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The Midwife

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Hi Chloe, many thanks for agreeing to talk to me. Could you tell me a bit about you and your work? 

 

My name is Chloë Mulholland. I am a midwife, a teacher and a mother. I currently work at a busy central London hospital and over the years I have worked as a community midwife attending home births, on the Birthing Unit, on the Postnatal Ward and on the Labour Ward. A varied experience indeed, which has shown me the many different types of birth experience.

 

 

Is there anything you wish all women and their partners knew about birth? 

 

I wish everyone knew what was normal. I wish everyone knew the physiological process (not down to a cellular level) but I wish they knew how the baby and the mother’s body work together to birth the baby. I wish everyone knew the importance of ‘undisturbed birth’- by that I mean the importance of a safe, calm, non-threatening environment. I wish everyone knew that everything is their choice, that they never have to agree to something that doesn't feel right and they should never be pressured to do something with inaccurate information.

 

I wish everyone knew the facts, not the scary stories spread by the media. I wish they knew how safe home birth is for a lot of mums. I wish they knew what a positive birth can look like- be that at home or in hospital, wherever, but I wish they knew what it looked like for a mum to be at the centre of the care, to be respected and to be listened to. 

 

I wish the common misconception of birth was completely overturned.

 

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Many women talked, in their birth stories, about feeling that they hadn’t been well prepared for what could happen during birth – from minor surprises to unexpected emergencies. How do you think women and their partners could be better prepared for different outcomes, without raising anxiety and fear?

 

We can do this by talking about scenarios where there will be a number of staff in the room, that this is common and doesn’t mean that the worst is happening. We are just lucky that when we need them we do have a lot of staff on hand to help. Also, that if you go into theatre to have your baby there will always be a lot of staff there, whether it’s an emergency or not. It’s really normal.

 

We could also share pictures of normal equipment found in a birthing room. It can look quite scary, especially if mums think that it’s not normal for that equipment to be there. If they know that it’s normal and routine for certain equipment to be in the room, then it takes some of the fear away.

 

 

Could women and their partners do anything to prepare themselves for an emergency outcome or difficulties arising during birth?

 

 

This is a difficult one. I don’t think there is any way of preventing an emergency, except for iatrogenic complications that arise (those caused by medical intervention). This would involve using less medical intervention in the first place, but of course that is easier said than done and I think this is down to doctors and midwives, rather than individual mums.

 

This frequently came up in women’s birth stories, Chloe – the influence of staff and services on a woman’s traumatic experience. You’ve said before that no healthcare professional goes to work wishing to cause trauma – so why do you think this sometimes ends up happening?

 

I think there is a pressure to get women to agree to care within the clinical guidelines of the hospital. Even though we are told that they are only guidelines and not protocols to be adhered to strictly, if a woman chooses care outside of the guidelines there can be a sense of responsibility bestowed upon the professional caring for her. These things are not necessarily spoken but they are there. Thoughts of ‘what if it goes wrong and I get blamed?’ or ‘will I get into trouble for allowing that decision to be made?’ or ‘if I don’t get her to make that decision then someone more senior will just come in and scare her into agreeing to it anyway’. It’s a fear of losing your professional registration, a fear of being mocked by colleagues, of being seen to be ‘soft’, a fear of being taken to court. It’s all imagined and in reality, not very likely but it’s there and it’s hard to ignore.

 

I also think we fear that we don’t have the time to fully explain the risks and benefits of an intervention, so we may just give the details we think will lead to the woman opting for the choice recommended by a guideline. This can be especially true in short antenatal appointments, when you don’t want to be running late for the next woman on the list. 

 

 

Women often spoke about feeling that things were not explained to them. Why might this happen?

 

This unfortunately happens all of the time. It can happen in clinic appointments, scans, on the wards, any time really. I think there are a few reasons it doesn’t happen. The most obvious reason is lack of time and I do think that this is a major factor, especially when appointments are only 20 minutes long and you have to keep to that time to see the next mum. However, there are some other reasons too. If a healthcare professional really went into the pros and cons of an intervention, there would be lots of mums that would be likely to decline that intervention. The trouble is, when faced with a mum declining an intervention, it can make professionals uncomfortable. There is a lack of knowledge of what to do next. The guideline doesn’t often say what to do when a mum declines a certain intervention, so it often requires input from a senior doctor. Finding that doctor and asking them to see the mum takes time and effort and it may well be that that doctor then persuades the mum to accept the intervention anyway. So, again, it comes down to time and a little bit of convenience I feel. I also think that there is a fear that if a mum declines something and there is a poor outcome for her or her baby, then the professional may worry about being sued or getting into trouble. They may also feel personally responsible for whatever happens and they may not want to live with any guilt associated to the situation.

 

What about the way in which it is explained? Some mums spoke about feeling that the language used by midwives and doctors was unhelpful, anxiety provoking or even aggressive. Is that something that is covered in midwifery training? 

 

This was covered in my hypnobirthing training. Talking about the power language can have on us and the effects it can create. However, I don’t recall it specifically being part of my midwifery degree. 

 

 

Some mums also spoke about disagreements they overheard between doctors and midwives. When this happens, how do you tend to deal with it? 

 

In this situation, my textbook answer would be to speak to the doctor outside of the room to discuss further. I would worry about causing a disagreement in front of the mum, in case she lost faith in her care providers.

 

In reality I may not speak up, it depends on the situation. I would need to feel very strongly that the doctor was making the wrong decision to actually disagree with them. 

 

Something that would certainly help me to speak up more would be if I knew the mum already. If I had already formed that bond with her then I would much more empowered to speak on her behalf and say what needed to be said.

 

 

And if a Mum or her partner is traumatised by their birth experience, how is that dealt with? Do you have services in place? 

 

Mums are able to debrief with a consultant midwife and/ or a midwife trained in counselling. The reason mums may not access this service is a lack of knowledge of its existence but I also think midwives may be reluctant to recommend it due to a lack of appointments or a lack of time to make the referral.

 

     

What about your own trauma following a difficult or upsetting birth? How is that dealt with?

 

It isn’t. I think there is sometimes a formal debrief for really traumatic cases but this is likely to be on a day you are working on the ward and unable to attend or on a day off, when you want to spend time with your family. 

 

 

Thanks Chloe, last of all - how do you think we can make birth better for everyone?

 

I think we need to have an overhaul of antenatal education. My experience of the local classes was less than inspiring and mainly consisted of what pain relief was available and when. Knowledge is power when it comes to childbirth and it’s no good trying to impart knowledge to a woman in labour, it needs to be done antenatally and partners need to be involved too.

 

I think we need to look after our healthcare professionals. To staff the wards adequately so that doctors and midwives can have a lunch break and time to drink water throughout the day. I think we need to remove the fear of litigation from staff. To empower staff to empower women to make the choices that are right for them, not just assume that ‘doctor knows best’.

 

I seriously believe that home birth is an important aspect too. A home environment naturally possesses all of the aspects of a good birth environment and if we can get that right, it is easier to get birth right. I know home birth will never be right for everyone but I am certain that it does have a role to play. It bemuses me that women are all too often told of the dangers of declining interventions but not told of the increased risks they face by planning a hospital birth, especially for ‘low-risk second/ third/ fourth time mums’.

 

Continuity of care also has an important role. We already know the benefits this type of care can bring to mums, and yet it is denied to many. Again, the risks of interventions always listed off to mums without being told of the risks of seeing a different midwife at each appointment. Selective sharing of information is inappropriate and unfair.

 

 

Staff need to be trained in sharing of information in an accurate and informative way. Telling a woman ‘your baby could die’ is not useful. The information needs to be quantified where possible and the risks AND benefits need to be shared. It needs to be accepted that women can make decisions for themselves and are able to take responsibility for these decisions.

 

 

We also know that birth is over-medicalised. We need to focus our energies into taking away medical interventions, when they are not needed. I think this means getting rid of ‘routine care’ and really looking at each mum as an individual. Fostering an environment where staff get to use their common sense, instead of feeling like they need to blindly follow a guideline. 

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Thanks for your time Chloe. 

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