UPDATED (2017) to include a section on the effects of adverse experiences on healthcare professionals, organisations and the wider community
“You know being born is important.
You know that nothing else was ever so important to you.”
(From ‘Being Born’ a poem by Carl Sandberg)
The Kirkup report was published after an independent investigation into the Morecambe Bay NHS Foundation Trust after the deaths of 19 babies and two mothers. The unit was described in the report as ‘seriously dysfunctional’ and that Midwifery actions to support ‘normal birth’ were partly to blame:
“…midwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care… We…heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal”. Over time, we believe that these incorrect and damaging practices spread to other midwives in the unit, probably quite widely.”
The Kirkup report about maternity care in Morecombe bay highlighted the apparent dichotomy between the ‘normal’ and ‘safe’ birth agendas. Proponents from both of these agendas claim to be interested in healthy mothers and babies.
“Midwives and obstetricians should be on the same side of the fence, but they’re still too busy trading insults over it about whose garden is better. Meanwhile, pregnant women are left to one side unsure of who to trust, pulled in opposite directions by competing cultures who both claim to provide the best care for them.”
When we say we all want a healthy mother and baby, what do we mean? It’s not so simple…
The World health organisation (WHO) definition of health (1946) is that: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Public health looks at the determinants of health, from individual health behaviours to social, economic and environmental conditions.
A mother has a fast, intervention free physiological birth, but she is shouted at by staff as things are happening quicker than anticipated. She is frightened and traumatised and struggles to bond with her healthy baby because she believes she endangered him.
A woman has a long, difficult induction, her baby is malpositioned and there are lots of changes of staff. She has over 25 vaginal exams by eight different people. She labours to 9cm but then needs an EMCS which she feels was caused by the induction. She has flashbacks and cannot drive past the maternity unit where she laboured.
A mother has a good birth experience and her baby is healthy. But she is frightened to go home because her partner has started drinking more whilst she has been pregnant. He gets in her face and shouts at her. She’s worried what he’s going to do if the baby cries.
Would you consider the women in these vignettes safe?
We need to recognise that there are lots of layers to concepts like ‘risk’ and safety’ in pregnancy and childbirth.
In 1997 the World Health Organisation published the following definition of a NB “Spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously [without help] in the vertex position [head down] between 37 and 42 completed weeks of pregnancy. After birth mother and baby are in good condtion.”
Does this mean that women that are high risk at the start of labour or women that become high risk in labour can’t go on to have a normal birth?
In 1997 Beverley Beech from the Association for Improvements in Maternity Services (AIMS) defined NB as “a Physiological Birth where the baby is delivered vaginally following a labour that has not been altered by technological interventions”. Specifically excluded from this definition were births that had had artificial rupture of membranes, induction or acceleration, epidural anaesthesia and episiotomy.
Variation in intervention rates
Intervention levels vary between maternity units, even those with similar demographics and levels of pregnancies with increased risk factors. In the US a recent study of over 41,000 low-risk women having their first babies in 20 California hospitals found caesarean rates for this population ranging from 11% – 30%. Statistical analysis found that over half of the variation between hospitals was a result of differing obstetric practices (Main et al, 2006).
Health outcomes related to birth interventions
Intervention in the birth process, whilst intended to reduce mortality and morbidity, may lead to negative health outcomes including increased likelihood of infection, on-going pain, or negative birth experience (Goer et al, 2008) which, may increase the likelihood of women developing post natal depression (PND) or post traumatic stress disorder (PTSD) (Creedy et al, 2000).
However it is also recognised that babies die and are left disabled after preventable events during pregnancy and labour.’ Each Baby Counts’ is the RCOG’s national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. TheRCOG estimate that In the UK, each year between 500 and 800 babies die or are left with severe brain injury because something goes wrong during labour. The Each Baby Counts project we are committed to reducing this unnecessary suffering and loss of life by 50% by 2020.https://www.rcog.org.uk/eachbabycounts
Benefits of birth without intervention
Women who give birth without intervention tend to have less post-natal pain and recover more quickly than those who have had interventions such as a forceps delivery or an episiotomy (Carroll et al, 2003). The length of time it takes to recover physically has implications for other areas of post-natal life, including self esteem (Llewellyn and Osborne, 1990), bonding, increased breastfeeding (Ransjö-Arvidson et al, 2001) and decreased Post Natal Depression (Sutter-Dallay et al, 2003; Soet et al, 2003).
Long term effects of difficult birth experiences
Some studies have found that women remember their births clearly, for example Takehara (2014) found that women remember their childbirth experience clearly 5 years later. Another study by Simkin (1992) found that two decades after birth, women’s memories were accurate and vivid, especially: onset of labor; rupture of the membranes; arrival at the hospital; actions of doctors, nurses, and partners: particular interventions; the birth; and first contact with the baby.
Disempowering experiences during childbirth have been found to persist throughout the lifetime, one study demonstrated that the effects of harsh and humiliating treatment, experienced by a number of Swedish women in antenatal care and childbirth in the mid-20th Century, endured for the rest of their lives.(Forssen 2012)
What happens when caregivers and women disagree about how to have a healthy birth?
There are instances when midwives and doctors might disagree on the best way to have a healthy birth or the parameters that make up a ‘normal’ labour, or at what point, deviation from normal becomes unsafe.
Several studies have indicated that at times midwives ‘do good by stealth’ by actions such as not doing vaginal exams so that women’s progress cannot be recorded on a partogram which could trigger interventions due to the crossing of the ‘action line’. This would then give more time for a slow labour to progress, and there is no consensus internationally on the speed at which the first or second stages of labour should progress.
One example of this ‘good by stealth’ is described on a study looking at midwives in Belgium
“Midwives considered themselves as advocates of normalcy and used different strategies to avoid interventions. Only some midwives openly negotiated with obstetricians about care. They were willing to ‘walk on the edges of the hospital rules’ to obtain normalcy. One midwife gave the example that when an obstetrician asked ‘rupture the membranes next time you examine the woman’, the midwife simply did not examine the woman. She thus ‘obeyed’ the obstetrician while at the same time she gave the woman what she thought she needed. One midwife also found that there was a strong sense of ‘social control’ between the midwives to strive for normalcy.”(Van Kelst 2013)
The study states: devious ways were required in order to achieve objectives that could not be voiced clearly and directly
This to me is the key issue. Lack of communication between health professional groups and women.
A study in Spain (del Roasarion Ruiz 2014) look at midwives and clinicians agreement on clinical practice guidelines for normal birth and found that:
“Midwives and obstetricians often have significantly divergent levels of agreement on key recommendations. The participating midwives saw pregnancy and childbirth as normal events, which should be treated accordingly. In their views obstetricians emphasised risks and hereby sometimes even ‘created’ pathology”
But many clinicians agree that our drive to reduce risk can cause harm at a population level. On one obstetricians blog he states: (http://ripe-tomato.org/2015/04/11/jims-tweet/)
“There is a battle here, and some truth on both sides. Modern obstetrics, the stuff I do every day, is obsessed by reducing risk. Caesareans for breeches, antibiotics for positive group B strep swabs, and heparin for anyone with a risk factor for thromboembolism are all unnecessary most of the time, but heaven preserve the doctor who skips them if a bad outcome occurs.
Our obsession with safety has a cost. It causes anxiety. Fetal monitoring does lead to unnecessary Caesareans. People popping in and out of rooms to review progress, give antibiotics and check heart beats, stops women relaxing and may actually slow labour.
And supporters of natural childbirth are right. Hospitals are not perfect. Too many women still labour on their backs. Doctors make stupid decisions. And even if we were perfect, it might still sometimes be better to take a bit of risk to allow nature to take its course.”
In situations where care givers disagree it has been shown that pregnant women have intervened where communication suboptimal. “They did this by rectifying information flows between community midwives and obstetric caregivers.”(Schölmerich 2013)
When factors that contribute to preventable harm in obstetric care are investigated we find that failure to communicate is prominent. (Berlung 2012)
“Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality”(Lyndon 2015)
Sometimes interventions have unexpected consequences, one example is the introduction of the clinical pathway for normal labour (Normal Labour Pathway) implemented in Wales, UK which aimed to support normal childbirth and reduce unnecessary childbirth interventions by promoting midwife-led care. A study was conducted to look at how the pathway influenced the inter-professional relationships and boundaries between midwives and doctors .It stated that:
“The ‘normal labour pathway’ was employed by midwives as an object of demarcation, which legitimised a midwifery model of care, clarified professional boundaries and accentuated differences in professional identities and approaches to childbirth. The pathway represented key characteristics of a professional project: achieving occupational autonomy and closure. Stricter delineation of the boundary between midwifery and obstetric work increased the confidence and professional visibility of midwives but left doctors feeling excluded and undervalued, and paradoxically reduced the scope of midwifery practice through redefining what counted as normal.”
Midwives training emphasises the benefits of physiological birth, but medical training does not appear to have the same emphasis. One trainee obstetrician shared her experience of colleague’s reaction to the sharing of her birth story.
“I’m a doctor training in obstetrics. I had a homebirth with my first baby. This week I was on a course in London with other junior doctors in obstetrics. I mentioned in passing that I’d had a home birth and was quite viciously attacked by 3 doctors I didn’t know. I’m used to raising an eyebrow or two, but have never had anyone be so rude to me. Words used included ‘mad’, ‘stupid’, ‘crazy’ and not in a nice, jokey way. One even said that homebirth was basically ‘mimicking 3rd world conditions’. I laughed out loud at her and pointed out various reasons why that was a ridiculous comparison. I quoted the statistics on why primips transfer to hospital (ie ‘failure’ to progress rather than acute emergencies etc)… but deep down I was really hurt by their attitude to me and to the women they look after. I just don’t understand some doctors and how they interact with their women… Surely it’s our job to provide information and give women the ability to make informed decisions, even if we don’t agree with them. The thought of these docs meeting one of you guys in a clinic makes me so sad at how they might behave.”
Midwives can also be dismissive and ridicule women’s birth plans and hopes, as has been featured on the Television series ‘One born every minute’.
Where does this lack of communication and teamwork leave women?
Women that experience traumatic births and go on to have another pregnancy need to reengage with health professionals to plan for a subsequent birth. This experience can profoundly shape the choices they make and whether they feel able to move forward feeling empowered or retraumatised.
Three women agreed to share their stories to enhance our understanding of the implications of good or bad communication:
Her first birth was an induction and her daughter was born 3 days later by EMCS:
“I demanded the section after I started to feel the trauma of the internal exams during the 3 day failed induction. When they said I could have a section instead it was like I went to heaven, it meant they wouldn’t touch me again or perform any more examinations.”
Clare really wanted to have a natural second birth. She organised to have a VBAC in a birth center, but at 37 weeks, was told it had now been decided that she could no longer birth there as she had had a previous cesarean.
“They wouldn’t support my wishes to birth on the birth suite because I’d had a previous section after telling me throughout my pregnancy that it was arranged. Called me in at 37 weeks saying I wasn’t welcome on the birth suite and if I insisted on birthing there then I wouldn’t be able to have a birth centre midwife and would have to be continuously monitored. Then when I sent an email in telling them how heartbroken I was they sent an email back telling me they’re sorry they couldn’t help me.”
She then transferred care to another trust that supported her wishes to have a homebirth. She got the pool set up and waited for labour to start, only to go overdue.
“One thing after another. Fighting with everyone. Changing my care. Justifying my wishes. Finding supportive people then to be let down. And then I had it sorted finally at 39 weeks preg I got my pool and was finally ok! Only for my body to not trigger labour. The panic is setting in”
Clare kept on waiting for labour to start, until:
“The scan showed decreased fluid today. Fluid was 4.5 just 5 days ago and is 2 today! So has decrease by half in 5 days and they said can be a sign that placenta isn’t working as well as it was. I’m 15 days overdue now. I’m not wanting to push past 15 days over (my mum went 3 weeks over with devastating results) so the worst case scenario is very close to home. So I requested a natural section. Where they drop the curtain and let you see your baby be born and the baby then goes straight onto your bare chest for skin to skin and all checks are carried out on your chest. I’ve seen the videos of this in the uk. Hospital flat out refused to consider dropping the curtain”
“Can they refuse me? It’s my baby. I want to see him born!! I can’t believe you can have a birth plan for a natural birth but you can’t for a section. It’s still a birth!”
Clare did her best to find a Trust or surgeon that would support her, but was increasingly being pushed into a corner where she either continued going further overdue with reducing fluids or gave up on her birth plan of a natural cesarean.
But at the very last minute, a consultant rang her at home, at night, to say that she had facilitated similar wishes in ELCS and as she was working nights over the weekend, she would add the CS for Clare on to the end of her shift in the morning.
“We did the gentle cesarean and it was the most amazing thing in the world. I watched him come out, They didn’t push at all. They let my uterus contract him out but by bit, first his head, then one shoulder, then the other, then his tummy, hips and legs! He was so calm during the first bits but once he was out to his tummy area the cool air put have hit him and he cried abit but I reached for him and as soon as he was on me he stopped and was calm, sniffed me and started searching for the nipple whilst he was having delayed cord clamping. It was truly amazing! They treated it completely like a vaginal birth! The obstetrician was amazing. I felt in complete control. . It would be easy to say that I could have gone on waiting to go into labour for longer and perhaps got my homebirth…but I’m so happy with the experience we had that there’s no point in feeling that way. For a second choice…it was perfect! No regrets. ! I really do feel that it was meant to be this way now, I can’t imagine it another way. I honestly don’t even think I’ll cry when I get home tomorrow and pack away the birth pool!
There needs to be a change for women who find themselves in a disappointing situation and they need to still be respected as a birthing mother instead of a patient. I even wrote a birth plan and they all took it very seriously! Second plans aren’t always so bad when supported by the right kind of people”
Describing her second birth:
“Despite it having huge potential to be very traumatic the care I’ve received has meant it was positive, and as a result I’m coping much better with life postnatally.
Pregnancy was littered with issues – high BP, low fluid around baby, small for dates, and repeated reduced movements in the third trimester. I was desperate for a “natural” experience, primarily because my first birth was a horrific induction ending in PPH. When Drs said they wanted to induce me at 39 weeks for RFM and small measurements I freaked out and refused. Some guidance and clarity from people on this group (MatExp) , and a clear discussion with a Dr next day helped me feel able to agree to the induction, although I knew my baby wasn’t ready to be born.
The MW who induced me was one I knew from clinic. She knew about my anxieties and was so supportive all day, offering me my own room even though they usually induce you on a ward, and just having a chat when my husband went to get himself lunch etc. Little things but important ones. At change over I met our night mw and her student. By this point I was contracting so they broke my waters. My birth plan stated I wanted to be mobile, but she really wanted to monitor me constantly. We ended up with me sitting at the end of the bed while the student held the monitor for baby on my belly and I gave a sign every time I had a contraction which they wrote down. This meant I didn’t need to go on the sintocin drip and maintained mobility despite it clearly being being a total pain for the midwives. I achieved a pain relief free labour mostly due to this I think.
At 7cm dilated they lost baby’s trace and asked my permission to put one on his head. I agreed and just as well I did as it became immediately clear that he wasn’t happy. His heart rate was at 30 bpm and not increasing, I was put on my side and it stayed low. The mw in charge and Dr came in. Both asked permission to examine me and both introduced themselves. They called a category one c section and even then they explained everything to me. We were running down a corridor with me on the trolley and a midwife found the time to hold my hand and tell me we were going to be fine. In theatre she sat by me and kept hold of my hand. Every single person in that room told me what they were doing and why. When they delivered him he was totally wrapped up in his cord. They’ve since said he wouldn’t have made it if he hadn’t been delivered there and then. I’m told baby was given almost immediate skin to skin with my husband, and as soon as I was awake he was placed skin to skin with me and that was how we stayed for 24 hours.
So many people from that night came in to see us over the next couple of days. They didn’t have to but they did. All just wanted to hold Oliver and check I was ok. The biggest thing about all of this for me has been the genuine care and compassion as well as total honesty about everything. Last time things were brushed aside or down played which made me feel like I was over reacting. Emotional Care is so important for new Mums and Dads and in our case made the difference between a positive and negative experience.”
“My first birth was traumatic… I felt disrespected by my hcps. I was not able to make informed consent. I was not supported to achieve my birth goals and I ended up with an emcs. As a result I developed distrust of the hcps in my local maternity unit.
For my second pregnancy I chose to sit outside the system and hired independant midwives. I chose to birth at home against consultant advice as I didn’t trust them to look after my best interests. I put in a lot or work and effort to prepare myself for a natural birth which payed off as I had a wonderful birth.
But i was very unlucky, my baby was born not breathing 40 minutes away from hospital from which he has sustained serious brain injury and will live with serious life long disabilities.
Now I will spend the rest of my life wondering whether I should have gone against every instinct in my body and done as I was told by people I didn’t trust. If I had done that would my son have arrived safely??
There is no doubt that the interventions they employed after birth saved his life for which I am grateful. And it is likely he would have had a better outcome if he’d been born in the hospital, if I’d been hooked up to cfm. What a shame that my trust had been completely abused and destroyed first time round.”
Nicola said about her birth “Although there were a few reasons why my birth was considered high risk, myself and my midwives went to great lengths to manage and monitor those risks. In the end none of those risks presented themselves. We were just desperately unlucky. Birth is inherently risky. We rolled the dice thinking it wouldn’t happen to us and we lost.”
What can we learn from these women’s stories?
It is vital that women are listened to, respected, treated like competent human beings and that health professionals work as multidisciplinary teams with one goal, a healthy baby and a healthy mother, on all levels.
Women that are disrespected, coerced, humiliated, terrified or traumatised lose respect for health care professionals and become hard to reach, if their attempts to communicate in a second pregnancy are met with rigidity, refusal or ridicule then women can feel pushed into making choices that take them outside of conventional care.
Interprofessional fighting increases risk to women and babies.
Where does this lack of communication and teamwork leave professionals and organisations?
Witnessing adverse events can lead to trauma to health professionals and can have long term effects also on the wider community and organisations community of practice. Both midwives and obstetricians have reported sleep disorders and depressive symptoms (Shroder 2016) and failure to acknowledge and deal with guilty feeling (even with no fault) can effect self forgiveness (Shroder 2017) the authors suggest “that the narrow focus on medico-legal and patient safety perspectives is complemented with moral philosophical perspectives to promote non-judgemental recognition and acknowledgement of guilt and of the fallible nature of medicine.”
Obstetrician Mary Higgins in a blog post for the BMj talks about the ‘fourth victim’ after adverse events which are future patients, and suggests witnessing adverse events can both harm and improve future practice. A study by McNamara (2017) corroborates this view and suggests that while there was some positive gains for HCPs following an intrapartum fetal death, the majority of their experience was negative. There is currently a lack of training and support for staff, teams and organisations to prepare for and deal with witnessing adverse events during childbirth and support systems should be put in place.
- Health professionals need to understand the importance of communication and teamwork, both inter professionally and with women.
- Medical education should emphasise physiological birth and ways to facilitate this for women, placements on community where students could have the opportunity of attending homebirths could be considered
- Measures to improve cohesion between multidisciplinary maternity teams should be considered, staff morale will be improved by establishment of a Community of practice and adequate staffing. Continuity of care would improve safety of mothers and babies
- Education should be provided to students and staff on self-care and training in adverse outcome (emotional) management .
- Consideration should also be given towards the development and maintenance of Schwartz Centre rounds in maternity hospitals
- Physiological birth and safety are not mutually exclusive
- Safe physiological birth leads to healthier mothers and babies in the short and long term
- Women want support for birth choices which increase their chances of a physiological birth, they want access to water, mobility, privacy, the option of a natural cesarean
- Technology exists and is being used in units in the UK to allow continuous fetal monitoring (CFM) that does not restrict mobility and can be used in water
- Women whose hopes and plans for birth are respected and taken seriously, are more likely to feel that care givers are on their side, care for them and want to ensure the safety of them and their baby, they are then more likely to trust their opinion if circumstances change, and negotiate a birth that is both safe and leaves them feeling happy, empowered and untraumatised.
Mobility and CFM
VBAC in water
Commissioning for safe healthy births
Ethics and VBAC
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