" 'over-zealous' pursuit of natural childbirth ‘at any cost’ led at times to unsafe care " and deaths in Morecambe Bay maternity unit

[inamaymaybewrong]

Thoughts on this, which is getting a lot of coverage today?

www.gov.uk/government/news/morecambe-bay-investigation-report-published

Official investigation into the uncessary deaths of babies and a mother at a hospital in Morecambe Bay cites 5 ways in which the maternity unit there was dynfunctional. including:Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.

I've seen some commentators point fingers at the Royal College of Midwives campaign eg www.morecambebayinquiry.co.uk/index.php/blog

What's been your experience of the extent to which these things are issues elsewhere in the country, whether you're a patient or a professional? Maybe the tide against the medicalisation of birth and intervention has started to turn too far? Or maybe (hopefully) this is an isolated incident?

FWIW, I'm part of a few online groups geared towards attachement parenting though I'm firmly on a different end of the spectrum to others involved in them who are fervently pro-home birth and anti-intervention and active in groups on those issues too. I can't imagine getting much balanced discussion of this there so posting here instead! I've name-changed too as I may post my own (patient) experience later depending how the thread goes and don't want to out myself!

The same could be said of obstetricians, if they deal with high risk, are they best equipped to pick out low risk women, as it is I think both are as equipped as the other to recognise something out of their remit, but crucially of course there are some who can't or wilfully don't - as happened here - but I don't think that is representative of midwifery/obstetrics across the UK.

Surely mothers have changed so much in the last 30 years that you'd expect them to need more interventions?

I'm guessing that

• the average age has increased
• the average weight has increased (of both baby and mother)

All of which would require more medicilasation. I had a CS because my baby was too big for my pelvis. He was 10lb. Probably 30 years ago I wouldn't have eaten so much sugar during my pregnancy so I wouldn't have had a 10lb baby so I wouldn't have needed a CS.

It all comes back to cause or correlation.

Didn't people smoke and drink more when pregnant 30 years ago, then now?

Which would also contribute to smaller babies? Leading to less intervention needed.

I would like to see the review get to the bottom of competing agendas in maternity care: Midwives who think natural birth is the priority, consultants obsessed with keeping the CS rate down, mums and babies discharged far too early to free up beds for others. It simply does not equate to the best care for women and their babies at a time when they are most vulnerable.

I have a friend who was a 'low risk' first time mum. Who laboured in hospital where midwives didn't want to intervene in the natural process, where they didn't check or monitor her as she wasn't far enough along and who ultimately had a stillborn son, despite them both being perfectly healthy at the start of labour. Knowing that she was 'low risk' (and had avoided the evils of CS) was of little consequence to her. My heart goes out to the Morecambe Bay families as I've seen it happen.

There are NHS protocols for categorising women's risk status. It is not left to the discretion of the midwife.

Midwives priority is the same as doctors - the healthiest and safest outcome for all births.

"Where they didn't check or monitor her as she wasn't far enough along and who ultimately had a stillborn son"

Not monitoring the mother or baby or checking progress is simply poor practice and in no way an expression of a 'natural birth agenda'. The only reason midwives in the UK would not do these checks on a labouring woman would be if she hadn't consented to them.

"Where they didn't check or monitor her as she wasn't far enough along and who ultimately had a stillborn son"

If your friend had a CS and the baby was stillborn the conclusion would be similar. She did not have appropriate care during labour. Babies and mothers can be put at risk, overall a greater risk depending on the context, via CS, not in your friends case but in the case of other women.

Inappropriate care is inappropriate care whether it is given by midwives or obs.

"The only reason midwives in the UK would not do these checks on a labouring woman would be if she hadn't consented to them."

Or if they were simply negligent.

mini are you aware of the following:

www.warringtonandhaltonhospitals.nhs.uk/page.asp?fldArea=1&fldMenu=5&fldSubMenu=9&fldKey=248

The report is interesting reading (and not nearly as long as the Morecambe one!) particularly page 8.

Initially they reacted to the problem by treating all women as high risk, stopping water births and making continuous monitoring 'compulsory'. (This didn't go down too well).

Yet the recommendation has eventually been to support a new MLU amongst other things.

Its picked up on:
Poor relationships between doctors and midwives.
How the investigation lead to a change in midwives behaviour.
Poor training and skills.
Poor risk assessment of women which led to them being wrongly assessed as low risk.
Failure to escalate concerns from midwives to obstetricians and to senior consultants.
Poor staffing levels

The case is very different to Morecambe - the hospital has never been regarded as dangerous and there hasn't been further investigation into the hospital.

However, I think there are some things that are jumping out there as being similar problems.

It also suggests to me, that fears of increased intervention might be unfounded. I strongly suspect that any national review into services will include having a look at this report as part of it, as its so recent, so the fact that the knee jerk reaction to introduce continuous monitoring for all wasn't a success and ultimately the RCOG recommended supporting the creation of a MLU instead is very interesting indeed.

In my opinion, FWIW, 'natural' v 'monitored/intervention' is the wrong question. As mentioned up thread we're all individuals and what's right for one won't be right for another. Instead of pursuing 'natural', we should be pursuing informed choice. 'The good birth project' by Dr Anne Lyerly Drapkin is an excellent book on the subject, based on her research with Duke University about what constitutes a 'good birth'. Of course it's not the method of delivery but how well informed, supported and secure a woman feels that tend to lead women to report a 'good' birth experience. As in all areas of life the 'best' experience is unique to the individual - but oddly in relation to birth we have a tendency to campaign for one method being better than another. If we could get over that hurdle, stop judging each other from all angles and be kinder to each other (and teach medical professionals from across the spectrum to actually listen to women) we might be able to help women find the best in their experience, whatever it is, instead of expecting fear and suffering. Drapkin

What gets me about these sorts of discussions is that there so rarely seems to be any sort of inclusive debate about what the mother wants.

There is talk of risk factors and intervention rates and increasing cascades and all that.

The decisions, of the NMC and of NICE, seem based to hugely around what is best for the baby. Now don't get me wrong, of course that's the priority in the end.

But discussing that a low intervention, non-medicalised vaginal birth is generally the optimum birth from a medical standpoint often ignores the possibility that it might well not be the optimum birth from the mother's standpoint.

There's a middle ground of what a mother wants, which I felt I fell into, which feels somewhat ignored. If you have a genuine fear of birth you can argue for an ELCS. But if you'd just prefer to not have a significant pain relief free birth - and by 'prefer' I do see that as very different from having a genuine phobia/fear - then you aren't really given a lot of choice up front. Like many Trusts, mine was "MLU if low risk and that's that." Yes, it was in the same location as the CLU, but you weren't allowed to say before birth that you really, really, really think you're going to want an epidural as soon as possible.

It's lack of choice for the mother's, in many places. A push for 'natural' birth that doesn't always consider what the mother might want to do.

What's sad is that no one will be held accountable for this. And those children and that woman are dead.

The dominant narratives around childbirth tend to be so polarised that the space for individualised, reflective discussion about birth keeps getting squeezed smaller and smaller.

It's interesting yet very concerning that the messages about SIDS - reducing risk etc are absolutely embedded into early infant care, although stillbirth and indeed postnatal depression are still not spoken or thought about.

When I was pregnant and my children were young, I saw posters and leaflets about reducing SIDS risks everywhere. Not a sight of anything about stillbirth or PND.

As mentioned up thread, there is enough clinical evidence to indicate that increased doppler monitoring would reduce the number of stillbirths in the UK. Also, there are support organisations and things that people can do themselves to help reduce the risk of PND but there's no public narrative about these things.

I think the point I'm trying to make is that discussions about birth are often so unempirical and so emotive that a calm consideration of available evidence and facts tends to be elusive.

I've name changed for this as I'm a local and don't want to link to my usual name.
For those who don't know the area morecambe bay health authority covers 3 hospitals furness general (in barrow-in-furness) which the report is about, Westmorland general in Kendal and Lancaster royal infirmary. These are spread over a large area geographically which is in the report as an issue. Fgh is an hour(on shit roads) to wgh or RLI. WGH has a mlu and FGH /RLI both have CLU.
I had 4 children at FGH my last was almost at RLI as FGH was downgraded briefly and the thought of travelling that distance as a high risk pregnancy was scary. The ambulance service fought to get Fgh upgraded again as they didn't have the capacity for those runs. So closing isn't the answer. It also appears limited experience due to only working in one place (with the culture ingrained from the top down) has had an impact.
It will be interesting to see what happens there.

Fgh was ok. I did complain about a few aspects of my care including not reading my notes on my last two pregnancies. I am someone who knows my medical details and am not afraid to question and I found it concerning that despite things being highlighted as a potential problem I was having to repeat this over and over again to my named MW never mind anyone else.

"Like many Trusts, mine was "MLU if low risk and that's that." Yes, it was in the same location as the CLU, but you weren't allowed to say before birth that you really, really, really think you're going to want an epidural as soon as possible".

Are low risk women told they cannot give birth on the CLU?

redtoothbrush All the midwives I know working in the NHS are struggling at the moment with their workload, and with the challenges of caring for women in environments and under protocols which are not supportive of physiological birth.

I'm shocked by the degree of paranoia and bullying some of them talk about, and really understand why some midwives are so unhappy and sometimes not able to meet the needs of women.

I think both these reports flag up important problems in the NHS system of maternity care and in the role of the modern midwife. :-(

As far as I am aware, minifingers. There was no discussion. All low risk, non-consultant led women were sent to the MLU. Once there you could request an epidural and be moved to the CLU if there was room, but you still had to go and talk to someone in the MLU first before you were moved.

I have only had one DC and went straight to the CLU has we were both ill (though all the checks I had going in and out during the few days of labour were in the MLU) but my understanding was very much that unless there was an actual reason why you required consultant care - because of a health factor, previous birth or requesting an epidural - then you would be solely under the midwives.

"that unless there was an actual reason why you required consultant care - because of a health factor, previous birth or requesting an epidural - then you would be solely under the midwives"

What other reason would you have for wanting to be on a CLU other than these things? You would still be receiving midwife led care in that setting.

When I read your post I was surprised that any trust would categorically deny low risk women access to epidurals, but it doesn't seem from your comments that this is the case.

Anecdotally, I know some women who were refused/fobbed off with their requests for epidurals.

One was along the lines of 'you don't need it, you're nearly there' which turned out to be true as she was fully dilated 30 mins later. She was annoyed at the time, but shortly afterwards was glad that she avoided it.

Another friend was fobbed off for hours (night shift), had a very long labour and ended up having a ventouse/episiotomy many hours later. She's still pissed off about it, was extremely traumatised afterwards and had a ELCS with her next baby.

I think protocols and provision are a bit woolly and patchy, tbh.

When I read your post I was surprised that any trust would categorically deny low risk women access to epidurals, but it doesn't seem from your comments that this is the case.

How can they provide access to epidurals when there isn't 24/7 cover for anaesthetists?

I was a student in a unit which at the time was a bit like how Morcombe Bay comes across in the report.

A group of pro normality midwives who at times were too keen to keep Drs out the room. So if a woman hadn't made "adequate progress" they didn't inform the Dr. Instead in their minds the rules about labour progress were over medicalised rubbish. Other stuff as well. I can remember if you came out your room and told the coordinator your woman wanted pethidine the coordinator said she wasn't allowed it and you were to go back in the room and be more supportive!!

Things have changed but it took some time I think for people to realise how bad it was and that it needed to change. Things don't get so bad overnight, it's a gradual creep. As a student I was oblivious to how bad it was but I shudder when I look back.

There was a big culture change in our unit, thankfully before we had things happen like in that report....but I read that report and wonder if it was just luck. The Drs took control more, 4 hourly ward rounds on labour ward where the Drs come into every room and get a run down of what's happening. Before they'd just be told "oh you don't need to know about Rm 12 as she's low risk", so they'd be oblivious to the fact she'd been pushing for two hours!

The MLU where I'm booked to give birth is opt out for low risk women - you are opted into it but you are welcome to opt out prior to birth. I'm sure it's the same in most trusts, women just aren't aware of it. I'm not sure being opted into an MLU is such a problem though. I went on a public tour of the MLU where I am booked, which was full of starry eyed primips desperate to have low risk water births. The senior midwife was quite frank, saying "look, remember that you might get here and be desperate for an epidural already, in which case we will take you to delivery suite."

This is certainly how it works in our unit too - if we triage a low risk woman on the phone who is already requesting an epidural, then we won't assess her in one of our MLU rooms (which is through some doors from delivery suite), we'll often just take her straight to delivery suite. I think units that try to cajole women into natural birth at all costs and deny epidurals are actually quite a rarity, they just garner more attention and discussion. Where I work it is incredibly, incredibly rare for a primip who wants an epidural at some point not to get one. It is more common for multips because they are often transitional by the time they're asking, and have the baby before anything can be done.

Viva - do you think that midwives who are involved in a lot of home births adhere as strictly to evidence based protocols, particularly in relation to progress, as midwives working in hospitals?

Where I work yes. Notes are audited frequently and if someone wasn't sticking to guidelines/protocols they'd be for it I reckon! I don't think people would risk it. I don't do home births but I know I wouldn't risk it.

If someone hadn't made progress and I was a community mifpdwife Id transfer them in /recommend they transfer in as protocol dictates. If I didn't and something bad happened, big post partum haemorrhage, problems with baby, etc not only would I have that on my conscience but from a selfish point of view im risking my registration. No way am I risking anything like that. Protocols are there for a reason and are evidence based for safety.