" '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!

So you believe in entirely protocol driven care?

What's the normal birth rate in your trust?

I agree, Donna. I would find it terrifying if the midwife took an "I know best" approach, rather than follow evidence-based care protocols. They're there for a reason, and it's unfortunately the case in any profession that individuals can develop biases based on their own experiences, which may not reflect the overall picture.

Protocols are fine, but I always remember Sheila Kitzinger saying in one of her books that they were a good servant but a bad master. Unfortunately some people do allow the protocol to be the master.

Only yesterday I was reading about differing CS rates in Europe The article says:
Prof Alison Macfarlane, professor of perinatal health at City University London, said: "Given that people are supposed to be practising according to evidence, it is surprising there are such wide variations between countries."

Which rather suggests that there is still some way to go before evidence based medicine is fully implemented.

Minifingers, if the protocol is evidence based then yes I believe in evidence based care. I also believe that as midwives we need to challenge protocols if they're not evidence based. But we can't just do our own thing. It would put women at risk.

On a personal level it would put my career at risk. Currently if notes are audited and something has not been done as per protocol that midwife will be disciplined. It may be that she gets a local development plan and has to audit some notes, write a reflective assignment, etc. she may be reported for a supervisory investigation, she may be put on supervised practice. If she did it repeatedly she'd be reported to the nmc and face disciplinary action from her trust. Also in the current climate if someone dies and a HCP hasn't followed protocol you run the risk of a manslaughter charge.

I respect Sheila Kitzingers work but with all respect shes not a midwife and as far as I know has never worked in the nhs. Nhs is now a blame culture with CQC, cnst, nhsla, risk management and clinical governance ruling supreme. She has no clue.

Our normal birth rate runs at about 60-65%.

And it certainly sounds like the Muskateers at Morcombe bay weren't adhereing to protocol. I wonder if you asked the relatives of the deceased women which they'd prefer; midwives doing their own thing and getting maybe a slightly higher NVB rate and potentially higher morbidity and mortality rates or adhereing to protocol and a higher section rate what their answer would be?

"Currently if notes are audited and something has not been done as per protocol that midwife will be disciplined."

Well - as long as there's no subtle or not so subtle coercion going on to gain consent to procedures in order to cover your backs.... though judging from what I've seen and heard it's no surprise that women so often use the phrase 'I wasn't allowed' when discussing decisions about their care

"I wonder if you asked the relatives of the deceased women which they'd prefer; midwives doing their own thing and getting maybe a slightly higher NVB rate and potentially higher morbidity and mortality rates or adhereing to protocol and a higher section rate what their answer would be?"

Nice one.

Like of course there are people out there who really think that's an exchange worth making.

"Our normal birth rate runs at about 60-65%."

Are you talking about a birth centre? I'm impressed that your normal birth rate for the trust is a 30% higher than the highest for any hospital I've seen in the UK, Scotland and Wales. Are you sure we're talking about the same thing?

30% higher? Really? In 2012-2013 the averge spontaneous vaginal birth rate was 61.7%. www.hscic.gov.uk/catalogue/PUB12744/nhs-mate-eng-2012-13-summ-repo-rep.pdf

I do work in a consultant led unit which probably has a slightly better than average spontaneous vaginal birth rate than other consultant led hints but it's not wildly higher.

I would never coerce anyone in order to gain consent so that I can stick to a protocol. I'm very happy to not stick to a protocol if that's what the woman wants if it's her informed choice. I'd never get into trouble for that as long as I've clearly documented that it's the woman's choice.

I'm talking about normal birth.

"I would never coerce anyone in order to gain consent"

I doubt there's a midwife in the land who'd admit to that, but I've heard it being done. A lot of the time it's very subtle.

Are you one of those who defines "normal" birth as no epidural or drugs? The majority of people when they say normal birth mean spontaneous vaginal...so not a section and not an instrumental.

Have to say I hate the term normal birth, it suggests that some births are abnormal.

I agree, I see a lot of subtle coercion. I don't like it and I try and make every effort to ensure I dont.

"You seem incredibly evangelical about babies being born a specific way"

How so?

Why is it that people who are questioning the status quo are called 'evangelical' about normal birth but strongly supporting the status quo isn't being 'evangelical' about the importance of high levels of intervention in labour? It's seen as being 'moderate' and 'reasonable'.

Nationally in the UK more than 1 in 4 mothers expecting their first baby is induced. In some hospitals this goes up to 1 in 3. Is raising concerns about this enough to mark you out as someone who is 'evangelical' about normal birth?

If you'd spoken to a midwife in 1990 when the caesarean section rate was not much above 10%, and told her that in the fairly near future it would be 26%, (and over 33% in some hospitals) , she would have been aghast and probably quite demoralised. Most doctors would probably have felt the same. But now raising an eyebrow and questioning the necessity and benefit of these astonishingly high levels of intervention in labour is a mark of a natural birth evangelist?

"Are you one of those who defines "normal" birth as no epidural or drugs?"

What - like those radical harpies the Royal College of Midwives?

A normal birth is one with normal physiology - hormonal and otherwise. Is there something problematic about this for you?

Like having a shit, walking or breathing. There is a normal physiology.

Of course some people can't breathe, shit or walk normally because of physiological problems. Ditto labour.

Incidentally - how do you convince women that birth is generally normal and safe when most women these days appear to be unable to do it without synthetic hormones, surgery or instruments?

Unable to do it?

Christ, that's a comment and a half

It seems like your low opinion of those who don't give give birth in the way you deem correct matches your low opinion of those who don't feed in the way you deem correct, minifingers. Does anybody ever actually live up to your standards?

I've had this debate with you several times mini. I'll go further on my comment above.

Your opinions on maternity services consistently ignore what the wishes of the mother might be. Many mothers want pain relief. Some mothers want a cesarean rather than a vaginal birth.

An epidural does bring with it a risk of other interviews. But it is only an increased risk. It is not a guarantee of forceps, and it is not like they are taking crack cocaine during labour. They are taking a drug approved of by the medical establishment for removing as much pain a possible during labour, because medical science has given us a drug which does this with very limited side effects and which the medical establish considers safe.

Implying that women who opt for a safe, approved method of pain relief during what can be a very long and painful experience are unable to do it or essential wimping out is a very low thing to say.

I don't convince women of anything. I provide balanced information so they can make informed decisions.

Like I say I hate the term normal birth and to be honest couldn't give a shit about epidural free, syntocinon free births. Some women want an epidural, they have it on their birth plan before labour even starts. Their choice. Sometimes syntocinon is the best thing for a woman to keep her and her baby safe even though there are slight risks. The alternative risks in some labours could be a really prolonged labour, massive pph, distressed baby with poor outcomes.

If a woman wants a drug free, no intervention birth im equally happy. Even if she's high risk im happy if it's her informed choice. Breech baby at home, fine. Twins in a tent, fine. Don't want me to listen into baby's heart beat throughout labour, fine. Their body, their choice.

I've seen midwives who when women have been begging for an epidural say no to them. Tell them they don't need one. How fucking insulting. How the hell do they know that. What right do they have to say that? I'm sure those midwives congratulate themselves after for getting the woman through the birth with no epidural. But the midwife doesn't see the threads on here afterwards from the traumatised woman who is having flashbacks and now has post partum depression and needs counselling.

I'm sure those midwives congratulate themselves after for getting the woman through the birth with no epidural. But the midwife doesn't see the threads on here afterwards from the traumatised woman who is having flashbacks and now has post partum depression and needs counselling

Exactly. My biggest fear, going into pregnancy, was ending up with a midwife who didn't listen to me and who might refuse to request an epidural.

And I do have a problem with saying that a normal birth is one with normal physiology, no epidural, no syntocinon.

The alternative is to tell women who have had an epidural or who have had syntocinon that they've had an abnormal birth. And yes, I very much have a problem with that.

Sadly Thurlow it does happen. Not as often as it used to I hope. I think as a profession we're getting less paternalistic.

I'm with you both, Viva and Thurlow. I've heard so many stories of friends being denied epidurals purely on the whim of whichever midwife she is unfortunate enough to be labouring in the "care" of. Their autonomy was completely disregarded because of the ideology/convenience of the midwife concerned. In one case it resulted in a forceps birth with no pain relief, which left the mother with PTSD and PND. It's terrifying and infuriating. Viva you sound great, but sadly many midwives aren't like you.

minifingers those putative 1990s midwives might be less aghast if you were to contextualise the rate of assisted birth with stats on current rates of obesity, older mothers and the current evidence base on the efficacy of interventions in preventing mortality and morbidity in mothers and babies.

Regardless of what women want or what midwives believe most labours will involve routine tampering with women's hormones and the mechanisms of birth, regardless of what anyone thinks because that is how our birth culture is.

and anyone who questions the wisdom or the safety of this way of doing things will be made to feel like a bullying woman hater.

Really depressing that you can't question medical practices and birth culture without accusations of cruelty.

And incidentally - what's all the nonsense about telling women they haven't had a normal birth? Who would even have that conversation with a mother?

I would have been unable to have my son in the 1990s.

My medical condition was only recognised in 2000.

Thankfully my mental health needs were recognised and I was given the support I needed. This isn't the case everywhere and maternal mental health is both poorly recognised and funded.

That said, over the last fifteen years things have improved. One of those things is women finding a voice and feeling able to talk about how they were psychologically damaged by the way they were treated whilst giving birth and trying to force the system to change.

I would rather live at a time where depression and anxiety are taken seriously and respected than a time when phrases are trotted out to make feel shit and not seek options that suit them better.

That doesn't mean intervention ultimately, but it does mean having freedom to make informed decisions.