Part of the tipping point: a time to ROAR

Reflecting on the roar....Torquay, Australia

Reflecting on the roar….Torquay, Australia

What a month February 2015 has been so far.  We are in Australia on an extended holiday, and as well as enjoying the positive culture and bright skies, I’ve been lucky enough to be part of so many inspiring maternity related conversations, twitter chats, initiatives and book publications. The ‘Tipping Point’ in maternity services, that I often talk about, is ever closer.

From the other side of the world I am excited and encouraged to see the connection of so many like-minded individuals in the UK, ‘meeting’ on Twitter, helping to improve the maternity experience for women and families in England. Initiated by the wonderful Kath Evans, head of patient experience for NHS England,  Gill Phillips, founder of ‘Whose Shoes’ is working closely with midwives, obstetricians, policy makers, parent organisations, academics and most importantly those using maternity services, to find out what really makes a difference to those using maternity services. Florence Wilcock, #FabObs obstetrician and divisional director at Kingston Hospitals in London, and a member of the London Maternity Strategic Clinical Leadership Group, is helping to lead this much needed initiative. You can read about, follow, and get involved on Twitter here #MatExp. The project is gaining momentum and beginning to influence services in London, and the fact that social media is being used to spread the word, to engage and to influence is adding to the success. It means the potential for exclusion is reduced, and collaboration increased. I can’t wait to get involved in person when I return to England.

I’ve also been privileged to review two fabulous books. The first is Milli Hill’s inspiring book ‘Waterbirth: stories to inspire and inform’ which is a collection of personal accounts of waterbirth, by mothers, fathers, siblings and maternity care workers and you can read my thoughts about the book here.

I finished reading the review copy of Rebecca Schiller’s new book All That Matters: Women’s Rights in Childbirth yesterday, and I was rocked. This superbly crafted and revealing book, written for the Guardian, is a ‘must-read’ for all those providing maternity care, and if we really aim to tip the balance, policy makers, parents to be, teenagers, in fact each member of society would do well to read and act on Rebecca’s words.  Rebecca is a mother of two young children, a writer, doula and birth activist, and she begins by making it clear that her book is about women, yet acknowledges those who support her during childbirth. She also clarifies early on that her book, whilst highlighting many appalling situations around the world, suggests that the problems are usually systemic and cultural, and not the fault of individual practitioners.

As well as detailing the horrors of reality that women experience in  several countries, All That Matters is full of insightful conclusions, which gave me assurance that Rebecca really understands personally and politically, what is happening around childbirth practices globally, and what needs to be done. There are examples of excellence too, where organisations and countries have responded to potentially damaging reproductive care practices and are providing positive approaches to supporting women around conception, pregnancy and childbirth. Connecting ‘childbirth’ as a reflection of societal attitudes, and feminism, really resonated with me…

‘As a mirror to society, childbirth, the attitudes to it, practices around it and experiences of women going through it, reflect the progress that has been made in advancing women’s rights’

I could carry on here explaining why you should buy and read All That Matters. I could fill two pages or more. However Maddie Mahon, doula extraordinaire, has written an excellent review of the book here, which represents my opinion and reflections too. Rebecca Schiller’s book is more than timely. It is being released just shortly before our book, The Roar Behind the Silence: why kindness, compassion and respect matter in maternity care.

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This is incredible, as collectively these books hold the potential to inform and influence the ‘tipping point’ by adding to the evidence already available that improving maternity care and respecting women’s rights enhances societal wellbeing.

Claire with baby, and Lynda her midwife and friend

Claire with baby, and Lynda her midwife and friend

And finally, I want to share this beautiful photograph of Claire having skin to skin with her newborn baby, and her midwife, Lynda Drummond. I worked with Lynda many years ago, and also supported her after a traumatic birth experience. I saw this photo on Facebook, and contacted Claire to ask if I could use it. This is what Claire said:

‘I’m so glad you like this photo, I really do. Through each of my 3 births my midwife has seemed like my angel and I’ll never forget the roles that they each played. Although Lynda was at my 3rd birth as a friend to me, she was the one who helped me get the birth I had always wanted, having her there gave me the confidence I needed to believe I could do it, she had me laughing and dancing throughout the labour, she managed to persuade the midwives on duty that I could go in the pool even though my first birth was an emergency section . This photo to me sums up how utterly amazing she is, gentle, caring, supporting, angelic. I hope she knows it.

 

I’ve also included a photo of me at 7cm dilated, the big cheesy grin is totally drug free and totally genuine. All down to Ina May and Lynda Drummond……… oh and the cheesy radio station playing Valentines day songs, I think Rod Stuart ‘If you think I’m sexy’ had just been on!’

Claire Riding

With our book in mind, I look at Claire’s birth photo and description of her midwife, and I sense the Roar Behind the Silence.

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The right to choose home birth: a debate in the UK

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Clara Ruth’s birth at home: meeting her family!

I am always alarmed, though not surprised, to see press articles such as this questioning the ‘rights’ of women requesting a home birth.  Over a period of 35 years as a midwife, I have cared for scores women who have given birth at home, and those occasions have been some of the most rewarding moments in my career.  We now have clear evidence that home birth is cost effective and safe.

My district nursing sister (who had her babies at home) tells me that when loved ones wish to die at home, the request is always respected. Services are mobilised to ensure those precious end of life moments are as comfortable as possible. To me, this is fundamental stuff, and choice at the beginning and end of life should have equal priority.  Yet in the above article, lawyer Barbara Hewson is quoted as stating that ‘mother’s don’t have a right to choose a home birth’.

I noticed that the Royal College of Midwives is debating this very issue at their forthcoming conference in November.

I was surprised that an obstetrician is speaking on the topic, and we are to hear perspectives from a panel made up of a lawyer, an obstetrician and a journalist. But where’s the midwife? Isn’t the midwife the one who facilitates home birth?

So I thought I would ask some questions to a similar panel, but to include a midwife, to get a debate going…please add your comments and experiences at the end of the post, and add to the conversation.

 The panel:

Professor Soo Downe OBE (Midwife)

Elizabeth Prochaska (Lawyer-Public Law and Human Rights)

Milli Hill (Journalist-Mother-Doula)

First of all, what do you think about the newspaper article, and Barbara Hewson’s stance on the matter?

 

SD: I was rather surprised to see the statement that women don’t have a right to a home birth in the UK. As far as I understand it, the Midwives Act 1902 gives women this right, by virtue of the fact that the midwife must attend a woman in labour if called. So, at the extreme, whatever clinical or social situation she is in, a woman in labour at home can call a midwife to her. Obviously, it is much better if this doesn’t happen at the last minute, and if this right to be attended in labour is translated into a an obligation for the maternity services to provide good antenatal care and planned support for the labour, the home birth right-or-not debate becomes a red herring.

The debate also sets up women in opposition to the fetus, and the midwife as having more obligations to her employer than to her Code of Practice and professional moral standards. Both of these developments are very sinister, and both should be resisted.

MH: Although my first reaction to the newspaper article was negative, on reflection I think the article is interesting.  To me it looks like an editor has given it a very attention seeking headline and chosen a particularly provocative sub heading (sometimes called the ‘sell’), which sadly complies to the popular notion that home birth is dangerous and probably shouldn’t be allowed.

However, the article is not really saying that birth is dangerous – Barbara Hewson balances this statement with the fact that birth can equally go wrong in hospital and that the litigation culture is probably causing unnecessary interventions. Nor is Hewson saying that ‘mothers don’t have the right to a home birth’ – although she is unpicking from the legal angle the question ‘what are mother’s rights when it comes to home birth’ – a subtle difference that the editor perhaps ignored in their search for traffic.

As a mother who has birthed at home twice (once last month!), the article made me very uneasy. When you put it alongside the current situation in Ireland highlighted by the recent case of Aja Teehan – and the current situation for Independent Midwives in the UK – and a similar struggle to save home birth in France – which I understand is also happening in South Africa… and then read details of the RCM conference debate – it really starts to feel almost like a backlash against the movement to reclaim birth.

Home birth – for me – was the place where I felt safest from unnecessary intervention – and I speak as someone who experienced an episiotomy and forceps delivery in hospital for my first birth, purely because the clock dictated I could not have any more time, although myself and baby were well.

In my two home births I have experienced how birth proceeds so normally in a safe and loving environment, and how wonderfully empowering it can be to birth your baby yourself, with nobody taking control or telling you what to do. I wonder why there is such an energy across the western world that seems determined to prevent women birthing like this? Is it really all about safety?

EP: Lawyers often have different views on the right interpretation of the law and there are rarely clear-cut answers to legal questions, especially when the question hasn’t been considered by a court. Nevertheless, when a lawyer purports to explain the law (rather than give their own opinion about it), it is incumbent on them to give a clear and balanced account. It is a shame that the headline to the article suggested that there is no ‘right’ to home birth, as this is not an accurate reflection of the law, and did not reflect the nuance of the article.

What are the mother’s legal rights to a have a home birth, and does it make a difference ‘if things go wrong?’

SD: Even in the very rare situations where the choice a woman makes for place of birth might lead to a very real risk to the baby, there is still no legal grounds for denying her her autonomy, as far as I’m aware. Consider, for example, the case of two identical twins. One is terminally ill with kidney failure, and his twin is the only possible donor match. However, for reasons best known to himself, the healthy twin refuses to donate his kidney to save his brother. Is there any conceivable situation when it would be legally and morally acceptable for the healthy brother to be taken against his will to hospital, subjected to necessary drug treatment to prepare him for surgery, be operated on against his will, and have his kidney removed, for the sake of the brother, however much we may struggle to understand the rationale for his refusal?

Why is it different for women who are refusing to go to hospital for the sake of their baby?

MH: Since learning about the case of Ternovsky vs Hungary at the European Court of Human Rights, I have been under the impression that women have a human right to give birth wherever they wish.

What Barbara Hewson seems to be saying is worrying – essentially that, although women may have the ‘right’ to give birth where they like, the state does not have an obligation to provide them with care in any setting, if this is not practical or they deem the birth to be too risky. This is exactly what has just happened to Aja Teehan, and it seems we are only a whisker away from a similar situation in the UK – the whisker being, as Hewson points out, that the NMC states that midwives have a duty of care to attend a woman no matter what.

Some women who are aware of this will currently insist on attendance by a midwife at home even if their local hospital states that they do not have enough staff to provide one.

But it would only take a small change – an insurance issue, for example – for us to be in a situation where it was impractical or even illegal for a midwife to attend a woman at home regardless of their employer’s wishes.

‘Things going wrong’, insurance, and the desire to minimize or even eliminate risk seem to be at the heart of the issue. Having had two ‘uninsured’ home births with Independent Midwives, I think it’s worth reminding ourselves that insurance only pays out in the case of negligence, and that ‘things going wrong’ in birth does not necessarily mean someone was to blame or that we would have been safer in hospital. I also feel that myself and my partner were capable of assessing any risks involved in home birth – exercising our autonomy as we did so, and being prepared to take responsibility for our decision no matter what happened.

Perhaps the most controversial aspect of Hewson’s piece is that she implies that mothers (and fathers) of unborn children may not be the best people to decide where their baby is born. She talks about births at home against medical advice that had tragic consequences. And she finishes by saying that insisting on having a midwife attend you at home against their employer’s wishes may not be ‘wise’.

This, too, is at the crux of the debate – who should decide where a baby is born? Of course, my view is that it should always be the mother, and that she can absolutely be trusted to make the right decision about this. However, this view is not shared by everybody – many still subscribe to a ‘doctor knows best’ attitude and are reluctant to examine the actual facts and figures that underpin medical advice and decisions. As Labour party Counsellor Ronan McManus tweeted in response to AIMS Ireland, “allowing someone untrained and emotionally involved to interpret the evidence is a dangerous trend.”

This breathtakingly misogynistic view sums up the problem that many people have with home birth – it puts the power and autonomy back into the hands of the mother, which is ‘dangerous’.

The voice of a home birth mother – or any mother – also seems conspicuous by its absence at the RCM debate?

Again I’m wondering – is the current backlash against home birth part of a drive towards safer births and better outcomes? Or does it contain an undercurrent of an age-old desire to limit or destroy the power of the birthing woman?

 

EP: We need to start from the basic premise that women are the best and only judge of where they give birth. If we start to question their capacity to make that decision, we undermine centuries of hard-won legal autonomy and we wouldn’t be far from advocating forced c-sections, which Barbara Hewson was instrumental in prohibiting in the 1990s.

The simple legal answer to the question whether a woman has a right to give birth at home is: yes, of course. She has a right to make choices about the circumstances in which she gives birth, including where the birth takes place. This is uncontroversial as a matter of English common law (which respects autonomous decision-making) and under Article 8 of the European Convention on Human Rights (which protects the right to private life and associated right to physical integrity).

A woman cannot be compelled to accept hospital services and she may give birth where she chooses. The real issue is whether this ‘negative’ right translates into a positive right to midwifery assistance at home. The European Court has recognised that the state is required to take steps to enable this positive right, but there will be acceptable limitations that can be placed on it. Barbara Hewson’s article dealt with those potential limitations. She suggested that staffing shortages might be one such limitation. In the absence of a case determining this point, we can only say that there may well be circumstances in which staffing issues would justify a limited service and cases when they would not. There isn’t a blanket rule when it comes to factual conditions that justify limitations on rights. Certainly, government and NMC policy mandating attendance of midwives at home would inform the court’s assessment of hospital decision-making about home birth.

You can read more about the debate on the Birthrights website: www.birthrights.org.uk

 

How can we ensure that the balance is right, with respect of what the woman wants, and what the care-giver wants and is able to provide, ensuring safe, high quality care?

 EP: The question of service-provision isn’t really about balance, it’s more about what women can reasonably expect from their maternity services. Clinical Commissioning Groups (CCG’s) in England and Health Boards in Scotland and Wales are under an obligation to provide services to meet local needs. Women invariably need to be provided with a variety of options for maternity services, including home birth. CCGs and Health Boards are also under an obligation to have regard to government policy on maternity choices, which requires them to make home birth available as a choice in all areas. In essence, women can expect to be provided with home birth services and should hold their local decision-makers to account if they are not provided, or are unreliable.

Do you think the issue of choice in place of birth influences the relationship between mother and midwife, and if so, why?

 

SD: Good maternity services = skilled and compassionate care in an authentic relationship with the woman. And this includes a stop to the quibbling about facilitating home birth for women, especially when the evidence says it is the most economic and safest place for most low risk women and babies to be;  and a turn towards providing the best possible care for women and babies in the place that suits them best.

EP: All the evidence suggests that choice of place of birth can have a profound effect on women’s experience of their birth experience, measured not only in improved clinical outcomes (and consequent public health savings) but also in terms of long-term emotional consequences for the mother and child. Continuity of carer, generally only achieved when the mother chooses a home birth, has a particularly positive effect for women, presumably because women build a trusting relationship with their midwife that enables better care and support. It is no surprise that the Department of Health seeks to promote home birth as a result.

 

If you have anything else to add….

MH: I don’t think the question should ever be asked, “Do mothers have the right to give birth at home?”, or, “Do women have the right to give birth where, how and with whom they choose?”. A woman’s right to have her baby where and how she chooses seems so fundamental to me and it feels wrong and dangerous to even question that basic right.

However, there are questions about the practicality of home birth in such times of midwife shortages, insurance issues etc, that are worth asking. Why are the RCM, for example, not debating ‘How can we encourage home birth to increase and flourish in the current climate?’, that would seem to make more sense.

We would like to know your thoughts, to start the debate…

More about the contributors

Milli Hill:

Founder Positive Birth Movement Twitter: ‪@birthpositive

Editor Water Birth: stories to inspire and inform Twitter ‪@waterbirthbook

Birth Columnist for Best Mag Daily ‪@BestMagDaily

Blog: the-mule.com Twitter @Millihill

Elizabeth Prochaska:   

Lawyer, Matrix Chambers 

Founder: Birthrights Twitter @birthrightsorg

Professor Soo Downe OBE

Professor of Midwifery University of Central Lancashire 

Previous post interviewing Soo Downe

Home Birth in the Netherlands……back to the future?

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Human Rights in Childbirth Conference
The Hague

Attending the second day of the Human Rights in Childbirth Conference  in the Hague on the 2nd June was a revelation, and a remarkable opportunity. I was unable to be part of the first day, as I was travelling by car to the Netherlands for a two week stay to see our brilliant Dutch grandchildren. When I wrote about the conference previously, I didn’t think I would be able to attend at all.

It was Hermine Hayes-Klein, an American Lawyer, who developed the idea for a conference with others after researching the politics of birth in the Netherlands and USA following the birth of her two children. Women’s right and authority to choose the place of birth for their baby, and to be supported in her choice was the key driver for Hermine.

The first day of the event aimed to bring attention to and focus on the issues surrounding the Ternovszky v. Hungary case. Although I thought I knew a fair deal about the horrific plight of Agnes Gereb, I learnt so much more as I absorbed the text within the conference’s detailed publication.

The implications of the Ternovsky case are apparent in other countries other than Hungary, and the holding of the case offers a potential solution globally. Experts from around the world were carefully chosen and they gathered willingly to debate human rights and childbirth and explore a way forward.

Day two was of particular interest to me because of my family link with Holland, and as an advocate of home birth, midwifery and maternity care in the Netherlands has always caught my attention.

It was utterly incredible to be in Den Haag and to listen to the debate surrounding birth in this small country. I found Dr Raymond De Vries‘s keynote address inspirational, and I couldn’t get enough of it. From Dr De Vries and then the panel of experts I heard an array of perspectives about the controversy surrounding the perinatal mortality rate in Holland, how it is higher than other European countries and proposed as one of the factors that is influencing women’s decisions on where to give birth. I heard how these statistics are being challenged, and how health professionals are exploring every opportunity to understand the situation.

Another issue raised was the Dutch maternity guideline, Verloskundige IndicatieLijst (VIL) and the restrictions it increasingly imposes on women’s choice to birth their baby at home. The introduction of market forces within Dutch health services and changes to how maternity services are funded is also believed to be a factor in the decline in home birth. And some suggest that some women in Holland have different priorities and are preferring to give birth in hospital…although others contest this claim.

I was particularly moved by Rebekka Visser  and  Marjolein Faber‘s address to the conference, they received standing ovations from the delegates and they gave the impression that they are forces to be reckoned with.

So what did I learn?

1. A country that has been the shining light for birth practice globally for decades is potentially under threat, and that is a travesty. I desperately hope the Netherlands doesn’t follow other countries in their quest to improve.

2. I realised that during my career as a midwife in East Lancashire in the UK I experienced something special. Because…

During her address Rebekka Visser said:

To me it’s of great importance to really listen to the woman –
and to the way she assesses risk for herself.
To guarantee absolute trust that she is the one in charge.
To provide her with all the information she asks for.
To be open about this towards other people.. My dream is to be able to do my work as a midwife in close cooperation with gynecologist and hospital, thus creating a network where women can be respected and supported in their choices.

I was able to provide such care. Obstetricians working closely with midwives to facilitate woman centred care collaboratively meant (and still means) that women do have a choice in home birth, birth centre birth and hospital birth…and their choice is respected and supported even if their individual needs and requests do not ‘fit’ a guideline.

3. That women in Holland using maternity services now and in the future need to ensure their voice is heard and maintain momentum from the conference. It is crucial.

I feel privileged to have been part of what I consider to be the cusp of a birth revolution. If you would like to learn more  you can visit the conference website and consider subscribing to the webinar.

You may also wish to read comments on Twitter from the two days, and pursue the various links from the posts.

Many thanks to Simone Valk and all the conference organisers for welcoming me on the 2nd.

Other blogs about the Conference:

Rebecca Schiller-The Hackney Doula

Dr Amali Lokugamage 

Human Rights and Childbirth: the mother, the baby and the carer

Human right to birth; human right to love

So much attention has been given to this topic in the midwifery world recently, due to the dreadful situation in Hungary with Agnes Gereb. And of course there is much concern about the future of Independent Midwifery in the UK.

Across the water in the Netherlands where my son and grandchildren live, a group of activist are rallying experts to debate the issue of women’s choice in place of birth.  The group have organised a unique  conference at the end of the month in the Hague, and a webinar that will be LIVE streamed and available for 30 days following the conference.  This webinar is being offered at a discounted rate if you book via the discount code detailed below. 

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The organisers are a small group of dedicated volunteers and have been working hard to get the conference funded and ready in time.  They are happy to report that the conference is going ahead, although it has been on a shoestring budget.  The line up of panelist is impressive; a team of international voices to help move the subject of human rights in childbirth from theory to reality.   The conference will be a platform to explore the practical aspects of human rights in 21st century healthcare systems, and how those systems can both maximize safety and respect the dignity of the women they support.

For details please visit the website: www.humanrightsinchildbirth.com.

About the Human Rights in Childbirth Webinar: 
This webinar provides a unique opportunity for professionals and parents around the world to be a part of the global discussion on human rights in childbirth.   The Human Rights in Childbirth Conference will be LIVE streamed by a professional team, so you can watch live and join the discussion via twitter.  If you are unable to join live, you will be able to watch the conference panels at your leisure VIA THE WEBINAR for 30 days following the conference, join the ongoing discussion via the Facebook page, and connect with the regional and international networks of professionals capable of protecting women’s fundamental right to authority and support in childbirth.

The organisers want the conference to be accessible for my contacts, and they have negotiated a special price for you to join this important event!

Regular Price: €175 inclusive the pre-conference publication.

Special Price for Sheena Byrom’s community:  €75 pre-conference publication not included.

How to get this special price:

1.    Go to the Registration Form: Registration Page

2.    Fill in the registration form and select the webinar (you will see the regular prices but don’t worry you will get your discount!), in the field “How did you learn about the conference? *” fill in “Catching Babies Discount”

3.    Do not pay by clicking on the PAY PAL directly (then you will pay the regular price). You will receive a confirmation email from our office with the discounted price and you can pay either via PAY PAL or via a bank transfer.  The details for this will be provided in the email confirmation (this is created by a human, it is not an automatic mail, so won’t be sent directly).

I think this is an amazing offer; by engaging with this event you will have the potential to influence global change in maternity care, through increased knowledge.

Congratulation to my colleagues in the Netherlands for their hard work and dedication in making this possible.