Helen Calvert

Time to Act on Infant Feeding

12 July 2015 by Helen Calvert / #MatExp Actions, Feeding, Informed Choice, Postnatal Care / 4 Comments

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?

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/%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

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:

The “Second Night Concept” – why does it seem as though everything has “gone wrong” on night 2?
What is normal behaviour for a newborn baby anyway?
If breastfeeding is so “natural” why is it so hard?
Who are all these different people who are qualified to support breastfeeding?
The hurt that is caused by the media constructed “mommy wars”
Why what I do with my breasts is none of your business
Are we really under pressure?
The part that the formula companies have to play
Are we being unfair to formula feeding mums?
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.

Helen Calvert

@heartmummy

2015

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Time to Act on Breastfeeding and Medications

10 July 2015 by Helen Calvert / #MatExp Actions, Feeding, Informed Choice, Postnatal Care / 1 Comment

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.

I have great pleasure in sharing with you a guest blog from Infant Feeding Coordinator Luisa Lyons, a midwife and IBCLC at Norfolk and Norwich University Hospital. Luisa led a discussion on the Facebook group about breastfeeding and medications, and this is here write up of that topic. Take it away Luisa!

Can you breastfeed after having a tattoo? Can you breastfeed if you are on Prozac? Can you breastfeed if you take antihistamines?

As part of #FlamingJune, the #MatExp group discussed the topic of breastfeeding and medication. An interesting discussion took place and some actions were generated to help move forwards on this important topic to improve maternity experiences.

Breastfeeding mothers are frequently misinformed by health professionals with regard to what they can and cannot take, and at what dose whilst breastfeeding. Many mothers are told to stop breastfeeding unnecessarily, to “pump and dump” when not necessary or denied medications that could benefit them.

Contributors to the discussion described being denied medications for mental health conditions, or being prescribed medications later found to be harmful, being told to stop breastfeeding in order to be able to take anti-depressants or other medications to treat mental health issues.

The hurt and frustration women feel at discovering the advice was wrong is considerable and stays with them.

The increased risks to mothers from not taking medication which is indicated, and the risks of not breastfeeding to maternal and infant health mean that everyone involved in supporting new mothers needs to be aware of breastfeeding and medication.

Themes that were raised were assumptions that babies do not “need breastmilk” over six months and therefore stopping breastfeeding in order to take medication was then indicated. We know this is incorrect and that as long as a mother and baby dyad continue to breastfeed, the longer the beneficial health effects last, in a dose response manner. The World Health Organisation recommends breastfeeding exclusively for the first 6 months and then continuing up to 2 years of age and beyond.

Another theme was women with chronic pain conditions finding difficulty in accessing accurate information. In addition there were reported inaccuracies about dental extractions/sedation. Another breastfeeding mother got in touch to say she had suffered from hayfever for months before discovering she could have been taking the antihistamine Loratidine with no concerns.

NICE guideline Maternal and Child Nutrition (NICE, 2008) describes the standard of care that should be implemented with regard to prescribing for breastfeeding mothers. In standard 15 it states:

Ensure health professionals and pharmacists who prescribe or dispense drugs to a breastfeeding mother consult supplementary sources (for example, the Drugs and Lactation Database [LactMed] or seek guidance from the UK Drugs in Lactation Advisory Service.
Health professionals should discuss the benefits and risks associated with the prescribed medication and encourage the mother to continue breastfeeding, if reasonable to do so. In most cases, it should be possible to identify a suitable medication which is safe to take during breastfeeding by analysing pharmokinetic and study data. Appendix 5 of the ‘British national formulary’ should only be used as a guide as it does not contain quantitative data on which to base individual decisions.
Health professionals should recognise that there may be adverse health consequences for both mother and baby if the mother does not breastfeed. They should also recognise that it may not be easy for the mother to stop breastfeeding abruptly – and that it is difficult to reverse.

Dr Wendy Jones, pharmacist and breastfeeding tutor with the Breastfeeding Network and Independent Prescriber, has been instrumental in raising awareness of the issue in the UK and supporting thousands of women to breastfeed whilst on medication. She has so far written many factsheets on breastfeeding whilst taking medications. They can be found here https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/drugs-factsheets/

So how can we ACT to improve experiences for mothers and babies?

Communicate to our colleagues and friends to signpost them to correct advice (see links above)
Publicise the Breastfeeding Network (BfN) Drugs in breastmilk helpline- 0844 412 4665
See https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/
Email queries to [email protected]
Feedback and if necessary make formal complaints about misinformation to the Trust via the complaints department PALS, a useful website is https://www.patientopinion.org.uk/ to give online feedback which is publicly visible
If you are an HCP, encourage your unit to “Save the Drugs in Breastmilk Helpline” by subscribing to the information service. Become a “friend” of the Drugs In Breastmilk Helpline and make a donation to help support and sustain this important service. Individual membership is £25 or organisations are £150. For this they receive hard copies of the DIBM factsheets and an electronic newsletter
Signpost clinicians to http://www.ukmi.nhs.uk/activities/specialistServices/default.asp?pageRef=2
Encourage prescribers in general practice, dentistry, obstetrics and paediatrics to be aware of the LactMed services listed above. A small but effective action is for all prescribers in these fields is to use the free LactMed app . This has been well received by many doctors in my hospital who find it useful for out of hours information at the touch of a button.

Empower women to question advice where they are told to stop breastfeeding in order to take a medication
Encourage evidence based information use to enable mothers to make informed decisions of risks and benefits where the evidence is not forthcoming on a particular drug
Devise e-learning packages for staff to learn more about infant feeding and include medications and breastfeeding in this training
Maternity units to forge closer links with public health departments to encourage joined up working
Make a poster for antenatal clinics asking women who are pregnant and on medications if they would like more information on their medications and future breastfeeding
Make the safety of Drugs in Breastmilk a less scary topic for HCP’s so that support can come upstream from the firefighting that Dr Wendy Jones and her colleagues have to do when mothers receive incorrect advice. The current system of women self-seeking information, largely online, means that less literate women are at a disadvantage

Luisa with Janette Westman who inspired her to get involved with infant feeding when they worked together in Bradford. — Luisa with Janette Westman, who inspired her to get involved with infant feeding when they worked together in Bradford.

Luisa Lyons
Infant Feeding Co-ordinator
Midwife and Lactation Consultant (IBCLC)
Maternity Services, West Block Level 3, Norfolk and Norwich University Hospital

2015.

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Time to Act for Dads & Partners

20 June 2015 by Helen Calvert / #MatExp Actions, Postnatal Care / 1 Comment

A topic that I brought up in the early days of the group was Dads & Partners. How can we support them? How can they support us? How can they be involved in maternity experience? What do they struggle with?

From the group discussion, and discussions I have had elsewhere, there are three key themes when it comes to Dads & Partners:

Including them in the maternity experience
Allowing them to stay with their new family
Supporting them with their own mental health & the mental health of their loved ones

It Takes Two

Including Dads & Partners in the maternity experience is helpful for all concerned. It helps them to understand what is going to happen to the woman in their life, to prepare themselves for the different scenarios of birth and the postnatal period. It empowers them to help the mother and brings them together as a unit, which is of huge benefit to the baby. Informing and supporting Dads & Partners is a gift to a new family – Mark Harris of Birthing for Blokes explained at the ABM Conference last week that a well informed and prepared partner is a consistent presence for the mother, helping her every day where healthcare professionals might only be available briefly and inconsistently.

Mark also explained how men are generally “goal orientated” creatures who like to understand their role and the expectations that go with it. Giving a man clear guidance as to how he can support the new mother in his life can be so helpful to the whole family. From a breastfeeding perspective, for example, there are so many things that a Dad or Partner can do to truly support a breastfeeding mother, as a great blog by The Milk Meg explains.

ACTION: healthcare professionals, please make sure that you find out who mum’s “cheerleaders” are going to be in pregnancy and in motherhood. This might not be a father or a partner, it could be a grandparent or a friend, but whoever it is needs to be informed and empowered for their own benefit and the benefit of the mother & baby they care about.

ACTION: parents and families, be sure to speak up if you feel that not every member of the family team is being adequately supported on your maternity journey.

Stay With Me

Allowing Dads and Partners to stay with their new family in hospital once the baby is born is something that I see suggested over and over again as a key issue for parents. NICU nurse Louise has written this blog post on the subject and I used it as an opener to the thread on the #MatExp group. This comment from a group member demonstrated the way that dads can feel uninvolved:

“My husband really struggled after our first son was born. He felt ignored, pushed aside and unimportant whilst I was in labour, no one would tell him anything when I was being prepped in theatre and half an hour after my son was born he was thrown out, not allowed to walk me to the ward or have any time with us. It was better on the ward, they were more relaxed but obviously he still had to leave. When I got pregnant again it became obvious he has some major birth trauma to work through as well” (#MatExp Facebook group member)

When talking about partners being asked to leave once the baby was born, group members described this as “shocking”, “barbaric”, “being torn away from your support system” and overwhelming feelings of loneliness and being alone when “confused, dizzy, bleeding, trying to read breastfeeding leaflets and change meconium-filled nappies in the dark.” The discussion was an emotional one, with many women feeling outrage that one half of their family and parenting team was ousted from the crucial first hours of the family and parenting experience.

I asked Mark Williams of Fathers Reaching Out for his thoughts on this:

“In my own experience it would have been easier for my wife after a twenty hour labour and an emergency C-Section for me to help her with my son. My wife hadn’t slept and was totally exhausted and coming down off medication so needed support, which I would have been able to give her.”

From my own personal perspective, choosing a homebirth with my first baby was due in large part to my utter terror at the idea of being left alone in hospital with a new baby without the one person who understands me, understands my anxieties, cares about my wellbeing and knows how to support me. This is Phil with Edward the morning after our son was born. Overnight he had helped me to feed him, changed his nappy, settled him and by the morning we both knew as much about our new son as each other. Why should any father be denied that?

ACTION: the goal of keeping families together to be at the forefront of maternity unit design.

ACTION: if your maternity unit does ask Dads & Partners to leave, please ensure that marketing reps are not allowed onto the unit at times when family members are not. This is grossly unjust.

Overlooked

Just as women can be traumatised by the birth experience, suffer postnatally with depression and anxiety and feel overwhelmed by the responsibilities of parenthood, so can Dads & Partners. Yet it was discussed on the group that men often don’t feel “allowed” to be traumatised or to be struggling. There are connections here to other themes, as feeling disempowered at the birth can lead to problems later on for the partner.

Mark Williams campaigns for recognition of the needs of Dads & Partners when it comes to perinatal mental health. This post on Stigma Fighters explains some of his journey. This Fathers’ Day Mark is launching Dads Matter UK and is asking for the health service to “develop a process for the screening and detecting of PND in fathers.” To read more about this campaign please have a look at this item from the Huffington Post.

Mark described to me what his own experiences have taught him about the needs of Dads & Partners:

“I feel dads need to know what is going on in order to help deal with their own anxiety – help from doulas could be a way forward. If you have a well dad or partner, you have a better chance the mother will be supported by them. Many fathers or partners I talk to just feel useless when dealing with the mother’s mental health, and sometimes that feeling of helplessness has an impact on them. Many dads isolate their true feelings so as not to upset the mother, or make matters worse. They only want the mother of their child to be well and gain a full recovery.”

ACTION: Follow @MarkWilliamsROW on Twitter and find out how you can join his campaigns.

ACTION: Recognise that Dads & Partners can suffer from perinatal mental illnesses too.

With best wishes to all the Dads & Partners out there, and to all those who are supporting mothers and caring for new babies.

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Time to Act for Midwives

14 June 2015 by Helen Calvert / #MatExp Actions, Environment and Facilities, Maternity Review / Comments Off

One of the subjects we started to tackle early on was Birth Trauma. This was an insightful discussion about parental experiences, but it was mentioned that midwives can also be traumatised by their experiences of birth. We started a thread specifically to discuss this issue and for me it got to the heart of some of the problems facing maternity care today.

I was at a user group at Salford University in May where a group of parents discussed the midwifery curriculum with some of the lecturers. We talked about all of the things that parents want – compassionate care, informed consent, skin to skin, optimal cord clamping, breastfeeding support – the usual topics. One of the lecturers commented that they had been teaching all of these things for years, why were the same complaints and comments still coming back from parents?

I really feel that midwives’ experiences and the way that these are dealt with is one of the answers.

A comment that particularly resonated with the group was from a third year student midwife and I would like to share it here in full:

“I agree, that the trauma for me is cumulative. Often a singular ‘traumatic birth’ is easier to process as the necessity for intervention is usually clearer, staff involvement/support is higher and women/families are offered enhanced care/debrief/support. It is the ‘routine’, less critical ‘procedures’ that affect me over time. The ‘heroic’ ARM, the VEs by doctors with inadequate consent, instrumental deliveries without compassion or the ignoring of important birth wishes (OCC for example). It calls into question your very notions of love, kindness and compassion. It hurts personally to see these violations of women, often by doctors. Usually it is not the ‘act’ itself but instead the loss of autonomy and consent that causes me so much pain. I also have noticed, how frequently these things are not noticed by women, because they don’t know it could be any different. And I feel that in that alone ‘we’, the system, have let her down. It took me a very long time to establish why I found the delivery suite so challenging. Now I understand that witnessing, sometimes being part of, repeated human rights violations is of course going to be distressing. It would be to anyone. The fact that this job is integral to my sense of self, identity, world view and beliefs makes the impact even greater. But I do think that without adequate support birthworkers (midwives, doctors, doulas, etc) may become detached or choose to leave the hospital setting to protect themselves. This has been my biggest challenge throughout my training and I know will continue to be as a NQM. I believe all birthworkers need nourishing support to continue to provide compassionate care. I have received this from a community of feminist birthworkers spread across the country but whose shared values inspire, support and encourage me. Having space held for me as a student midwife by fellow birthworkers has taught me more about how to provide loving care than almost anything else.”

A retired midwife commented “I’m old hand in some respects and you basically brushed yourself down and moved forward. The difficulty occurs I think in the future as over time as you find that the coping mechanisms aren’t working as well and you exist with a high level of adrenaline running around your body; it becomes more and more challenging to cope.”

Birth workers discussed crying in the toilets whilst at work, fire-fighting from one emergency situation to another, feeling vulnerable, angry and frustrated. Cutting costs and box ticking were mentioned and a lack of compassion amongst the management system, with policies slowly eroding midwives’ scope of practice.

“As a student, I have found morale amongst midwives one of the hardest things to deal with. The majority dislike their jobs for many reasons (too many to list but management and politics play a huge part) and are unresponsive to students enthusiasm. I have even been told by mentors that they don’t like having student? This obviously has an impact on learning and emotions. When experiencing birth trauma with a midwife that shows no emotion, even after the event, it is hard for a student to deal with and can have a huge impact on students emotional/mental well being. That being said, there are some fantastic mentors. However, students leaving training due to lack of support is unacceptable.”

Immediate, short term actions:

Find out if your Trust has guidelines about supporting families AND staff after difficult births
If anyone has good guidelines from their Trust that they are able to share please let us know
Midwives at all levels to reassure one another that it is acceptable to have difficulties coping with some of the births that they witness, and to talk about coping strategies that they have found helpful.
Mindfulness classes to be offered to staff
Read The Roar Behind The Silence (and encourage colleagues and managers to read it) – many of these issues are discussed in the book and action points suggested
Use Random Acts of Kindness and Paying It Forward in your workplace to support colleagues

Long term actions:

Consideration to be given to what will replace supervision of midwives if it is to be dismantled, in terms of who midwives are going to go to for support
Explore the model of Restorative Supervision
“We need a powerhouse of strong and courageous managers, midwives and students who are able to steer midwifery towards kinder more humane care keeping in mind our goal for physically safe and emotionally satisfying outcomes for women.” (midwifery student)

“The emotional investment of midwifery takes its toll”

Time to Act on Anxiety

4 June 2015 by Helen Calvert / #MatExp Actions, Baby Loss, Birth Trauma / 1 Comment

There have been some fantastic conversations taking place on the MatExp Facebook group, with a new ACTION thread every day 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 first topics we looked at was Anxiety, as it had been one of the first issues raised on the MatExp ABC.

“Anxiety” covers a number of areas when we look at maternity experience. Mothers can have existing problems with anxiety, that have already been identified. They could have had anxiety for some time but the experience of having a baby has intensified it (my experience). It could be that they begin to suffer with anxiety postnatally – Emma Jane Sasaru has written here of her experience of perinatal anxiety. Or perhaps their anxiety is focused on giving birth – many mothers are incredibly anxious about what the end of pregnancy has in store for them. Finally, there will be mothers who have experienced birth trauma or baby loss and this can understandably provide a background for anxiety in subsequent pregnancies.

Anxiety UK says of anxiety that it is “something that can persist whether or not the cause is clear to the sufferer”. The organisation lists the symptoms as

Anxiety UK Registered Charity Number (1113403) Established 1970

Certainly, on a personal note, “feeling detached from your environment and the people in it” goes some way to explaining why it took me such a long time to properly “fall in love” with my babies. There was no “rush of love” for me when I gave birth and first held my children, despite my having positive birth experiences both times. “Feeling like wanting to run away / escape from the situation” – many new mums feel like this at times when coping with a newborn baby but it is important to recognise when feeling like this “now and again” has accumulated into something more problematic.

So how can we ACT when anxiety is a factor in maternity experience? Let us first look at how women can help themselves:

Practice HYPNOBIRTHING – a number of people involved in the #MatExp campaign suggested this as a great way to alleviate anxiety in pregnancy and anxiety about birth itself. Pregnancy Coach Suzy Ashworth explains here what hypnobirthing is all about, and how it’s beneficial for all women regardless of the way they plan to give birth.
BE HONEST and try to explain your anxieties to your healthcare professionals. Find out as much as you can about anxiety and ways to manage it.
GET HELP.

Now these actions all assume that the woman in question is aware that she is struggling with anxiety. But this is certainly not always the case. This is where the birth professionals come in. How can they act when anxiety is a factor?

Understand how anxiety can manifest itself. If a women is finding it difficult to talk about something, if she is quiet and refusing to engage with a situation, if she practices avoidance by walking out on a conversation then think “anxiety”.
Give women the opportunity to talk openly about their fears, and really LISTEN.
Offering reassurance can be helpful but it can also be dismissive – being told “don’t worry, that won’t happen” can heighten a woman’s anxiety as she will feel as though her fears are not being taken seriously. Always remember that those fears are REAL to her, however bizarre they may seem to you

What services are available to women in your area who are struggling with anxiety? Are the following available (and do you know how to access them?) or do they need to be put in place?

Hypnobirthing, mindfulness and meditation classes
Cognitive Behavioural Therapy (CBT)
Specialist mental health midwifery teams
Training for midwives and health visitors on recognising anxiety

Where services are available, there are simple ways in which women’s access to them could be improved:

Please check on the mental health of the women you care for throughout their pregnancy and postnatal period, not just at their booking in appointment.
If you offer anxiety support, please make it possible for women to enquire about these services by email, not just by phone. Phone conversations are very difficult for many anxious people, and services only being accessible by initial phone assessment put up a real barrier.

When we look specifically at prenatal anxiety, there are changes to our birth culture that could make a big difference:

Empower women to trust their bodies. Too many women fear that they will not be able to give birth safely – how can we help them to understand how their body works and reacts in labour, and how it can be supported and encouraged to do its job?
Ensure that women understand that they have the control to make their own birth choices. Feeling as though they have no control is a huge factor for anxious people, but encouraging informed choice and putting women at the centre of their birth experience can help to alleviate this.

As with almost every discussion of maternity experience, continuity of care becomes an issue. Where women know their birth professionals and have built up a relationship with them, anxieties are reduced. Whilst continuity of carer is offered in places on the NHS this is far from the norm at this moment in time. If you struggle with anxiety then there are care options available to you to ensure that you have continuity in pregnancy and beyond:

Use an independent midwife. There is a cost involved in engaging the services of these professionals, but it is always worth speaking to them before dismissing the idea on the basis of cost, as there may be ways that the cost can be reduced.
Use a OnetoOne midwife. This is a “free at the point of delivery” service, but unfortunately it is only available in some areas. Find out if they are commissioned near you.
Use a doula. Doulas support women and their families during pregnancy, childbirth and early parenthood. This support is practical and emotional but non-medical in nature. Again, there is a cost involved, but there are ways that this can be reduced so it is worth contacting your nearest doulas to discuss the options open to you.

Lindsey Middlemiss (aka “Newbury Doula”) is having lots of discussions at the moment about the wider provision of doula support for women with high anxiety of at high risk of PND, including women who have experienced baby loss or who have had birth trauma. There is a possibility of some NHS funded pilots and research studies in the future, and the Doula UK Access Fund will likely be changing and expanding its criteria. We eagerly await developments in this regard.

#MatExp “Language” Champion Leigh Kendall has written extensively about support for bereaved parents and I know she will be suggesting further actions during #FlamingJune. Therefore I don’t want to focus too much here on anxiety in those who have experienced loss, but one thing did come out loud and clear from the discussions we had on Facebook:

There is currently no standard care pathway for those who are pregnant following the loss of their baby. They might be labelled “high risk” depending on whether baby loss was a result of pregnancy complications, but their emotional needs are not automatically met.

This is staggering to me.

This has to change.

On a positive note, one member of our community is aware of midwives at her local hospital looking into setting up Rainbow Antenatal Clinics specifically for those who are pregnant following loss. Is this something that you could look into at your hospital? Is this something you already offer?

Another positive that I would like to finish on is the new provision of antenatal appointments from our health visiting teams. Vanessa (aka Frustrated HV) had this to say on the subject, with specific reference to pregnancy following loss:

“I really do hope that the antenatal visiting programme being undertaken by health visitors & the increased communication between midwives & health visitors & GPs will mean that fewer women experience this neglect… Because it has to! A known history of loss in or around pregnancy should now automatically trigger (through midwife reporting) a Universal Plus antenatal health visiting service. Which would mean that you would have support throughout the pregnancy (as well as after) & signposting/referral to more specialist services if needed. No one should still be experiencing this type of trauma. You are correct that lots still needs to be done, but lines of communication are being created & general awareness is improving & I know that with the continued efforts of all the people I have seen in #MatExp & through all the conversations & wisdom shown, we will change things for the better.”

Join the conversation. #MatExp #FlamingJune

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#MatExp – Lights, Camera, Action!

2 June 2015 by Helen Calvert / #MatExp Actions, The #MatExp Journey / Comments Off

It was on 12^th May that Leigh Kendall and Helen Calvert thought about starting a Facebook group for the #MatExp campaign. JFDI and all that, the group was started two days later. Three weeks in and we’re at 450 members. You’ve got to love this campaign, nothing happens slowly!

The group is administrated by Emma Jane Sasaru, Helen Calvert, Leigh Kendall and Susanne Remic, and is the Facebook outlet for a campaign that has already gained huge momentum on Twitter. Florence Wilcock, the obstetrician at Kingston Hospital who started the campaign, has always wanted it to be focused on ACTION and this theme is central to the group. Each day a member of the admin team starts a thread on a chosen topic with questions/talking points and a request for actions that families and birth professionals can take to improve maternity experience in this area. We ask that actions are S.M.A.R.T.

Florence and Gill Phillips have a Month of Action planned for June, so we had originally hoped to do a blog post at the start of June detailing the actions put forward so far by the Facebook group and asking that people get involved. The snag is there have been so many fabulous actions put forward already on a number of important topics. The topics are being chosen in alphabetical order as a nod towards the #MatExp ABC that provided so much impetus on Twitter, and we are so far only on “H” – already the actions are numerous and thought provoking.

So we have quickly realised that it might be better for each of the admin team members to do individual blog posts on the topics that they have introduced to the group. These posts will start to come through soon, but for now we still wanted to give you a flavour of the suggestions and we hope that you will join us on Facebook or Twitter (or both) to get involved.

ACTION!

The actions that have been suggested on each of the threads can be divided into two categories:

Immediate – just get up and do it actions that anybody can take, here and now. These tend to be small things but they can still have an impact.
Long-term – group actions that require input and buy-in from different places and will probably require campaigns of their own.

Both are very important to the campaign. There are big issues that need to be addressed in maternity care and the NHS Maternity Review is looking at these right now. We are hoping to work with the review panel and to share our ideas with them. But we also need to remember that simple acts of kindness can change the experience of anyone with whom we come into contact. Sharing a piece of information could send someone down a different path. Signposting to a service could make the difference for that individual. No one needs to sit back and wait for a bandwagon to jump on. We can all of us get up and act today.

So what has been suggested so far? Here is a snapshot of some of the topics we have discussed:

A is for Anxiety

Immediate actions –

Anxious mums to use hypnotherapy techniques in pregnancy
Be honest about your anxieties and find out as much as you can on how to manage them
Midwives please ask mums about their mental health throughout their pregnancy, not just on booking in; anxious mums to look into mindfulness techniques

Long-term actions –

All health visitors need training in identifying and supporting pre and postnatal anxiety
Subsidised doula provision for anxious families
Continuity of care for anxious families
Refer anxiety sufferers to specialist mental health support

B is for Bereavement

Immediate actions –

The most important immediate action can be done by anyone, anywhere, anytime – acknowledge the baby the parents have lost. If you know the baby’s name, use it. If you don’t know the baby’s name, ask. Take the parents’ lead on whether or not they want to talk about their loss. Try not to worry about saying the ‘wrong’ thing. The worst thing you can do is to skirt around the subject, or ignore it completely. To do so insulting and upsetting to bereaved parents.

Long-term actions –

Clear, concise, sensible, and up-to-date information to be provided to bereaved parents when they leave the hospital after the death of their baby. Parents need reassurance about the emotions they are likely to feel, and a few pointers about how to navigate grief, especially during the raw early weeks. The information also needs to clearly state how the parents can access appropriate support as and when they are ready.
Access to counselling support. Too many bereaved parents have had to fight for the counselling and psychological support they need – or have gone without. Some hospitals do offer counselling services: hospitals need to make clear to parents that this is available, and how to access it. Funding issues mean that not every area is able to provide these services, but charities thankfully do exist to fill the gap. Hospital and GP practice staff need to know what support is available locally so they can signpost parents appropriately, or where appropriate make referrals for them. Leaving bereaved parents to source their own support at a time when they are least able to have the tenacity to deal with ‘the system’ is unacceptable.
Training in bereavement care for health professionals. Surprisingly, many don’t receive this as standard practice. The vast majority of health professionals are caring individuals, but a lack of appropriate training means many are unsure about how best to deal with bereavement, which may lead them to saying things that are less than helpful to parents. What is said to parents at this sad time stays with them forever, so the importance of this training cannot be underestimated. This training should be extended to all staff involved with maternity/NNUs (including admin, housekeeping et al) to help prevent unnecessary upsets.
Debrief/support to care for the needs of maternity, obstetric and NNU staff after the death of a baby. These staff are deeply affected by the loss of a baby in their care.

B is for Birth Trauma (families)

Immediate actions –

Use of language when discussing birth trauma with families- lots of women have felt their feelings were dismissed, or that they were being ‘silly’. Women also felt that they had failed. Language in notes also very important.
Immediate debrief after a traumatic birth; women felt that they were discharged and sent home without having the chance to talk through events.
Communication- tell women and their families what is happening and why.

Long-term actions –

Birth trauma support groups for women to access after a traumatic birth.
Birth reflections and birth trauma counsellors to be accessed for as long as women and their families need them. Trained counsellors to support, and health visitors to be able to signpost the necessary services too.
Better recognition of PTSD following birth trauma and better support for dads too.
Emotional support for women in subsequent pregnancies.
Ensure that women know how to access appropriate services following birth trauma.

B is for Birth Trauma (midwives)

Immediate actions –

Make sure your colleagues know that they don’t have to “cope” – it’s okay to admit that they have been traumatised by a particular birth experience
Ask if your Trust has guidelines in place for supporting staff after a difficult birth.

Long-term actions –

Stringent debrief sessions put in place for each instrumental birth and any birth that is not straightforward
Tackle trauma that accumulates from seeing the same things again and again – e.g. vaginal exams with inadequate consent, instrumental deliveries without compassion, loss of autonomy and consent.

C is for C-sections

Immediate actions –

Skin to skin in theatre.
Ensure that women are supported in their decision to have a c-section and help them to write a birth plan to feel empowered during surgery. Discussion of gentle c-section options.
Help women to find comfortable positions to breastfeed.

Long-term actions –

Identify reasons for c-sections and look to see where these can be reduced.
Educate women during subsequent pregnancies, ensuring that up to date information is given with regards to VBAC. Ensure access to VBAC clinic is given.
Better patient leaflets with more information on what happens during surgery and what recovery is like.
Debrief from surgeon on how the c-section went and how subsequent pregnancies are likely to be affected.
Better support for women after an emergency c-section.
Provide emotional support and/ or counselling after a c-section for women who require it.

C is for Complications

Immediate actions –

Communication was a common theme in the responses in this thread. Women – especially those who experienced complications around the time of the birth of their baby – wanted professionals to explain what was happening. Not knowing what was happening, and why, added to these women’s anxiety. Women (and their birth partners) need to be told as much as is appropriate at the time what is happening and why, in simple language.
Health professionals need to remember that consent is still vital!
Explain everything – as a health professional, certain things that you consider routine may be daunting or scary to a woman in your care. Make sure you explain everything that is happening, and be patient if they need the information to be repeated – it can often be difficult to take things in when you are in a crisis situation.

Long-term actions –

Information: there is a lot of difference in the quality and content of information pregnant women receive from hospitals and community midwives. It can create confusion, especially combined with the wealth of information available from charities and the internet. While the internet can’t be controlled of course, it would make sense for hospitals nationwide to have consistent leaflets from a central source, with the ability to personalise information as appropriate.
Connected to this point, knowing how much information to tell women about complications is difficult. We want them to know enough so they can recognise symptoms if they appear, but not so much they are stressed and scared. The balance is hard to strike. To compound this, there are women who do not attend antenatal appointments so are unable to receive this information.
For A&E staff to be better aware of pregnancy complications, and to consult maternity/obstetrics staff when needed.
For women to be proactively contacted when pathology (blood/urine etc) tests come back with warning signs, rather than relying on the woman to remember to phone for results.

C is for Continuity of Care

Immediate actions –

Managers to talk to the independent midwives and social enterprise midwives who are knowledgeable in how case-loading can work
Look at the Streatham Valley midwifery team in London for a working model
If a woman is not receiving continuity of care, please ensure as a birth professional that you read her notes thoroughly and write good notes for the next person she sees.

Long-term actions –

We need strong leaders at the helm of Trusts who understand how to lead midwives towards the implementation of continuity of care
Join up with the RCM Better Births Campaign
We need more midwives
Look into personalised budgets where the NHS would allocate women funding to choose the service they want.

D is for Dads (and Partners)

Immediate actions –

Birth professionals please keep Dads and Partners informed during the birth
If Dads and Partners are not allowed on the ward at specific times please ensure the Bounty rep is not allowed on either
Recognise that Dads can suffer birth trauma too.

Long-term actions –

Keep families together, find ways to allow Dads and Partners to stay in hospital
More paternal leave for fathers of premature babies – 2 weeks at birth and 2 weeks at discharge (the same for sick term babies too).

E is for Emotional Wellbeing

Immediate actions –

Kindness, dignity and compassionate patient-centred care.
Accurate information to support informed choice for families.
Support for traumatic births, families that have a baby on NICU and paediatric wards.
Good communication between staff, wards and with parents.
Include partners and realise they need support too.

Long-term actions –

More support services including peer support groups.
Healthcare professionals aware of support services and therapies to signpost families to.
Antenatal education to help parents prepare for parenthood and the impact birth has emotionally.
Training for midwives and health visitors on all mental health disorders and how to spot/support.
Specialist perinatal counselling available nationally.
Continuation of care for families especially if previous trauma or mental health disorders.
Peer support on NICU units to provide emotional support reduce risks of PTSD.

And before we started the ABC we already had a hot topic that grabbed our participants’ interest:

Tongue Tie

Long-term actions –

Tongue tie assessment needs to feature in doctor and health visitor training
Better postnatal care – need skilled assessment of baby, mother and feeding rather than families being sent home ASAP
Tongue tie assessment to become a part of the newborn checks.

What would you add? What will you do? What have you already done? Come and join the conversation – and join in the ACTION! #MatExp #FlamingJune

Emma, Helen, Leigh & Susanne on behalf of #MatExp.

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#MatExp Survey – The Results Are In!

29 May 2015 by Helen Calvert / The #MatExp Journey / Comments Off

As you will have seen, I have been sharing maternity experiences on this blog from women I know. Some good, some bad, some unacceptable. But all anonymous. And it occurred to me that this was somewhat unfair on the birth professionals working to support pregnant women, many of whom I have become friends with on Twitter. So I thought it would be good to be able to share the other side of the story, the thoughts and views of the birth professionals, who have also been afforded the luxury of anonymity. Thus the #MatExp survey was born!

As with everything I do, I JFDI it one evening (thank you for that phrase Florence Wilcock!) and popped it up on Twitter. To my great delight, I have had 150 responses from midwives, student midwives, independent midwives, doulas, obstetricians, anaesthetists, antenatal teachers and other birth professionals. Thank you to everyone who has taken part, your input is much appreciated.

This is the split of respondents:

We also had responses from a neonatal registrar, a perinatal psychiatrist, three midwifery lecturers / educators, a research midwife, two hypnobirthing instructors, an anaesthetist and three antenatal teachers. Many are new to their profession, many have been supporting women for one, two or three decades, and one respondent has been a birth professional for 43 years.

The first thing I wanted to know was “What is the best thing about your job?” The vast majority of respondents talked about the women they work with and being able to support them as being the best part of their role. One student midwife caught the general mood with the comment “Supporting women and being there for them no matter what.” Responses included:

“Witnessing the women I support find their strength and power. Witnessing the love between the couple and the birth of a new little family.” (Doula)

“Being a part of a woman and family’s journey into parenthood.” (Independent Midwife)

“Being part of the transformation of woman to mother” (NHS Midwife)

“Supporting and empowering women, whatever the outcome of their pregnancy” (Obstetrician)

“Making a difference to women. To be present & witness to most beautiful time in life” (Student Midwife)

“Seeing women empowered and birth partners knowing their role and both having calm births” (Hypnobirthing Instructor)

“Privileged to be part of the miracle” (Obstetrician)

Unsurprisingly, the independent midwives found that being able to offer continuity of care and build a relationship with the women they support to be one of the best parts of their job. Many of the obstetricians felt that the best part of their role was “averting danger”, “saving lives”, “helping women to have as healthy a pregnancy and birth as possible”, but also “working with women caring for them at such a life changing moment in their lives” and “being able to reduce anxiety with appropriate explanation”. A fair few of the doulas talked about “witnessing the women I support find their strength and power” and “empowering women”. One explained that the best part of her job is voluntary work “with vulnerable women – asylum seekers, poverty, isolation – who may not otherwise feel worthy of advocacy”.

The word “support” comes up a lot in the responses of NHS midwives, and wonderful comments such as “Making a special time, simply awesome!!!”, “Having the honour and privilege of being a part of a very special time in people’s lives” and “working with the women through an amazing experience”. The student midwives made similar comments, but I particularly liked these two responses:

“The list is endless, but one that currently stands out is being able to turn it around when a woman is panicking in labour and giving them confidence in their own body to give birth! Saying a few words of reassurance and visibly seeing the change is incredible.”

“Supporting women on their journey whatever their circumstances or choices and feeling a sense of fullfillment when you know you’ve made a difference to someone’s pregnancy/birth.”

So from these inspiring comments from people who clearly adore their jobs, we move on to the question “What is the biggest challenge currently facing your profession?” Overwhelmingly the response was NOT ENOUGH MIDWIVES! My recent blog post explores the experience from a woman’s point of view when a unit is short staffed. This really is the biggest challenge as far as these respondents are concerned. Closely followed by fear – “The fear of litigation and professional accountability. The wake of the kirkup report savages midwives and their portrayal is unfair. We may all be tarred with the same brush. Normality is under attack again.” For midwives, morale is also a concern – “we are CONSTANTLY being told what we are doing wrong. Such a culture of fear.”

For obstetricians the challenges are different. Comments included:

“Letting the lawyers decide what information we say and letting them take an additional cut. When the press report a 5.2 million payout the lawyers award themselves a further 6 figure payout.”

“More and more ‘high risk’ women embarking on pregnancies.”

“Too much focus on everything EXCEPT caring for patients!”

“Unnecessary obstetric intervention”

For doulas, they are struggling with a lack of awareness of their role and “dispelling the myth that only the wealthy can afford us”. Lack of awareness from families – “People understanding what support we can provide and the value of it” – and from medical professionals – “Being misunderstood – doulas work alongside NOT in place of HCP”. Some respondents even felt that there is resistance to doulas amongst the medical community.

Where student midwives are concerned, the biggest challenges include:

“Feeling left alone and overwhelmed when its busy because my mentors are rushed off their feet.”

“Bullying… NHS culture”

“Working with midwives who don’t use up to date evidence such a optimal cord clamping”

“Guidelines that seem to have very little evidence base.”

“Bad attitudes, both to those in our care and to each other!”

The over-medicalisation of birth was also mentioned by many respondents.

So what can birth professionals do to meet these challenges? The #MatExp campaign is all about action, and everyone being able to make a difference. Respondents were asked “What do you feel you personally can do to face that challenge?”

Whilst some said “not a lot”, “not sure” and “nothing”, most felt that they had ways to meet the challenges they faced. Answers included the simple “keep on caring”, “keep going” and “raise awareness”. Others said:

“By empowering women to have a voice and question these [hospital procedures]. Also, working together with OBs and MWs to also understand their point of view and what challenges they face. So we can all change this together.” (Doula)

“With 3 colleagues I have set up a social enterprise to provide a caseload midwifery service through NHS commissioning at tariff – the battle is to get it accepted by those who resist changing the status quo” (Independent Midwife)

“Keep going, keep trying to provide compassionate, excellent, evidence-based care, serve the women in my care as best as I can doing my best every shift” (NHS Midwife)

“Not resign myself to that’s how things have to be, think about ways to improve and make suggestions, continue to make every contact with women as positive as possible” (NHS Midwife)

“Show by example how important it is to respect and listen to a woman at all stages of antenatal, labour and postnatal care.” (Doula)

“Ensure that I act within my own values despite others in my environment, find support and positivity from like minded individuals. I love Twitter for that!” (Student Midwife)

“Train our midwives to the highest level to avoid litigation. Test their knowledge to ensure they’ve learned from the training. Keep on asking for more staff and bigger units. Never give up!!” (NHS Midwife)

“Trying to individualise care and support women’s choices Positive birth” (Obstetrician)

“I need to remember I’m a student and should be supernumerary. I need to speak up more to make sure I’m learning each day rather than doing what I know or making beds.” (Student Midwife)

“Continue to practise in the best interests of women rather than defensively and vote against abolition of supervision” (NHS Midwife)

“Try as far as possible to support ‘normal birth’, educate women about the risks of high BMI pregnancies etc.” (Obstetrician)

“Be prepared with an abundance of solid evidence” (Student Midwife)

“Keep my heart strong, separate the bigger picture from the day to day interactions of care, do mindfulness, be compassionate to self, inspire trust in women’s bodies” (Student Midwife)

On a personal note, I particularly like the doula who is determined to be “rigorously evidence-based, and relentlessly compassionate.”

I was keen to see how many of the respondents were aware of the #MatExp Campaign. Many would be of course as the survey started out being publicised to people I knew on Twitter, many of whom I have linked up with due to #MatExp. It gradually worked its way out of that community though, and by the time the survey closed the split was as follows:

The orange line is “I have heard of it but don’t know a lot about it”.

I then outlined the aims of #MatExp as they appear on the NHS Change Day website

The next question was “What do you feel you can do to support these aims?” Many respondents felt that renewed or continued work with their MSLC (Maternity Services Liaison Committee) was the answer. Others simply want to “spread the word” and “let mums know”. Other comments included:

“I encourage women to speak up about things they’re not happy with. Raise it at a higher level if you have to, use the SoM or similar. Empower women so they don’t feel intimidated by professionals telling them what they are and are not ‘allowed’ to do.” (Doula)

“Ensure patient feedback is received acknowledged and acted upon. Continue daily ward visits” (NHS Midwife)

“Support AIMS [Association for Improvements in the Maternity Services]” (Independent Midwife)

“Keep banging the drum for parity of esteem for maternal mental health” (Perinatal Psychiatrist)

“Keep raising awareness on Facebook, hold antenatal classes, tell all the women I come across everything is in their power – try to banish the word ‘allow'” (NHS Midwife)

“Probably the friends and family questionnaires would help and I can make sure these are handed out.” (Student Midwife)

“As a researcher I can help to make maternity service user views more visible and I am also doing a lot of work around ways to increase opportunities for service users to get involved in research/maternity service improvement activities. I am also very interested in the idea of co-creation in research (so working alongside service users and frontline staff to develop, do and use research). Part of the work I am involved with at the moment involves empowering pregnant women and midwives to use research evidence more effectively.” (Research Midwife)

“I’m an increasing Twitter user. Social media seems to be the way forward” (NHS Midwife)

The next question looked at the specific areas that the #MatExp campaign covers, including the area for which I am one of the champions: “Life with a new baby”. The full list is:

Skin-to-skin – see Jenny Clarke’s video

Optimal cord clamping – meet Amanda, optimal cord clamping champion

How does lithotomy feel as a woman in labour – read about obstetrician Florence Wilcock’s NHS Change Day lithotomy challenge

Language used towards pregnant women (e.g. “failed induction”, “poor maternal effort”) – this area is championed for the campaign by Leigh Kendall

Life with a new baby – including perinatal mental health and breastfeeding. Read about Rosey PND&Me and also the blog post that Emma Sasaru and I put together on supporting breastfeeding.

Informed Choice – see this example of risk being explained in a user accessible way

Respondents were asked to rank these areas in order of importance and the results were:

A couple of respondents had (very fair) specific comments on the above question, namely “our unit is already changing skin to skin and delayed cord clamping, hence their low ranking, otherwise I would have placed them higher, my next project is to reduce the use of lithotomy” (Obstetrician) and “it is impossible to rate these in order. In general they each impact on each other, by improving informed choice you are creating a healthier postnatal environment etc. so rankings don’t mean that skin to skin is the least important” (NHS Midwife).

The response to the next question was fairly definite!

Finally, I asked “If you could change one thing about maternity care in the UK what would it be?” Staffing levels were mentioned again by a lot of respondents, as was caseloading / one to one care. Many of the answers were also indicative of the tensions between different birth professions and professionals:

“For more medical staff to witness natural birth.” (Doula)

“Doctors and midwives respecting each other” (NHS Midwife)

“Obstetricians” (NHS Midwife)

“If we loved and treated our colleagues better, collaborated and supported each other, we’d be a happier, more efficient more compassionate and passionate workforce- and this would filter through to the women we support” (NHS Midwife)

“Reduce obgyn lead care.” (Doula)

“NCT didn’t have such a negative influence on women. No one failed because they didn’t have a vaginal birth. A lot of what is taught is inaccurate and based on personal opinion which is not informed choice.” (NHS Midwife)

“Slow down the relentless overuse of induction…encourage/ optimise midwife led care home birth and birth centres and caseloading model of care.” (Student Midwife)

“Don’t always go and try to enforce your procedures. Listen to women. Use of language for the purpose of influencing a labouring woman into accepting the best thing for hospital such as I witnessed: ” This baby has had enough” is very detrimental, and to say the least, manipulative.” (Doula)

“I would offer a single additional session to antenatal classes/NCT classes etc about the reasons for medical interventions in labour and the risks and benefits. It is unbelievable that in an age of information, when women have spent time with midwives and NCT instructors, we still regularly see birth plans that say “don’t want forceps unless necessary”! It immediately disadvantages obstetricians and puts them on the back foot, as we not only are seen as “the bad guys” for forcing these interventions on women, but often have a matter of minutes to explain the risks and benefits in an urgent situation, which is frankly laughable. Obstetric trainees should be involved in antenatal education; just a single group session on the what, when and why of CTGs, forceps, FBS and Caesarean would I think remove a lot of the fear from women and help those for whom labour does not progress smoothly to feel more empowered and informed.” (Obstetrician)

“More trust in women to make the right choices for themselves. Less bullying and misinformation.” (Independent Midwife)

“Obs and midwifery attitudes to each other.” (Anaesthetist)

I would also like to highlight this heartfelt plea from an NHS Midwife: “I don’t even know where to start… Let’s be compassionate again – let’s treat EVERY woman like our sister. Even the smelly, rude, unpleasant ones. Let’s try.”

Along with a number of #MatExp participants on Twitter, I have been saying that respect and compassion are two vital elements of a positive birth experience, regardless of vaginal birth, c-section, place of birth and so on. This comment from a doula certainly chimes with my personal view on what could change in UK maternity care: “I’d like it to be less of a lottery, some professionals are kind, supportive, informed, happy to discuss options with women. Some are not. On the same wards, in the same hospitals too. I’d like the good experiences that many have to be normal for all. The feedback I get is this comes down to how the woman is treated rather than the final outcome of the birth experience.”

The full results of the survey have been passed to Florence Wilcock, #FabObs of the #MatExp campaign.

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#MatExp at 36+2 – dangerously understaffed

29 May 2015 by Helen Calvert / Birth Trauma, Environment and Facilities, Postnatal Care / Comments Off

One final blog post in this initial round of #MatExp feedback from my Facebook group. Once again, this story is told in the mum’s own words….

“I had a very straightforward pregnancy and was expecting to to go overdue (I was born 14 days late).

My waters broke at 36 + 2 with absolutely no warning, I’d had some indigestion earlier in the day but that had gone by the evening and I was out for dinner with my partner, his Grandad and his Grandad’s friends. We live in Manchester and the meal was in Wakefield, my waters going was very obvious and completely mortifying but luckily I was wearing black jeans and restaurant floor was pretty dark. We called Pinderfields Hospital (a couple of miles from the restaurant) who said to come in as my waters had gone before 37 weeks. I got to the hospital at about 9.30pm and I was hooked up to a monitor for 2 hours which confirmed that the baby’s heartbeat was fine. They were clearly very busy but at about midnight I was examined and they also confirmed that I was not in labour, I wasn’t having any pain at this stage. They said that because I was early I would have to be induced within 24 hours if it didn’t happen naturally or I could go back to Manchester where they have a different policy and they’d let me go to 37 weeks (not sure this was true). They said they couldn’t advise us to move to Manchester but they didn’t think it would be a problem. I felt pretty confident as I wasn’t having any contractions and I’d been reassured by the monitoring. I was also worried about the baby being small and so I was keen to go to 37 weeks if possible. All my notes, stuff for hospital etc was all in Manchester.

St Mary's Hospital, Manchester — St Mary’s Hospital, Manchester

We decided to leave and waited 2 hours for a discharge letter (during this time we drove to a nearby garage for water and haribo) eventually they said they’d call St Mary’s instead and we left, the journey only took about 40 minutes and we got to St. Mary’s at 3.30am. I’d started to feel pains in the car and by the time we arrived at St Mary’s these were 3-4 mins apart. They weren’t strong and seemed quite bearable but I had no idea whether they were ‘proper’ contractions. I told them this when we arrived and they were quite dismissive, they said someone would talk to me about pain relief after a doctor had seen me and I couldn’t do anything before seeing a doctor as I was now high risk.

I was then told to wait in a small, hot triage room and my partner was sent home (an hour round trip) for my notes. Over the next three hours nurses came in periodically (never the same one twice) and I was put on a monitor for a while. I asked if I could moved to a room with a pool (as in my vague birth plan) but we were told we couldn’t have one, then I asked for a normal bath or shower but I was told I couldn’t have anything until a doctor had seen me. It felt like I was left for a really, really long time. I didn’t have anything practical with me (other than my kindle) and was still in my jeans and boots. Contractions were getting more frequent, I kept sending my partner out to see if someone could come and either no one was there or they told him no one was free, a nurse eventually gave me two paracetamol.

Finally, three hours after we arrived I told him that he had to make someone come, I still didn’t know whether I was properly in labour and I wasn’t sure I would be able to cope with the pain. I felt like I needed the loo but it was a huge effort to make it down the corridor to the patient toilets. I was starting to think that I was in labour, but if not I definitely wanted all the pain relief available! I’d had about 20 minutes of quite serious pain and I had heard stories of people being in labour for days. Finally, at about 7 am a doctor arrived to examine me and told me I was fully dilated (which was a huge relief) and then it all happened really fast.

I was rushed round to the birthing suite where there were two midwives, they hooked me up to gas and air but then said I couldn’t have it as I had to push. I was flat on my back and in quite an uncomfortable position, I felt like it was too late to move and no one asked if I wanted to, even though I was staring at a ‘natural birth positions’ poster all the way through. The pushing was quite painful but much easier to cope with as I knew it would be nearly over. I heard a loud pop and (I think) I cracked a rib. That was the most painful bit. The pushing stage was very short and in 15 minutes the baby was out. I had a second degree tear but didn’t feel it at all at the time. As I was pushing the midwife told me that I was going to tear which I didn’t find particularly helpful.

They put the baby straight on me and it was amazing, I felt much less tearful than I had expected as I think I was in shock. After about 5 minutes we looked and saw that she was a girl (we didn’t know beforehand). To our relief, she was obviously not tiny even though she was early and when she was weighed we were told that she was 7lb 5oz. I think I had an injection and the placenta was out very soon afterwards, I wasn’t paying much attention. The next few hours were brilliant but then I did start to get sore, they were still waiting for a doctor to sew me up and in the end it wasn’t done until 4 hours after the birth. I had gas and air while the local anaesthetic was going in.

The stiches felt fine until the local anaesthetic wore off and then the pain was unbelievable, far worse than any part of the labour, I fainted and then lost a lot of blood. I was given paracetamol (again) without being examined and told, quite patronisingly, that I could expect it to hurt for a while. I tried to explain that it was too much pain to cope with but probably wasn’t very coherent. At this point my partner had baby (with no real clue what to do) and was trying to get someone to help as I kept fainting. I didn’t want to take her as I was so shaky I was worried I’d fall off the bed. Eventually, after a couple of hours a midwife looked at my stitches and said that there was a haematoma the size of her fist (nice) which was pushing out all the stitches. They said this would have to be drained and my stitches redone but by that time I didn’t care, I was just so happy that they were going to do something about the pain. I was told that I could have an epidural (finally!) for the procedure. I was supposed to be waiting for a slot in theatre but another midwife came in to borrow some equipment and noticed that I had lost a lot more blood. She went to get someone who was looking after me and then they said I would have to have a general anaesthetic because of the blood loss. I was rushed round to theatre where I was knocked out. They sorted out the stitches and gave me a blood transfusion.

I came round a few hours later and spent the first night on the high dependancy unit. This was (comparatively) brilliant as I had my own room and a nurse there most of the time. I had drips in both hands and my ribs and stitches were very, very painful so it was fantastic to have someone help lift my daughter out of the cot. Unfortunately after that we were taken to the ward and that was just awful.

My little girl hadn’t been able to breastfeed as she had a tongue tie, this was recognised straight away but we didn’t see the same midwife twice and they kept saying that she might manage it anyway. Because she was early she was being cup fed formula as they were monitoring something (possibly blood sugar) and my milk hadn’t come in. I ended up staying in for 5 nights trying to establish feeding but baby just wasn’t interested and when she did latch on she couldn’t suck. We were told she had to be either breastfeeding successfully or bottle feeding, we couldn’t go home cup feeding. I was so exhausted after 4 nights on the ward that we just decided to bottle feed her to get out of hospital.

The time in hospital seems like such a blur as I was just so tired, my partner, mum etc all helped as much as they could during the day but I was still left alone from 8pm until 10am every night with almost no support. Sometimes there was a midwife around to help during the night but often not and with painful ribs/stitches I did feel like I needed help. Baby didn’t settle unless she was on me (which I knew was totally normal) and I fell asleep like that several times. Being back home was amazing, I was finally able to sleep for more than 20 minutes and I was able to enjoy my baby.

The midwives that looked after me were all lovely but they were dangerously understaffed, I rarely saw the same one twice and I think this caused problems afterwards, I had to explain about Anna’s tongue tie every time someone tried to help with feeding and almost everyone mentioned that residual pain relief from labour was probably causing her feeding problems without bothering to look and see that I hadn’t had any.

Being on the ward with no support was dangerous, I would never have fallen asleep with my baby on me in such a precarious position at home because I could have had her in the bed with me and I would have had support, or someone to take her so I could nap for 20 minutes. 14 hours is too long to have to look after a newborn with no help and in unfamiliar surroundings. Allowing partners to stay overnight would have changed the whole experience for me, even having a shorter period with no partners/visitors (e.g 12-6am) would have been so much better, 6 hours is manageable.

I’m very aware that I was incredibly lucky to have an ‘easy’ birth (and my daughter is heathy and wonderful) but I’m still so angry about how I was treated, I think a lot if the fear and difficulty I had was purely due to the treatment in hospital and not the birth process at all – so unnecessary.”

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#MatExp – Caught in the Middle

29 May 2015 by Helen Calvert / Continuity of Care, Environment and Facilities, Pregnancy Complications / Comments Off

I am very grateful to yet another member of my Facebook group for providing me with her maternity experience to share with you. In her own words…..

“My antenatal experiences with my NHS midwife and one consultant led to me transferring to the One-to-One Midwifery Service from about 30 weeks into my second pregnancy. The main issues I had with the NHS were:

The cold and distant manner of the midwife

The total lack of concern or questioning when I declined the breastfeeding DVD (as a natural term breastfeeder with my older son, with intention to tandem feed, I felt I didn’t need it – the midwife simply moved on to the next item and made no attempt to find out why I didn’t take the DVD. I found this shocking.)

At a consultant appointment the consultant informed me that she had booked me in for an induction on my due date, due to my maternal age. No discussion. told her that that would not be happening.

I had my heart set on a MLU, natural water birth, and I raised the issue of booking an induction without discussion or my consent issue with my MW. Her response was that I will do as the consultant decides. At this point I referred myself to One-to-One.

Final point – one slightly raised blood pressure reading triggered off me being designated a high risk pregnancy, so I would have found myself on the consultant led side of things to give birth. Another big driver to move service. My BP was fine throughout the remainder of my pregnancy (with the help of Labetelol).

The whole experience was very ‘tick boxey’, with little or no consideration of the overall picture i.e. my health and fitness, my wishes, previous birth etc. I was very disappointed by the apparent lack of breastfeeding promotion.

So I had my second baby by natural home water birth, with the support of One-to-One Midwives. I ended up in hospital for ten days postnatally with HELLP Syndrome. One issue arising there was the strained relationship, and lack of joined up care provision, between the NHS staff and One-to-One. Before transferring myself to One-to-One, I had heard from a fellow NCT Refresher class Mum, that she had had a bad experience in this regard also.

I was transferred via ambulance to Arrowe Park Hospital following the birth of my daughter in April 2014, with what turned out to be HELLP Syndrome. My daughter came with me. We were in for a total of ten nights.

Although I was a patient, my daughter was not. This became a problem when she needed to have her 72 hour check. In the initial stages, my partner was doing the communicating with my One-to-One midwife; and she told us that my baby would have to be taken to an alternative venue for the check by noon on the Saturday. I was in no fit state to add to the discussion, being quite poorly and ‘not with it’.

Ostensibly One-to-One staff were not allowed on the hospital premises to carry out the check; NHS staff could not do it as my daughter was not a patient. I did become involved in the discussions when Saturday morning arrived, my partner was trying to arrange child care for our older child (not easy as we have no family close by), and it dawned on me that my newborn baby was about to be taken away from me. Breastfeeding aside, that would be traumatic for all involved – baby, me and Dad!

Bearing in mind that the main issue for me was dangerously high blood pressure at that point, I was drawn into having direct telephone conversations with One-to-One, and quite heated talks with NHS staff – who made out that there was absolutely no way One-to-One could come into the hospital to do the checks – no insurance I think was the issue from memory? As my baby was not a patient then they definitely could not perform the check – to do so would generate a second NHS number for her, which I was told would have the potential to cause us problems when trying to register her birth. The systems would not be able to cope with it. We felt that systems were taking priority over the well-being of our newborn baby.

In the end a One-to-One midwife did come into the hospital to do the check. There was an uncomfortable atmosphere between the two sets of staff.

On a side note, my daughter was diagnosed with a mild tongue tie and a referral supposedly made. In fact no appointment ever came through. Fortunately the tongue tie was never an issue.

My One-to-One midwife came to see me in hospital on a number of occasions; each time I picked up on tension between the parties.

Apart from the stress around my daughter’s check, I have to say that the majority of the care I received on the labour ward was fantastic. Apart from one incident where I suffered a huge loss of dignity and lack of respect or concern for my personal space and being. In fact I felt totally humiliated. It happened on my final night at Arrowe Park (so day ten of my stay); I was rushed down from the maternity ward to the labour ward as my blood pressure was so high. I was given intravenous drugs to bring it down; it would have been a trip to the cardiac unit if this had not worked. I needed the toilet – and not just a wee. I was told I had to remain on the bed and my request to use a commode was refused. So I had to use a pot under the sheets. Except the sheet was inadequate and I knew that I wasn’t covered up. So I tried to throw my dressing gown over my knees. People were coming and going in and out of the room. I had a sudden moment of realisation of the total indignity of the situation – people could well have been able to see me trying to have a poo, knees up in the air, largely uncovered. I cried. I just wanted to go home, with my baby.”

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#MatExp – A Midwife’s View

29 May 2015 by Helen Calvert / Informed Choice, Postnatal Care / Comments Off

As promised in my first MatExp feedback post, I have more stories to share with you. Today I have pleasure in sharing the maternity experience of a mum with a different perspective on the care she received, as she has worked as a midwife. In her own words:

“There was nothing truly awful to say about my care, I was just a bit disappointed. I couldn’t take my old consultant hat off so kept thinking about the improvements that were needed and where would I start?! I’ll try and outline the issues as I saw them as briefly as my general verbosity will allow!

Good points first! All 5 midwives I met antenatally and the 2 postnatally were very nice and cheery. The appointments ran pretty much on time and the postnatal visits happened when they said. The antenatal classes were really good. Pitched at just the right level and even my husband enjoyed them. Although there wasn’t much time for socialising, the midwife orchestrated a no pressure way for us to swap contact details and as a result I have made a really good friend. They told me about the Cherubs group, which was good. The handover to the health visitors seemed pretty smooth. Oh yes – this is the best one! My experience of giving birth at the Wythenshawe midwife led unit was fantastic. Every aspect was exactly what we needed and we felt cared for and very special, which is difficult to achieve in a busy unit like that.

Ok, now the not so good! At my booking it was presumed I was ‘low-risk’ (which I am, but the midwife would not have known that). All of the information about care etc was given prior to finding out if that care was going to be appropriate for me or not. I was only asked about ‘me’ at the end and this was a very tick-box exercise. Don’t get me wrong, I know from experience how tough it is to do a booking visit in an hour (or even an hour and a half), but it is possible to individualise the discussion and make the woman feel that this is about the service fitting around her needs rather than her just fitting into the service. Despite the presumption about my low risk status I was not told about my birth place options. The midwife said ‘so you’ll be coming to Macclesfield, right?’ And ticked the place of birth discussion box! Home birth was barely mentioned and the option of using the local midwife led unit was not mentioned at all at any of my appointments, including my longer birth planning appointment. I found out (through Google) about the Wythenshawe MLU at 39 weeks (as I was new to the area I didn’t know where hospitals were and what provision they had).

Thankfully Wythenshawe were excellent – booked me in the next day, gave me a tour of the unit and I had an excellent experience of intrapartum care there.

In general, the information provision was poor. Despite quite long ‘chats’ about topics like the weather, the midwife’s daughter’s pram choices, new granddaughter, for example, little time was spent on birth planning info, breastfeeding info etc. so I don’t think this was a ‘time’ issue. There were no discussions, I was just told how things would be. For example, “we won’t let you go past 41+5 weeks”, “we will induce you”, etc. It made me very worried for women who are not aware of the concept of informed choice, or who are aware but are too polite / nervous / grateful to ask what their options are. I am aware that some of this could have been down to the fact I was a midwife. But actually I don’t think the 2 midwives I told remembered this (I could tell from the way one of them briefly explained Vitamin K to me), so I’m fairly sure I saw an accurate picture of the care most women get.

Probably the most notable thing was an issue with growth measurements. I was measuring slightly under (2cms below my gestation) for 2 consecutive appointments. I hadn’t been that worried until over the next 2 weeks between appointments I felt like I hadn’t grown at all. I said this to the midwife at my 36 week appointment who measured me and said that I measured 36cms so no need to worry. However, she had not actually found my fundus (top of the uterus) and just put her tape measure to my sternum, where my fundus should have been at that gestation. Only, the whole point was that it was not there! It was much lower – 4cms lower, and I had not grown at all in the past 2 weeks, as I suspected. The midwife was a little embarrassed (understandably) when I pointed this out. She flippantly remarked that she could make those measurements anything she wanted to, so they were pointless. After some discussion she referred me to a consultant, who referred me for a scan as she was concerned about the growth. In the end it was all fine, baby was bang on average weight. But that wasn’t the point, a truly compromised baby could have been missed.

I also had a problem with the way they gathered feedback. They were doing the Government’s ‘friends and family test’ and gave out cards for feedback. No problem there. However the midwife handed it to me in an appointment and insisted on me doing it there and then in front of her. So no anonymity and no chance of honest, useful feedback. I refused to do this, but I was accosted by the receptionist at my next appointment and was jokingly told that I was not allowed to leave until I filled it in. This time it was the receptionist watching (not so bad), but it had my initials pre-written on the top of my card. I was honest in my brief feedback, but felt very uncomfortable about it, which I’m sure most women would.

My postnatal care was pretty lacking. On the day after I came home I received a phone call to see how I was and to arrange an appointment on day 3 (actually day 4). This is pretty standard practice now and is a change from all women getting a home visit the day after they get home. I don’t have a problem with this as services need to be individualised and not all women want or need a visit, a phone call will do. But the call was not used to find out if I felt I needed a visit, it was to tell me that there would be no visit until day 4. Then a few clinical questions were fired at me! Again, I was fine, but what if I hadn’t have been? The day 4 visit was a whirlwind. I was still in bed, so my dad let the midwife in and showed her upstairs. By the time I met her in the nursery she had said 3 times that she was “only here to weigh the baby”. She set her stall out early that she would not be staying long! Baby had put on weight, so she said well done and left after quickly asking about my blood loss, whether I’d pooed and giving me the contact phone number. I could tell she was busy (it was a Saturday, skeleton staff and she had visits all over Cheshire), so I didn’t dare ask anything!

So, that’s it! I’m afraid to say that I think this might be pretty typical. It probably says more about the model of care, the resources in the team and the workload than the individual midwives. It’s not easy, but individualised, supportive, positive, evidence-based care can be given in a busy NHS maternity service.

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