BEING WITH THIS WOMAN

Birth Stories, motherhood

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Today is International Day of the Midwife and I couldn’t allow the day to pass without acknowledging a woman who has had such a huge impact on my life. This woman who I now consider to be a dear friend, is my wonderful midwife Natalie, who has supported me through my last two pregnancies, births and postnatal periods. When I state that having Natalie as my midwife changed my life, I don’t say that lightly. The birth experiences I have had with Natalie’s support have changed me profoundly as a woman, as a mother, have inspired my career and shaped the path my life is taking.

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Natalie was with me for the birth of my second baby, who was born at home under the twinkling lights of the Christmas tree (you can read my home birth story here). Unfortunately I ended up transferring into hospital due to losing too much blood. The decision therefore about where to give birth third time round was complicated. I loved my home birth experience but the advice and medical recommendation was for me to be on labour ward due to being at ‘high risk’ of having another bleed. I did not want to be on labour ward and so Natalie created what is known as an ‘out of guidelines care plan’ to accommodate me in the birth centre.

I went on to have the most incredible and peaceful water birth with Natalie by my side, feeling safe and supported in my choices (you can read that birth story here). In the end I lost so little blood, far less even than what is considered normal blood loss after birth. Which just goes to show that what has happened before, doesn’t necessarily happen again! However I don’t ever regret not giving birth at home third time around. The birth centre was like a spa and I loved my beautiful water birth. Mostly I’m happy knowing I listened to my intuition and I chose a birth place that felt right for me. I am forever grateful that I was given a choice and supported in my decision. I have no doubt that I would not have had the same experience had I followed recommendation and been on the labour ward under continuous monitoring.

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In the period where I was making the decision about where to give birth, I don’t think I ever considered how Natalie was feeling about things in her role as midwife, which is shameful to admit. I suppose I was naive and a bit ignorant, thinking that what I was processing and going through would not be having an effect on her. I was wrong and it turns out Natalie was feeling just as torn as me. In this wonderful piece, written by Natalie herself, it becomes clear just how heavy the weight of responsibility weighs on the shoulders of midwives. Not just their responsibility to follow guidelines and ensure a safe delivery of baby (which is big enough!) but to also consider the value of the birth experience itself for the mother, to respect and support her wishes even when they go against medical advice and to recognise the importance of mental wellbeing as well as physical, and how achieving that enormous balance can sometimes be extremely challenging, leaving midwives questioning themselves.

The world is lucky to have such wonderful midwives like Natalie in it, so on this day, International Day of the Midwife, I’m sharing these insights, in Natalie’s own words…

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To be a midwife, to be ‘with woman’, is to support her, inform her, hear her, nurture her and sometimes challenge her. There is an art to this delicate balance of support. We want women and their babies to be safe and healthy, in mind, body and spirit. None of us should ever underestimate the power that the birthing experience itself has on a woman and her state of ‘health’. What happens then, when recommendations for safe care are in conflict with a woman’s dreams?

This woman, Siobhan, will tell her story. I am the voice of her midwife and we have been through two pregnancies and births together. Siobhan had a very empowering and healing homebirth with her second son, an experience which I believe will fill her with joy for the rest of her days. But she also had her second haemorrhage at this birth and required a transfer to hospital for ongoing care. As we began her journey into her third pregnancy I knew that birth planning would be harder this time around, I knew I was going to ‘pop’ her bubble.

It is a great responsibility to be a midwife; even the language and singular words I choose to use can have a life lasting effect, good and bad. How do I begin to say, I don’t believe it’s safe for you to have your baby at home again? When I know she’s living and dreaming the experience already! Do you approach it sooner rather than later, to allow time for consideration and thought, or does that stress take away a part of their pregnancy? There is of course no easy answer to this and knowing the woman helps immensely.

I spoke of it early, around 28 weeks, I knew she would need time. My hospital guidelines strongly recommended labour ward care after two haemorrhages. I would of course support her in any birth environment and it was entirely her choice to make, but in the event of another haemorrhage, which seemed more likely than the last time, was home the right place for birth? I needed her to consider all her options, do all the necessary research and then feel safe in the place she chose. I think this challenge devastated her, the home birth vision slipping away amid fears of a catastrophic bleed. I am responsible for that, rightly so I think, but it doesn’t feel good, nor does the worry that you’ve used the wrong language, biased or pressured them?

Thank goodness for birth centres ☺

It’s not home I know, it never will be, but it’s a great middle ground. A protected space to make your own, a home from home with the philosophy of care to match but with medical assistance for that higher risk woman just around the corner, should you need it. Turns out, Siobhan didn’t need it, not this time. The birth of her third son was beautiful, she was beautiful and I was honoured all over again to be her midwife. It was calm and peaceful and this woman showed once again the immense strength that she has. But it wasn’t at home, and she didn’t bleed. Was I wrong, does she wish she’d made a different choice? Only she knows……

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(All photos by Susie Fisher: http://susiefisherphotography.com/)

Another factor that played a huge role in my experiences of giving birth was my hypnobirthing practice. Hypnobirthing is a bit like the psychology of birth and nothing to do with hypnosis or hippies! You learn how birth works on a physiological level so you are informed about your body. You learn how to let go of fears you are holding on to that are detrimental to the progression of natural labour. You learn techniques you can use to make your labour more comfortable. I guarantee by the time you finish a course with me, that you will be feeling excited and looking forward to giving birth! Because it can be amazing. You can find out more about hypnobirthing and the classes I run on my website The Positive Birth Company. I teach monthly in London, Devon and Birmingham.

An open letter to the Daily Mail…

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Dear Daily Mail,

I liked your headline “Why NO woman should have a home birth: Government drive to free up hospital beds will lead to rise in ‘dead or damaged babies’, doctor warns“. It was certainly attention grabbing, which is the measure of a great headline, right? It’s less important of course that the headline be accurate.

It was particularly eye opening for me because I have read a lot about the new proposals to support birth choice with a great deal of interest, as both an expectant Mum and antenatal teacher, but I never knew it was motivated by a desire to free up hospital beds. You must have insider knowledge. I was naive enough to think it was a positive step to empower women and improve outcomes for mothers and babies.

The ‘dead or damaged babies’ was a powerful bit of alliteration. Nobody wants a dead or indeed ‘damaged’ baby, which brings to mind images of babies with limbs twisted and broken like pen-marked, discarded dolls of old. To pop that next to ‘NO woman should have a home birth’ (caps included of course to reinforce the message) was particularly effective. It definitely made home birth seem like a seriously dangerous option with horrific, nightmarish outcomes.

And a ‘doctor warns’! Then it must be true! That’s the golden seal of approval. Bravo! ‘Says a lecturer from Hong Kong who has no experience of current maternity services having not worked in the UK for three decades’ wouldn’t have worked half as well, even though it would have been more accurate. Good copy editor you’ve got there.

The strange thing though about the whole ‘NO woman should have a home birth’ because we at the Daily Mail want to save all the babies from being born dead or damaged thing, is that the birth place study (from which the stats you use in the article are taken) says that for mums with straight forward pregnancies expecting their second or subsequent babies, home birth is as safe for babies as birth centres and labour wards but has significantly lower risks when it comes to medical intervention including assisted delivery and unplanned caesareans. In fact a mum expecting her second or subsequent baby, enjoying a uncomplicated pregnancy, is a full 8 times more likely to end up having an unplanned caesarean if she is on labour ward compared to having a home birth! So I’m sorry if I’ve missed something but why exactly should NO woman have a home birth?!

It seems pretty clear from the birth place study that home birth is a statistically better AND safer option for a lot of women. Which means by advocating that all women should go into hospital, even those for which being in hospital is totally unnecessary, you are actually significantly increasing their risk of having medical intervention and major abdominal surgery, with no improvement in outcome for baby! Why is it that you wish to endanger women in this way, under the guise that you are trying to protect their babies?! All the steps being taken by the NHS are to ensure women are informed, empowered and supported in their choices. Why is that you seek to misinform and mislead? Why is it you wish to put women with uncomplicated pregnancies at risk? It’s almost as if you want to manipulate women, using their strong maternal desire to protect their unborn babies from being ‘damaged’, into choosing to birth in a statistically more dangerous setting. It’s irresponsible of a national paper and to be totally honest it’s really pissed me off.

So here’s my response. I’m going to try and keep it based on facts, research and real-life relevant experience (as opposed to what you have done). I will try very hard to lock down my inner rage…

From your point of view it must be regrettable that you were unable to find an expert working in maternity services in the UK who actually practices medicine to share Dr Lord’s opinion. That would have added some weight to your claims. I’m sure you tried but of course no UK Doctor would say this.

However I still read what Dr Lord, a Hong-Kong based lecturer who has not worked in the UK for the last 27 years, had to say about our maternity services and the positive steps being taken by our NHS to empower women. I can’t say it was an enjoyable read but I was definitely hooked.

Whilst I whole heartedly agree with the closing paragraph that women in the UK who are fully informed and aware of the findings of the birth place study will not take unnecessary risks and choose to birth in dangerous places nor wish to put their baby in harm’s way, there are a number of points I think require some clarification/ correcting.

I should probably also mention my ‘qualifications’ because, although I’m not a doctor, I do believe I have quite a lot more experience of current maternity services in the UK than Dr Lord does. I am a mother of 2 with a third due in the next few weeks. I also work in the field of antenatal education as a hypnobirthing teacher. I had a labour ward birth with my first, a home birth with my second and am currently deciding between home or the birth centre for my third. Due to my circumstances I have regular contact with community midwife and also my obstetrician.

My wonderful midwife, Natalie Carter, contrary to Dr Lord’s ill-informed opinion of community midwives, is challenging me to consider the risks of having a home birth again after a previous bleed and has encouraged me to use the birth centre this time. A friend of mine, Clemmie Hooper, who is a case-loading midwife and an advocate of home birth (for the right women) is also doing the same. It may come as a surprise but midwives, even those who support and facilitate home births, do not wish to put women or babies in dangerous situations. In fact quite the opposite.

My obstetrician, Mr Fabian Imoh-ita, (whose name I DO know Dr Lord) is friendly and warm and I have nothing but respect for his opinion and vast experience. I am lucky to see the same midwife for all of my ante-natal visits as with my last baby and same goes with my obstetrician who I also saw in my last pregnancy. I do not live in rural England but in the busy city of London. I feel incredible grateful for the amazing maternity services we have on offer. I only wish Dr Lord was able to experience the same. She might learn a thing or two.

So here are the points that I’m not totally onboard with…

1. I don’t know if Dr Lord has ever spoken to a community midwife in the UK. From what she says I would hazard a guess that she has not. My community midwife, as mentioned above, certainly encourages me to make difficult decisions regarding everything from place of birth, to delayed cord clamping to active management of the third stage etc. Our chat is not all airy-fairy and idealistic as Dr Lord suggests, although of course we do discuss my wishes and preferences because guess what?! We are talking about my womb and my baby, so I do get a say in the matter (thank goodness!). My midwife ensures that I am fully informed about the risks as well as the benefits of everything so that I can make informed decisions and give informed consent, which is a necessary and legal part of medical practice in the uk. I’m not sure about the rules in Hong Kong but here in the UK if women don’t give informed consent to a procedure conducted on themselves, it’s considered common assault. In my individual case, I have to weigh up the benefits for baby of various things like delayed cord clamping versus the risk to myself as I have a history of post partum haemorrhage. These decisions aren’t easy but I am grateful for the advice I am given but that ultimately the choice is mine to make.

Also one note on delayed cord clamping, which Dr Lord lists alongside other things she considers part of a misguided idealised version of birth, is that delayed cord clamping as of 2014 is recommended by the National Institute for Clinical Excellence and the Royal College of Obstetricians and Gynaecologists in the UK. So it’s not something that irresponsible risk-taking mothers request but actually recommended best practice. I guess that Dr Lord missed the memo or is unaware because she hasn’t worked in the UK for almost 30 years and obviously doesn’t keep up with the research. That’s ok but if you’re going to comment in a national paper it would be kind of cool to check stuff like that out beforehand.

2. There are without a doubt numerous long term benefits of a positive birth experience, be that at home or in hospital. There are so many women suffering from post traumatic stress syndrome after giving birth and even more who haven’t been diagnosed but are left distraught, disappointed and disempowered. This effects everything from bonding to breastfeeding. The long term benefits of a positive birth and a woman feeing empowered and confident as she embarks on motherhood for the first time are immeasurable in value. You would have to be totally ignorant to overlook or diminish the importance of the birth experience. It is arguably the most defining moment of a woman’s life.

3. The risks. There are risks with everything. There are risks with home birth yes. There are also risks with hospital births. Yup, you read that right! There are many risks associated with choosing to have a hospital birth. These are less publicised and may come as a surprise because we are conditioned to believe hospitals are safe places. For example the risk of intervention is increased by just being in a hospital setting and this includes everything from epidurals to assisted delivery to major surgery in the form of a cesarean section. The risk of infection is also higher in hospital. Dr Lord doesn’t even give these risks a moment of airtime, which seems somewhat unfair/unbalanced given she is discussing birth place choices.

She quotes a from the birth place study published in 2011 and claims that 0.35% of babies born to first time mums have an adverse outcome in hospital compared to 0.95% of babies born at home to first time mums. It would probably help if she actually got the stats right. And Daily Mail, I’m surprised this slipped through your production editor’s net, although I suspect perhaps it was deliberate. The truth is 0.53% of babies born in hospital to first time mums experience adverse outcomes. In both settings the absolute risk is less than 1%.

For second time mums with uncomplicated pregnancies or those having subsequent babies, the study showed that home birth was the statistically safer option. Of course Dr Lord didn’t mention this finding. That would somewhat contradict the catchy headline!

That’s not to say second, third, fourth time mums should be berated for choosing a hospital birth or accused of being dangerous and taking risks. I’m not suggesting the Daily Mail run the headline ‘Why NO woman should have a hospital birth and risk episiotomies, paralysis, being sliced and diced and having a dead baby in a bid to cost tax payers more money’. The idea seems outrageous (although you’ve got to admit, it does sound like it could be a Daily Mail headline). But it is just as outrageous to suggest first time mums are taking unnecessary risks by choosing to have their babies at home.

Also what hasn’t been considered is the 99.07% of babies born at home to first time mums without adverse effects, how many of these births would have been negatively effected by being in hospital??

If we are weighing up risks to make an informed decision regarding birth place, we need to understand the risks of both settings. For example, the birth place study showed that low risk women expecting their second or subsequent baby are eight times more likely to have major surgery (cesarean section) just by stepping foot in an obstetric unit compared to being at home. They are also six times more likely to have an assisted delivery, over six times more likely to have labour sped up using drugs (augmented), five times more likely to have an epidural and five times more likely to have an episiotomy.  For first time Mums with uncomplicated pregnancies the risk of having an unplanned cesarean, assisted delivery, augmentation, epidural and/or episiotomy almost doubles just by being in hospital.

I am all for encouraging women to be informed about risks and made aware of the birth place study findings, but this goes both ways: women need to be informed about the risks of being in hospital, just as they need to be informed of the risks of being at home, so they can make informed choices and decisions. I cannot comprehend why anyone would be in disagreement with this proposal. Of course women should have choices and be able to make their own decisions. We may be pregnant but we are still mentally-competent adults.

Also necessary to making informed decisions is the need to understand the benefits of various settings. All Dr Lord has mentioned is the risk factor of home births for first time mums. But what of the benefits for baby and for mother of being at home? Less likely to have medical intervention, instrumental delivery or major surgery. Therefore quicker recovery times. Less likely to be left waiting in a busy triage waiting room. Less likely to be put on a drip to speed things up. Less likely to have an epidural. Less likely for baby to experience distress in utero. Able to birth in the comfort of your own home and control your environment. Able to eat your own food. Able to get into your own bed. Able to have your partner stay with you throughout. Able to ensure access to a birth pool. Feeling safe and relaxed enough to produce the necessary oxytocin to enable the body to work efficiently, therefore resulting in an easier, quicker and more comfortable birth for mother and baby. Having 1:1 care throughout your labour with the midwife present being in a position to focus solely on you and two midwives at the point of delivery. All of these benefits to being at home must be considered when making a decision.

In life if we only ever looked at risk we would never leave our homes and risk being run over or mugged. Certainly that’s less likely to happen and the risk reduced if we stay inside. But of course we go out because we believe the numerous benefits outweigh the slight increased risk of a rare but adverse outcome. Same goes when we get in a car, or board a plane. We take ‘risks’ with our lives every single day to enjoy the benefits of life. I feel for those who focus only on risk and ignore everything else, for they miss out on the greatest joys in life. Speaking from experience, my home birth was the single most amazing day of my life and I truly hope many, many, many more women get to experience that, if it is right for them.

So as a woman expecting a baby imminently I know there is no birth setting that promises me zero risk. What one has to do, myself included, is weigh up the benefits and risks of all the settings available and make an informed choice that is right for them and their individual circumstances.

Isn’t it truly amazing that our NHS supports and facilitate this and does not take a one-size-fits-all approach? I feel so lucky that we are treated as autonomous individuals and receive such a high level of woman-centred care. Why would anyone want it any other way?!

I can’t think of anyone apart from Dr Lord, who has a serious mis-understanding of community midwives, believes women to be incapable of making sensible informed decisions and who wants to continue working with scalpel in hand until the day she dies / retires. I feel very sorry for the pregnant and vulnerable victims that come into contact with her and her scalpel blade. We can only hope that one day they will be in a position to make informed choices too.

And Daily Mail, next time you want to slate home birth, how about you start by firstly getting someone who has some relevant experience to comment and secondly check your bloody facts.
 
Yours Sincerely,

Siobhan Miller

Mum of (soon to be) three and Founder of The Positive Birth Company.

Instagram: @the_double_mama@thepositivebirthcompany
Twitter: @thedoublemama@theposbirthco
Facebook: The Positive Birth Company.