their mouth, is too short or tight. If your baby has tongue-tie, it can affect the tongues movement, preventing it from moving freely, this can cause problems with feeding, either at the breast or a bottle, speech, and moving on to solid food. Tongue tie can vary in degree, from a mild form in which the tongue’s movement is only slightly impaired, to a severe form in which the tongue is completely fused to the floor of the mouth. Feeding difficulties may arise due to the inability to move the tongue in a normal way and therefore impacting on attachment, sucking, making a seal and removing milk effectively. Many tongue-ties do not require treatment. However, if the condition is causing problems with feeding, surgical division of the frenulum can be recommended and carried out as soon as possible. It is important that families receive support from trained people as not all tongue ties can be clearly seen and each mother and baby will be different.h9991638_003

How does tongue tie affect a mother and baby? If a mother is breastfeeding tongue tie can affect latching to the breast, in fact some babies are completely unable to latch. It can be difficult for the baby to make a good seal on the breast or maintain the latch during a feed. The results can be sore nipples for mom, static or loss of weight in baby due to poor milk transfer, this in turn can affect milk supply and maintaining breastfeeding.  Some babies feed inefficiently for a short periods of time, get fed up, fall off the breast asleep and exhausted, and then wake an hour later as they are still hungry, so that they are feeding almost continuously. Continuing to breastfeed can become almost impossible with the constant feeding, sore nipples and effect on supply. Babies can become exhausted, and so trying to feed becomes more difficult thus affecting the health of the baby.

With bottle-feeding babies, tongue tie makes it difficult to make a good seal around the teat. The suck is inefficient, and the feed can take two to three times longer. As the seal is leaky, babies will often dribble milk in varying amounts, thus not getting a full feed. As the milk leaks out, air can get in and is swallowed. Both breastfeed and bottlefed babies can be very ‘windy’ with the possibility of increased colic and irritability.

So Tongue tie can have massive consequences on both breastfeed and bottlefed babies. For breastfeeding moms it can mean the end of their breastfeeding journey can can affect their emotional wellbeing too.

So the question raised is, how can we support families and improve services for babies with a Tongue tie?

From the discussions on the Matexp facebook page there were three clear areas that were highlighted.

1. Clear pathways of care. Many commented and shared their experiences of lack of support. There seemed great differences in support available from area to area and it was not always clear where or to whom mothers should be referred to for assessment, diagnosis and division of tongue tie. Some commented that perhaps it should be part of the newborn checks for babies, while others discussed the wisdom in waiting a while to see how feeding progressed before doing a division.

Either way, what was clear was the need for all areas to have a simple, clear pathway to help families get the support they need.

  • These pathways should be known by all including breastfeeding support workers, midwives, health visitors, neonatal nurses, paediatric doctors and G.P’s, as well as parents.
  • The pathway should include trained staff to assess, diagnosis and divide tongue ties.
  • That there should be support post division for feeding.
  • Joined up working between private, NHS and voluntary organisations.
  • Actual acknowledgement of the effects of tongue tie, something some parents reported they did not receive.

2. Trained staff . Many of the comments reflected the fact that there seems to be little in the way of trained staff to assess, diagnose and divide tongue tie. Many reported that despite problems they were told feeding was going well and getting checked for tongue tie was difficult. Some reported having to pay privately for both the assessment and treatment, as there was no one trained available in their area.  Others commented on confusion between healthcare professionals regarding the signs of tongue tie and its impact on feeding, some commented that they were told that the tongue tie needed to be cut without any assessment. Also even when tongue was diagnosed many said they faced long waiting lists with no help to support feeding or maintain lactation. In areas where there are no trained NHS staff, there is no where to refer families to and so the only option is private care which has led to often a costly private market which many families are unable to afford.

So what actions were suggested?

  • All areas to have trained NHS staff to assess, diagnose and divide tongue ties.
  • Working together of NHS and private care to support families, provide services, if there is a lack of trained NHS staff.
  • Staff trained on what a tongue tie is and the signs, effects, it can have on feeding.
  • National recognised, agreed method of assessing knowledge, skills and training.
  • Regular weekly clinics to keep waiting times down.

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3.  Support. By far the biggest number of comments were about support. Families commented again and again about the lack of support for tongue tie. There was a big discussion regarding definition of roles, appreciation of roles and how this impacts on support given. Many felt they received more support from voluntary support roles than health professionals, but then found that support limited or not not valued. Others said they received no support at all which resulted in loss of breastfeeding relationships. Others said that due to lack of support with breastfeeding, tongue tie became the issue that everyone ‘hung their hat’ on as a magical quick fix but then were left with no post division support and felt left alone to get feeding established. One mum said she ‘wished someone had just listened’ because she knew feeding was not progressing ok.

So what actions came forward regarding support?

  • Always listen to the mother, if she feels something isn’t right remember she knows her baby best.
  • Full assessments of feeds by qualified staff to see if feeding is affected by tongue tie.
  • Information and awareness of the signs of tongue tie for HCP’s, and parents.
  • Support with breastfeeding is essential as often support to position and attach baby well can be enough to improve feeding and prevent the need for division.
  • Support for families who bottlefeed on ways to improve feeding pre and post division.
  • Parents need information and support to make an informed choice as to whether to have a tongue tie division.
  • Post division support with breastfeeding and follow up.
  • Help to support lactation, pump loan.
  • Specialist support for premature babies with tongue tie.
  • Appreciation of roles in both the NHS, private and Voluntary sectors. All working together to provide integrated care for families.
  • Clear definition for families and HCP’s on roles, who can do what and who can offer support.

Tongue tie can be a difficult issue that families face, accessing support, finding information and getting lost in the system can leave them feeling frustrated and let down. Of course we all wish we had a magic wand to instantly provide clear pathways, much needed training and support and also weekly clinics that enabled those that needed tongue tie divisions to be seen as soon as possible to lessen its impact. However, while at present support varies from area to area, what can we all do to help make changes to help families?

  • Write to your local MSLC, head of midwifery, head of health visiting, PALS, commissioners or NHS trust and tell them both your struggles to access help but also when you have experienced great support.
  • We can also build on good existing services or use these as a model for setting up services in other areas.
  • If your a HCP and suspect a baby has a tongue tie but are not trained or unsure then signpost or refer the family to someone that is. Find out what is available in your local area.
  • If your a parent that suspects your baby has a tongue tie and isn’t feeding well, seek help and keep on asking! Research tongue tie for yourself so you can make an informed choice and remember is not a quick fix but feeding will take time to settle and adjust after division.
  • As support workers, breastfeeding counsellors, IBCLCs, healthcare professionals and NHS Trusts let us all listen to families and work together to provide them with the care, support and services they need, to give their little ones the best start we can.

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Tongue tie support http://tonguetieuk.org/network/ 

Emma Jane Sasaru

@ESasaruNHS

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Time to Act on Infant Feeding

There have been some fantastic conversations taking place on the #MatExp Facebook group, with lots of ACTION threads being posted to generate discussion. The aim of these discussions is to identify ways that we can ACT to improve maternity experiences. Big, long-term actions that might require system change or a change in culture. And small, immediate actions, that professionals and individuals can take today to improve the maternity experience of those around them.

A topic I was keen to bring up was Infant Feeding, as Emma Sasaru and I are the “breastfeeding champions” for #MatExp (see our original “call to action” blog post). I was less keen to put together the subsequent blog post as it is such a huge and emotive topic, but I have finally put on my big girl pants and pulled it all together. The resulting post is in two parts: firstly, the actions and comments from the group thread. Secondly a little library of links to some fantastic blogs and articles that I really would recommend if you have an interest in this subject.

When I put up the thread on the Facebook group I asked the following questions:

Question 1: How can we ensure that every family is offered appropriate support to feed their own child, with respect to their individual circumstances?

Question 2: If you wanted to breastfeed but could not, was that due to a lack of appropriate support? If so, what support would have made a difference for you?

Question 3: If you wanted to breastfeed but could not, was that due to a medical issue that no amount of support could have alleviated? If so, what emotional support were you offered?

Question 4: If you formula feed, were you given good information about how to safely make up a bottle, skin-to-skin and paced / responsive feeding? As a healthcare professional do you have access to this information?

Question 5: Are all healthcare professionals now aware of and using First Steps Nutrition as their reference point for information about infant formula?

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A really interesting discussion ensued with lots of different experiences shared. The resulting action suggestions are as follows:

  • Far better infant feeding education antenatally – including what to expect, normal newborn behaviour, cluster feeding and safe & effective formula/bottle feeding. Explain that breastfeeding is a skill that mum and baby both have to learn and that it is difficult, but it does get easier. Emphasise the importance of asking for help and support.

  • If a family wants to breastfeed it is worth finding out whether anyone else in the family has done that before. Breastfeeding is much harder when those close to you do not understand it or are distrustful of it.

  • Don’t be so quick to discharge – observe a FULL feed before deciding that the baby is feeding effectively. Longer term consideration needs to be given to how long families can stay in hospital as quick discharge can mean mum is struggling by day 3.

  • Breastfeeding support needs to be 24/7 – one mum reported having a baby on the Wednesday and being unable to find NHS support when she hit “crisis point” at the weekend.

  • If part of your job is to support infant feeding, make it your mission to find out all of the places to which you can signpost families who are struggling. There is a lot of support and information out there but too often HCPs do not send families to it.

  • Be aware that birth professionals and other healthcare professionals often do not have sufficient training to deal with complex breastfeeding problems. As a parent, do not be afraid to question and ask for additional support. As an HCP, see above re signposting – know what is available in your area.

  • The NHS should provide information on non-NHS support options – International Board Certified Lactation Consultants (IBCLCs), breastfeeding counsellors and peer supporters, all the major voluntary organisations and doulas.

  • Full time, dedicated breastfeeding support midwives on every maternity ward, and support available after discharge. Relying on volunteer peer supporters is not a sustainable model. Unpaid peer supporters do an amazing job but to truly make a difference to infant feeding more paid staff are required.

  • Tongue tie to be checked for as part of the routine newborn checks. (Click here for more #MatExp discussion on this)

  • Be mindful of IV fluids used in labour when assessing the amount of weight a baby has lost. The initial birth weight may well have been inflated.

  • Where supplementary feeding is necessary, try to use a supplementary nursing system (SNS). They help to stimulate milk supply whilst giving the “top up” of formula or expressed milk.

  • Where a woman wants to breastfeed but has been unable to, please ensure she is given good quality, independent information on formula feeding AND emotional support around the fact that she was not able to meet her breastfeeding goals. A debrief with someone qualified in breastfeeding support would help to work through what happened and deal with some of those destructive (and unnecessary) feelings of guilt.

  • Empower, educate and support women so that they can make a genuine choice about how they want to use their body and how they want to feed their child. Once that genuine choice has been made, support that choice regardless of your personal viewpoint.

  • Do not be so quick to “blame” the dyad for breastfeeding difficulties. Look at potential underlying medical issues.

  • Normalise breastfeeding for the next generation by including it as part of the science/personal development curriculum

  • Support to feed babies at the breast needs to be moved far higher up the agenda for governments and healthcare commissioners alike

Remember this which Elizabeth Pantley shared on her Facebook page:

via http://www.pantley.com/elizabeth/ via http://www.pantley.com/elizabeth/%5B/caption%5D

We need to look after the “someones”. Understand their goals and fears, their preconceptions and their anxieties.

One of the mums on my private Facebook group gave a great summary the other day of how it’s all gone a bit wrong for infant feeding in the UK:

“Pressure from health professionals to feed but a lack of support to do so, meaning when mum comes across difficulties she just blames herself and feels she has to stop. (“I had no milk.”)

Decades of bottle feeding being promoted as “best” meaning our parents and grandparents don’t understand breastfeeding, and encourage formula feeding instead. (“Just put him on a bottle, it never did you any harm.”)

A formula feeding society making it seem that babies should be sleeping through the night and “in a routine” undermining the confidence of breastfeeding mums. (“Tom has been sleeping through from 2 weeks!”)

No counselling or debriefing for mums who felt they had to stop breastfeeding before they were ready.

The formula companies and their advertising promoting “mommy wars.”

A refusal to talk about bottle feeding openly and frankly by health professionals due to fear of causing offence.

The high price of formula making mums feel punished for bottle feeding.

We’re getting it all so, so wrong as a society and segregating parents when we should be uniting them. How you feed your baby shouldn’t even be an issue – the issue should be whether or not you are supported.”

Lucy, Dorset

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So what would I recommend as a bit of infant feeding bedtime reading? There are so many fantastic resources, but based on the actions above and recent discussions this is my current pick of the pops:

  1. The “Second Night Concept” – why does it seem as though everything has “gone wrong” on night 2? 

  2. What is normal behaviour for a newborn baby anyway?

  3. If breastfeeding is so “natural” why is it so hard

  4. Who are all these different people who are qualified to support breastfeeding? 

  5. The hurt that is caused by the media constructed “mommy wars” 

  6. Why what I do with my breasts is none of your business 

  7. Are we really under pressure

  8. The part that the formula companies have to play 

  9. Are we being unfair to formula feeding mums?  

  10. Supporting women to breastfeed when they need medications 

 

There is also of course my own #hospitalbreastfeeding campaign which focuses on the support available for breastfeeding families on children’s wards and in children’s hospitals. There is another selection of fantastic links under the Guidance section on my website http://www.heartmummy.co.uk and for more discussion on this particular area please see https://heartmummy1980.wordpress.com/2015/05/10/when-hospitalbreastfeeding-met-wenurses-2/

Finally, if you are still suffering from insomnia, there is my own feeding story which covers formula feeding, combi feeding and natural term breastfeeding – I’ve tried to sample a bit of everything with my boys! 

I saw Mark Harris speak at the Association of Breastfeeding Mothers conference last month and he said something many will have heard him say before: “evidence is not the same as truth”. This has particular resonance for me when it comes to infant feeding. The evidence is about statistics, nationwide trends, health outcomes across generations and demographics. Truth is about what you can see with your own eyes and understand about your own family. There is no need to question or reject the evidence to protect your own truth. The evidence says quite clearly that my eldest son has a higher likelihood of poor health outcomes in later life because he was formula fed from 10 weeks old. The truth is that if I had tried to continue breastfeeding he had a 100% likelihood of being shouted at and rejected by his mother.

We all have our own truths. Finding someone with the same truth as you is so empowering but it is important to recognise that other people’s experiences are no less valid than yours. The evidence is important for parents making informed choices, and for commissioners when deciding on what priority to give infant feeding. The truth of your own circumstances and experiences is important for deciding what is best for you, and only you and your family know what that is.

The important thing is not what choices we make. The important thing is that we are supported so that we can make those choices. And at the moment far too many families are having their choice to breastfeed taken away. This has to change.

Reap benefits

Helen Calvert

@heartmummy

2015

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