Make Birth Better Network
www.makebirthbetter.org
October Workshop – Birth
Present
Emma Svanberg – Clinical Psychologist
Rebecca Moore – Perinatal Psychiatrist
Debbie Chippington Derrick – Chair of AIMS
Beki Hogan – Lived experience contributor and BBC journalist
Chloe Mulholland – Midwife
Sophie Fletcher – Clinical Hypnotherapist, Mindful Mamma
Sophie Burch – Hypnobirthing teacher & Cognitive Behavioural Hypnotherapist
Minutes
We updated the group on the last meeting. We had many apologies for this
workshop, due to the proximity of the date to the previous workshop. Apologies
for this, but this was the only week in October both Becca and Emma were able
to attend.
Matters Arising
Since the last meeting, Emma & Becca have been approached by NHS England to
bid for co-creating a document. We have decided, alongside some partners, to bid
and will let you know more as soon as we do. We hope to use the very rich data
we are collecting within the workshops to inform this work. Whether or not we
get the bid, though, we have a number of plans for future work and campaigns
already arising from the workshops and conversations to date. The material we
collect from the workshops will be used to expand on the ‘Trauma-Focused
Maternity Journey’ Emma drafted after the Make Birth Better birth stories
campaign.
Northern Branch
Jan has agreed to set up a ‘Northern branch’ of the Make Birth Better Network,
and will be chairing a meeting in November at the same time as we meet to
discuss the postnatal period. If you’d like to go along, email her on
janice@healthyyoultd.co.uk
Social Media
Sophie B will email some pointers around for social media posting
Barnsley Conference
Becca fed back from the Barnsley conference, which was a very inspiring day. In
particular, we discussed a presentation on how to respond to error as an HCP.
! Becca to send details
Workshop
As in our previous workshop, we held a discussion then broke into smaller
groups to explore the key focus questions. The key themes arising from these
discussions and feedback from the breakout groups are detailed below:
Empathy
Throughout the discussions, empathy was raised as a key concern – it can be
difficult for staff to be empathic, particularly when they are overworked but also
as they may lose awareness through their own experience, of how monumental
this experience is for a woman and her family. The need for empathic
interpersonal care was emphasised, with the relationship between a woman and
her healthcare professional being an opportunity to influence the outcome of her
experience. The question was how can HCPs remain kind when under immense
pressure? Rather than ‘box-ticking’, or following a script, how can HCPs
continually ask parents and other staff ‘how are you?’
Language
A key topic of the discussions was around language. Beki shared her experience
of birth, and we discussed the balance HCPs need to strike when there may be a
medical emergency, but the urgency of the situation can be highly distressing for
a mother – which often seems to be unacknowledged in traumatic situations.
There is of course a human element to this, a medic may be panicking too, but
finding a way to contain this and remain compassionate could be the difference
between leaving a woman (and her partner) feeling traumatised or feeling held.
How can medical terminology be framed in such a way to minimise distress but
get across the urgency of the situation (NB. BMJ Blog on language, AIMS poster).
Sophie F shared the work she does with professionals around reframing
language. The ‘Israeli model’ was raised – a project at Rabin Medical Center-
Helen Schneider Women’s Hospital where ‘hypnotic language’ was used to
reduce pain (Sophie F has more information)
! ACTION – Social media campaign about language to be conducted
! IDEA FOR THE FUTURE – Sophie F to work with MBB on reframing
language training workshop
Choice and Violation
We shared the frequency with which women describe their birth as ‘assault’ or
‘violation’. This is both in physical terms (e.g. one attendee was incredulous that
internal examinations are still standard practice considering how many other
ways there are for progression of labour to be assessed), and in removal of
choice. We acknowledged that the argument that complicated births lead to the
need for choices to be made by HCPs as flawed, due to many examples of
complicated births where women have felt central to decision making. Even in
more complicated situations, there are examples of women-centred care (e.g.
Andy Simm’s work around gentle C section).
Training
One training need identified was the need for staff and birth partners to know
what it looks like if someone begins to dissociate, and being trained in grounding
techniques. There was a question about whether hypnobirthing could trigger
dissociation in women with previous histories of trauma?
It was reiterated that trauma-focused training would need to address every level
of care- not just maternity ward staff but also receptionists, GPs, A&E staff etc.
The Birth Plan
Birth planning as a topic came up repeatedly – and the discrepancy existing
between women being encouraged to plan and then being faced with resistance
when they come into hospital. This leads to the entire plan feeling ‘derailed’.
Reasons for this:
• Birth plans may feel overly simple or idealised to staff, so that when
something does not ‘go to plan’ this can feel catastrophic and quickly
creates an ‘us vs them’ dynamic
• Fear of litigation. Midwives may see a plan and feel anxious about a
woman’s requests (“I’m not risking my pin, I’ll get in trouble”)
• Lack of continuity of carer – it is difficult to plan with a midwife you do
not know, and without awareness of what might be available or possible
in your Trust.
We discussed how helpful it would be – both in terms of risk and expectations –
for conversations to be had antenatally in the birth planning process so that
women and their partners are aware of the different events that can happen, are
offered non-biased evidence based advice and support in their decision making.
In this way birth plans include what is right for that particular woman in her
particular circumstances, rather than around the needs of the maternity system.
Often, sharing information can be framed in a way that is persuasive, due to a
‘compliance culture’. AIMS help women in thinking about what to say if they
would like to decline a particular intervention, but there is a need for midwives
and HCPs to also feel supported in helping women in these circumstances. At the
moment, they rely on ‘resilience’ if a decision is against Trust advice.
Declining Care
The difficulty women have in declining care, and for HCPs to accept this, can be
very hard to navigate. Women often feel that they have to ‘put up a fight’ and
HCPs may be concerned about how this will reflect on their personal practice.
The ‘Dead Baby Card’ was raised as a phrase women still hear too frequently. We
discussed how much more women-centred NICE guidance has become, but this
is not always reflected in services.
Involving the Birth Partner
Often birth partners can feel excluded from the birth process, particularly where
difficulties arise and they may not be communicated with. Antenatally, it may be
useful to think about communication between partners and with HCPs (Mindful
Mamma integrate this in their antenatal courses). It is helpful to also think about
and work with the birth partners’ fears. We discussed examples where the
anxiety of the birth partner has been used in a coercive way to influence the
birthing woman. Mark Harris’ Birthing 4 Blokes was mentioned as a useful
resource for fathers.
Birth partners often become a partner in the trauma, but can also be ‘heroes’
when women are feeling vulnerable. They could be a fantastic support for
women if they feel properly supported themselves.
Involving Others
Some Trusts have used doulas (C&W had an early labour ‘nest’ employing
doulas, but this has now been closed. There was some uncertainty in the Trust
and from parents about the role of the doula). We wondered about areas where
there has been successful shared care between doulas and NHS, also
independent midwives (e.g. Neighbourhood Midwives, 1 to 1 Midwives, Sanctum
Midwives)
We also discussed how little women are encouraged to think carefully about who
they would like to be present at birth. This is not usually part of antenatal
education.
! ACTION POINT – Search for examples of successful shared care
between NHS and external providers
Education
We again discussed how information about mental health needs and support
might be disseminated to reach a wider group, not just those who ask for it or
are felt to be in need. Leaflets are often handed out, but new parents may not feel
inclined to read this. This creates an impression for women that ‘there is nothing
out there for them’.
Could we make better use of red books and handheld notes? It would be useful to
have many different points where parents and staff can gather information about
mental health, birth trauma and available support.
Best Beginnings’ videos are all aimed at reading age of 8, and are accessed widely
by those who do not speak English as a first language. This could be useful when
sharing information
! ACTION – Emma to find out what is in red book and handheld notes as
standard
! ACTION – Debbie to inform us about NHS Digital Meeting
Continuity of Care
Again, this topic arose throughout the discussions, in relation to support during
labour, help with birth planning, language used and so on. Women are more
likely to feel they have choice, are respected and feel supported if they have a
trusted HCP with them.
There were doubts raised again about the likelihood of continuity of carer being
implemented. Emphasis was placed instead on continuity of CARE not careR – if
all staff have a similar ethos and overarching way of working, as well as more
efficient information sharing systems, this may be one way of promoting
continuity. However, for women who have a previous history of trauma it may be
particularly important to have continuous care with a trusted professional.
Psychology Staffing
There are a number of examples where a psychology service sits within the
maternity setting – Hillingdon Hospital, Warwick etc. It was noted that this still
does not feel like enough staff to adequately support all families and members of
staff. At St Thomas’, there are two psychologists on the ward, 2 within IAPT and
1 in the PIMH.
Role of MCA
We discussed the role of the Maternity Care Assistant and whether this could be
broadened. This may be for extra support if birth has become more complicated,
so that partners have someone there with the explicit goal of offering emotional
support if needed. Also, e.g. for A&E liaison for women attending with emergency
needs, and for the post partum period, and in NICU to offer support when other
professionals are not available. Some reflected that this may be as simple as
‘hand-holding’, offering active listening.
The Birth Environment
It was acknowledged that many antenatal courses focus on environment, and
that a dark and peaceful environment in an undisturbed setting can promote
straightforward birth. Natalie Meddings has written on the difficulty in giving
birth in standard hospital settings. A number of ideas were raised to create
positive environments within hospital and birth centre settings:
• Photos of birth and positive birth experiences around the location
• Equipment ‘hidden’ unless needed (e.g. Mansfield, equipment behind a
wood panelled wall, a curtain would also be useful)
• Arrange rooms - bed pushed away from centre of the room, low lighting
etc.
• There is a stark difference between birth centre and labour ward. Could it
not be possible to make them more similar. It can add to feelings of
dichotomy around ‘natural’ and ‘interventionist’ birth when there are
such strong differences, and the environment of the labour ward may
make it more difficult for women to labour (see Natalie Meddings).
• There was an expressed need to protect the ‘culture’ of the birth centre –
we discussed areas where women are brought to the birth centre due to
lack of beds in the labour or postnatal ward and how disturbing this can
feel.
• As more women are being identified as high risk, birth centres are closing
– so there is an urgent need to ensure that all environments are looked at.
• More generally, in many services there is a need for better
communication and support among obstetricians and midwives, to bridge
differences in culture. This might support a whole-team dynamic change.
Obstetricians often do not witness many (sometimes any) uncomplicated
births.
Whole Systems
One theme which arose, and which often arises in discussions around birth, was
how quickly ideas become dichotomised, creating an ‘us-and-them’ dynamic.
Discussed how often discussions around birth become about safety – as of course
for everyone the safety of mum and baby are paramount. Discussion turned to
the increasing evidence that woman-centred care is not only safer but leads to
more satisfactory outcomes. Yet, there is an increase in intervention, increase in
women experiencing complications. 40% of women are now considered high
risk.
One idea which came up was to have somebody on the ward who has a ‘traumafocused
mindset’. This could be a psychologist, a specialist midwife, perhaps a
birth trauma specialist midwife as a new role. At least one person to hold in mind
the impact of historical trauma and birth-related trauma on not just patients but
staff too, to be mindful of language, consent issues and signposting for
appropriate support.
NB for postnatal workshop – we also had a discussion about how much
defensive practice can influence the birth experience. When families do decide to
seek legal advice, often claims can take years to settle causing prolonged distress.
We discussed the Swedish model, where there is a system of rapid redress. Here,
HSIB may serve a similar role?