Disappointed in the RCM #ButNotMaternity Response

I’m disappointed and angry today. This year has been difficult for everyone, but for people accessing maternity services it has been particularly traumatic and unnecessarily anxiety inducing. When the NHS released new guidance on Wednesday, clarifying that (at last!) people should “have access to support at all times during their maternity journey“. It finally seemed like someone was listening, and some of this stress may begin to ease. But no. I’m really disappointed in the RCM response, who say “safety is being sacrificed in favour of popularity” and that they cannot support it.

We all understood the situation in March, and reluctantly accepted that lockdown restrictions were necessary. But when those restrictions relaxed, when we could visit pubs and theme parks, fly on planes and eat in restaurants, with the government encouraging us to Eat Out To Help Out, and with children returning to school, strangely we did not see much easing of restrictions in maternity services.

Pregnant Then Screwed have been raising this issue (and several others about the inequitable treatment of pregnant women and those with kids during Covid) for months.

Pregnant Then Screwed website

When still nothing had essentially changed for most people accessing maternity services by 5th November, MPs in the All Party Parliamentary Group on Baby Loss shared some very personal experiences as a call to action for NHS England and the Department of Health and Social Care.

Pregnant Then Screwed letter to the CEO of the NHS

On behalf of BigBirthas.co.uk, I was one of the signatories on this letter of 14th November;

Dear Simon Stevens (the Chief Executive of the NHS),

We are writing to you as a group of academics, healthcare professionals, politicians, charities and campaigners and MPs to ask that the NHS recognises pregnancy and birth as one of life’s most significant events and not an illness or medical procedure. We ask that you consider the evidence which shows that women have fewer complications during childbirth if they have a trusted partner with them, and we ask that you take into consideration the increased levels of stress and anxiety amongst pregnant women who are forced to go through other parts of their maternity journey without a trusted companion.

A recent survey of 15,000 pregnant women and new mothers by the charity and campaign group, Pregnant Then Screwed found that 90% of pregnant women say hospital restrictions are having a negative impact on their mental health, with 97% saying that the restrictions have increased their anxiety around childbirth. Worryingly, of the women who gave birth in a hospital which prevented partners attending until they were in established labour, 17.4% said they felt forced to have a vaginal examination and 82% cited that this felt like a requirement so that they could be reunited with their partner. This is a breach of women’s human rights when they are at their most vulnerable. The long term impact of these restrictions for new mothers and their family could be catastrophic.

We firmly believe that no-one should have to hear that their baby’s heart has stopped beating without their partner’s hand to hold. No one should be induced while their partner sleeps in a bike shed in the car park for days on end. No one should be left to look after a newborn baby whilst recovering from major abdominal surgery.

In addition to ensuring the 15 minute rapid COVID-19 tests are swiftly rolled out in maternity settings, we ask that you direct Trusts in England to treat maternity as a special case where women have the right to be supported and partners have a right to be present during each step of their maternity journey. Coronavirus has stolen so many precious moments from so many people. It doesn’t have to be this way in maternity services. Where other precautions are in place there is little evidence that partners increase the infection risk to staff or other service users. Please ensure that parents-to-be can have the birth they deserve even during the pandemic.

Yours sincerely

So, of course, I was delighted when the NHS guidance recommended partners be accommodated!

The Royal College of Midwives’ Response

Sadly, that delight didn’t last. The Royal College of Midwives chief executive Gill Walton has responded: “With more areas moving into tier-three restrictions, many will question the common sense of releasing this new guidance now.

No I don’t Gill. I question the lack of common sense and humanity in your not supporting a change in policy before now!? The RCM could have issued guidance long ago and chose not to. After all you were able to swiftly issue this public letter to all maternity staff that you don’t support the NHS position on the same day!

What’s baffling is if you read the two press statements, they both sound pretty aligned? The RCM states that they believe attendance of partners is a priority, after all. But it took several readings to realise that while the NHS guidance recommends partners should be able to attend all appointments, the RCM conspicuously mention attendance during labour and birth only, and even then, they want Trusts to retain decision making on this at a local level.

On the surface of it, the RCM say it’s ‘because the NHSE has not completely adopted all 10 of the principles’ the RCM suggested. I mean, I can’t legitimately see how the NHSE could, when two of the RCM principles say they’re the most important principle…?

Grammatical concerns aside, the RCM could have chosen more positive, supportive language. They could have reassured users of maternity services and said they support the guidance in spirit. They could have said they would hope trusts would read this guidance in conjunction with their own 10 principles, and while being mindful of local risks. I can only guess that the confrontational tone hints at some tension between the DoH and the RCM at the moment?

This response will not have helped ease pregnant families’ anxieties. Some reports of success when waving a copy of the new NHS guidance have filtered through, but others report no change in their area, adding to further feelings of injustice.

Positives of restricting partner access?

What’s even more galling is that the RCMs own website boasted about the positives of the current restrictions, in a response to a Times article in October entitled “Covid rules have gone too far“. Rather than acknowledge the multiple genuine stories of trauma and distress experienced up and down the country, Gill Walton dismissed them out of hand as situations “few women who have given birth over the past six months would recognise” and then go on to make unsubstantiated claims that women report “benefits of fewer visitors on postnatal wards: finding it easier to start breastfeeding, and opportunities to bond with other new mothers”.

When I’m not rolling my eyes at this, I’m hearing from other sources that the rules restricting partner attendance at maternity appointments have been good, because they’ve helped victims of domestic violence to come forward and receive help. Forgive me, but it’s hard to believe that this is all done with perinatal safety as the primary concern. After all, no-one seems to be considering the long term safety implications of perinatal mental health for these families? And surely it just begs the question what lessons can be learnt from this period, without metaphorically throwing the baby out with the bathwater and banning partners altogether?

Is there another, hidden agenda?

I, and many others with close links to maternity services have heard from midwives up and down the country at all levels about how many midwives prefer the current ‘woman alone’ setup. Their jobs are much easier with fewer people to accommodate. Of course that’s also fewer people to ask questions, and fewer people to advocate for the pregnant/labouring person when there are concerns (and fewer people to argue with when they don’t want to do what you think they should). While certainly not all midwives agree, it seems plausible that could also be a factor in explaining the RCMs slowness to react.

I don’t wish to be cynical, but better support for victims of DV and RCMs boasts of ‘bonding mothers’ notwithstanding, there certainly don’t seem to be widespread better experiences for people in maternity care right now. I’m hearing too many tales of trauma, coercion from clinicians, even of people having panic attacks while being separated at the door from their trusted supporter, and having to make difficult choices between their place of birth and their own mental wellbeing.

I’m not seeing positives represented in the stats published from multiple trusts either. Poor rates of skin-to-skin & breastfeeding initiation, fewer vaginal births, and more inductions. If support and advocacy in pregnancy were ever needed, it’s clearly now.

Of course, some inductions are necessary! An obsession with ‘natural birth’ was highlighted by the media as being at the heart of poor decision making at Shrewsbury & Telford Trust in the recent review of poor care there. But there was also a lack of a culture of listening to women, and poor continuity of care. It’s a shame that the media have focused more on the ‘reluctance to perform c-sections’ and less on the lack of compassion that was a key finding in the independent review.

My call to action for Gill Walton and the RCM

Unsurprisingly, given this background, a recent study by King’s College London, who surveyed 1,754 women who were either pregnant or had given birth since the beginning of lockdown, have discovered huge increases in the numbers of families considering freebirth.

The study, and the potential reasons for the shift are covered in this excellent Guardian article:

https://www.theguardian.com/lifeandstyle/2020/dec/05/women-give-birth-alone-the-rise-of-freebirthing

So why is the RCM not responding with concern to this worrying rejection of their services in far greater numbers than ever seen before? I really hope they can swiftly recommend a solution to this problem that brings partners and supporters back into maternity services ASAP. Pleas and complaints have been ignored for too long, and there simply is no good evidence that partners increase risk to staff or other service users, and plenty of evidence that this is causing very real trauma and potentially long-lasting repercussions for families.

If Gill Walton doesn’t recognise this, and wants to continue asserting that its a situation “few women who have given birth over the past six months would recognise” I recommend she check out https://www.theysaidtome.com/ (if she’s feeling strong). The submissions to that page starkly illustrate the myriad ways in which women and birthing people report they are being poorly served by health care professionals right now, and by extrapolation, why birth partners are absolutely essential in helping return the balance of power in the birthing room.

I’m really disappointed in the RCM that instead they’re ignoring these reports and gaslighting the people who’ve experienced them. It’s worth remembering these stories are not everyone’s experience of hospital birth, but they are occurring all too often and the RCM needs to recognise and address this issue, and fast.



Tannice’s Covid-19 Birth Story

‘May you live in Interesting Times’, so the ancient curse goes. This year has been full of twists and turns, and if you’re pregnant, it comes with added anxiety about what that will be like. Will you be able to give birth where you want, with whom you want to support you? Usually I try to give advice that’s applicable on a national scale – but at the moment, with seemingly each NHS Trust making up their own rules as they go along, and those rules changing frequently, it’s impossible to know what the situation is on an individual level. So what I have done is focus on publishing individual experiences as a clue to what may be possible right now, and how other people have approached and experienced birthing in a time of Covid. This is an excerpt of Tannice’s Covid-19 Birth Story, published with permission. You can read the full version here.

Tannice's first child with her third on the day of his birth - a Covid-19 Birth Story
My first child with my third on the day of his birth

Tannice’s Covid-19 Birth Story

“Giving birth at home was something I’d wanted since after my first was born in 2016. Admittedly, when I was pregnant with my first, the idea of giving birth at home never even crossed my mind. As I was a “high risk” pregnancy, due to my high BMI, it was never even presented as an option.

My first labour was augmented with syntocinon – synthetic oxytocin – presumably because stress caused my contractions to slow down. After the shift change of midwives, I started to lose energy and momentum. I was also stressed by being prevented from eating (I had gestational diabetes and had thrown up my dinner from the night before after being a little too liberal with wonderful entonox).

I did all I was told during that labour – from having an epidural as a matter of course (in case my fat body couldn’t give birth naturally and I’d need a caesarean, they said) to readily agreeing to induction because of the gestational diabetes, I simply toed the line entirely.

Unfortunately “doing as you’re told” isn’t always the protective act you’d hope when it comes to labour and birth. It was not as beautiful an experience as I’d hoped. Whilst I narrowly avoided an emergency caesarean, I did beg for an episiotomy as I was so exhausted. I simply wanted it all to be over. Which wasn’t the way I’d imagined I’d feel about my daughter’s birth at all.

By the time I was pregnant with my second, however, the trauma of the first birth lent itself to my husband and I loving the idea of home birth.

Sadly, my second child was breech and I was taken to hospital gravely ill from a pulmonary embolism that kept me in the high dependency unit for about 10 days at 35 weeks’ pregnant. Now I’ve had my third child in a pool, at home, I realise that it would have been far tougher were I struggling to breathe, too. So I don’t regret the caesarean that I had with my middle child.

How safe is a home birth during a pandemic?

The environment for the birth of "baby A"
The environment for the birth of “baby A”

Many home birth services were suspended at the height of the first wave of the Coronavirus pandemic: the main reason being that paramedics were unable to provide category 1 (the highest emergency level) support for those giving birth at home. There were also concerns about sending midwives into a home setting with respect to distancing from other members of the household and the extended amount of time that the requisite two midwives would have to spend potentially exposed to Coronavirus in any asymptomatic but infected household. The viral load on those midwives was a consideration all hospital trusts had to factor in. 

However, there is no question that, when you purely look at the safety of a birthing dyad – mother and baby – it is quite clear that a home birth is safest for them. At a home birth you have just two midwives, the birthing person, the birth partner and any other members of the extended family, who can be asked to distance. This limits potential transmission to any of the family within the home. With Covid-19 restrictions on visiting, antenatal appointments, scans and attendance at birth (usually you must be in established labour – 6cm – before your chosen birth partner can join you) people having babies are struggling for support. 

Midwives do have policies designed to protect themselves and can of course wear as high a level of PPE as they think is prudent, but given they are in someone else’s home, they may feel uncomfortable insisting that, for example, the birth partner wears a mask or that other occupants of the home may not be present. This all serves to make the environment more tense and thereby will affect the birthing family’s experience. It’s essential, then, that the midwives attending feel comfortable doing so. Their hospital trust have a duty of care to them, too, at least under the Health and Safety Act 1974, if not just morally and ethically.

Tannice in her pool - So different from the hospital environment
So different from the hospital environment

What’s it like to have a home birth?

All in all, my home birth was a magical experience. I started having contractions as early as 22nd August but my son was not born until 11 September. We called out the midwives that first night and were close to calling several times again on various evenings until, on 10 September at around 8:30pm, the day after a stretch and sweep, my waters broke.

I was disheartened when the midwives decided that things were not progressing and that they would leave. I got back in my pool and was in a great deal of pain as the contractions continued. They came closer together and were even stronger than before so we called the midwives back a few hours later, after calling my parents to come and take care of our two older children. They were convinced there was a monster in the house after hearing my contraction-induced moaning!

Doubts

I was suddenly worried what would happen if I needed to transfer in for a repeat caesarean. Having previously been convinced it wouldn’t be necessary, I was suddenly struggling with the pain. After so long of having what’s called prodromal labour, I was exhausted from constant contractions and the anxiety around the increase in Covid cases across the country was making me suspect home birth could again be suspended.

That day I’d done an interview with local TV station, KMTV, talking about my fears about this very such problem.

The midwives returned with entonox and boy… was I glad to have it. So glad in fact that I blew through the remaining 1.5 tanks (I’d used half the first time they attended) and we were on. From waters breaking to Ares’ birth at 7:30am, the whole labour was 11 hours. The most primal and intensive experience of my life, his birth put me firmly in control of my environment and my body.

When I’d finally done all the work and he emerged, in my home, all I could shriek was “I did it!” and “I made him and I did it!”

I was truly elated and felt so very healed from the varied trauma of my first two births. I loved my body again and felt so connected to my own being that I felt the anxiety and historical grief melt away.

‘Advocating’ for the birth you want? It shouldn’t even be in our vocabulary

I had to advocate hard to get the birth I wanted. I had done so much research into home birth in preparation to birth my second child that I know everything I needed to about my rights and the NHS’ responsibilities to me under the law.

Of course, we hadn’t factored in the suspension of home births across the UK due to an unprecedented pandemic – but I did know the (small) risks involved when wanting a home birth after caesarean (HBAC). It wasn’t long after my first son was extracted from me that I began reading about HBAC. I carefully scoured the literature for all the factors involved in successful vaginal birth after caesarean (VBAC) to inform my decision to birth my last child at home. 

To sum up this weighty defence and advocation of birthing at home, the evidence is persuasive and significant. Historically, women have birthed in their own environment for far longer than they have within hospitals. Whilst I’m not against intervention, it’s hard to really know which interventions were truly necessary.

Birth Trauma Awareness Week

The medical profession will always, of course, err on the side of caution. But survival of mother and baby alone is not the only marker of a good birth. Ares was born during Birth Trauma Awareness week (7-13 September 2020). So many laid bare their traumatic experiences on social media that I felt almost guilty, despite my own history, that I’d had such a wonderful final birth.

We can have better births. We should never underestimate the importance of informed consent, personal choice, bodily autonomy and sovereignty. One shouldn’t need to know the system inside out to be able to get a good birth.

Once I had come down from the elation of my greatest birth of three, I realised something quite sad. I was celebrating not having been traumatised from the final birth I’ll ever have. Not to have been devastated by iatrogenic harm, discompassionate medical staff and a lack of postnatal care. I’d had a good birth. Sad really. It’s not much to ask for.”

Tannice and Baby Ares in the few hours after birth - a Covid-19 Birth Story
Tannice and baby Ares

Thanks Tannice for Sharing Your Covid-19 Birth Story!

And welcome to the world, baby Ares! Don’t forget, this is only an excerpt. You can read the full version of Tannice’s story, including links to articles for reference here.

Are you looking for a supportive community of like-minded people to discuss all things high BMI pregnancy? Pop along to our Facebook Group!

If you’d like to read more Birth Stories, you can find them here.

Your Rights in Pregnancy and Birth

AIMS (Association for Improvements in the Maternity Services) are pleased to announce the third book in their Guide series: The AIMS Guide to Your Rights in Pregnancy & Birth. This replaces their book ‘Am I Allowed?’. I’m a big fan of AIMS’ work, and not just because they published my Water Birth article last year!

I haven’t read a copy as it’s not published yet, so I do need to caveat this recommendation. But everything AIMS produces is well researched and evidenced, so I have no doubts this will be of high quality.

Their blurb:

“Not only does this book provide clear information about your rights in pregnancy and birth, but provides the tools to assert those rights.”

The book is currently available for pre-order so that you get a copy hot off the press in November.

Asserting your Rights

In terms of rights in pregnancy, Birthrights are also very good for information and they’re currently looking for people who would be interested in legally challenging visitor restrictions in maternity services at their local Trust. You could be in the early stages of pregnancy and concerned about the fact that your partner will not be with you during scans or at other crucial points during your maternity care.

You could also be a partner who is keen to be at their loved one’s side. Or you could already have been affected by the restrictions, for example, having received bad news on your own, having asked for your partner to be there. You are unlikely to receive financial compensation, but Birthrights will ensure your legal costs are covered. To find out more with no commitment you can contact them at [email protected]

Making Decisions

If you’re trying to make decisions, it’s always worth remembering that everything suggested to you is an offer. You’re only being offered treatment, you don’t have to accept it, if you don’t want it! (It may not seem like it at times, but it’s your body and your decisions to make). It’s also helpful to use the BRAIN acronym to make sure you’re getting all the information you need.

Front cover for The AIMS Guide

Nitisha’s Birth Story – Home Birth After Caesarean

I love a birthing story! I’m always excited to read about other mamas experiences in the Big Birthas Facebook group, and so I asked for permission to share this one with you. This is Nitisha’s home birth after caesarean. It actually took place in November 2019, but proving that baby brain is a lifetime condition, I completely forgot to add it until now. Sorry about that, and welcome baby Maya!

Nitisha's home birth after caesarean - welcome baby Maya!
Welcome baby Maya!

I got my homebirth after caesarean! 💪🏾

  • Waters broke at 36+7 naturally and so did contractions
  • 1 sweep at 37+3
  • Natural birth (no pain relief, too quick to get into my birth pool) delayed active management
  • Risks: high bmi, age, previous caesarean
  • Prep: yoga, aquanatal, positive birth company digital pack hynobirthing, saw a chiropractor, spinning babies exercises, positive birth after caesarean audio course.
  • Birth partner: Doula + hubby
  • Main sources of information: chilled mama and positive birth after caesarean.
  • Hyperemesis gravidarum (4-26wks) and pelvic girdle pain
  • I denied consultant led care after first appointment as we both agreed I was informed about the risks for a vbac and I felt there was nothing he could tell me that I didn’t already know /mythbust
  • Previous birth: induction led to fetal distress and emergency caesarean
  • Breastfed toddler throughout pregnancy
  • Toddler upstairs asleep through whole thing (rare occasion of sleeping through the night in his own bed)

After not feeling very informed in my last birth (waters broke, spontaneous start to contractions, induced before 24hrs post waters breaking) I was determined to be informed regardless of location and delivery.

This pregnancy and birth was so healing for me.

I really felt in control of my body, conversations which took place, and all options around delivery. I’d planned for hbac, hospital vbac, and caesarean, wanting to take control over any situation. I hadn’t planned for my labour starting the same way but was determined for it not to end emotionally the same way.

The VBAC consultant midwife was supportive and has changed hospital policy for midwives to use sense and monitoring birthing mums to individualise care and reduce need for vaginal exams! I had requested a meeting with her before the 36wk birth choices meeting as I didn’t want to be blindsided by policy and what they “wanted”. I had this at 32wks and planned my birth plan before of what I would accept and wanted. By the end of both meetings I was happy with my birth plan.

Home Birth After Caesarean

My waters broke 36+7. At 37 weeks I went to the Antenatal Day Assessment Unit and they confirmed my waters had broken. They checked mine and bubs stats; we were all fine so I respectfully declined any intervention for 72 hrs and said I would monitor bubs and fluid release.

Irregular contractions started within 24hrs of waters breaking. At 37+1 I went back to hospital for fetal monitoring and to check my stats and everything was fine. 37+2 – no checks, irregular contractions which increased during the night. 37+3 72hrs were up. I went back for monitoring and talk with a consultant and our stats were checked. The consultant said she thought I should be induced or have a caesarean because of my bmi being so high, I was told I only had 20% chance of giving birth vaginally.

I had a vaginal exam to assess options: cervix was 1cm thick, soft and 2cm dilated. Considered BRAIN and opted for a sweep. No contractions following sweep. Toddler wanted more feeds that night and we danced together. 37+4 still no contractions: walk with hubs, went for breakfast, chilled, massages, naps, laughs and lovin’, once toddler returned from nursery, more feeding. Rang doula to discuss plan.

I had settled that I would have an appointment at 37+5 to arrange what would happen if baby hadn’t come by 38wks. I would be induced with as little dose as possible of syntocinon. Once contractions began, turn the syntocinon off to allow body to do what it could and turn on if any stalls. The plan was also to discuss intervals of drip dosing and levels & what point I would have a caesarean section.

The contractions came back!

At 11pm, in bed, contractions came back. I was so chuffed as I felt the sweep was really invasive, made me feel uncomfortable and thought I shouldn’t have done it. I didn’t monitor, just let it happen. They became regular, so started to monitor. 1am I woke hubs and he rang doula and mother-in-law.

Just before doula arrived I went to my birthing room to relax and take in what was happening. At this point didn’t know whether we would stay at home or go hospital. Initially I was dancing to my 90s RnB club hits, but I was getting sleepy so laid down with a leg elevated to keep my sacrum free. The contractions were starting to increase and I needed my doula to push on my hips. I needed to change position, I went on my knees with my ankles out further than knees (one strong mama tip) and leaned on the sofa with my hips being pressed down during contractions.

Midwives arrived

Things progressed quickly, midwives called at 04:xx arrived 06:xx. During this time I carried on as I was, but the pain getting more intense. It felt like my whole pelvis was expanding. This is normal, I just didn’t know. I did keep checking my puppy pad for blood or meconium. At one point my hubby said I turned and growled at him.

When midwives arrived I wanted to go to hospital because I didn’t know that the pelvis pain was normal, instead I had 1 vaginal exam with consent, I was 10cm and midwife could feel baby’s head. I wanted to get in the pool but couldn’t wait, one breath and baby was out! I didn’t get a chance to catch her but I did cut the cord.

During birth I didn’t think I was Hynobirthing breathing well & didn’t really work for me, I was a bit too cave-woman rather than peaceful 😂 but my doula said I was doing it at the start and to relax but the elevator breath and the final breathing the baby out was great.

Congratulations Nitisha and welcome baby Maya!

Hopefully your husband has completely forgiven you for growling at him!

You can read more birth stories here:

Sarah’s Homebirth Story

Birth in a time of Covid-19

Twin Home Birth at 42+2

Or look under ‘Birth Stories’ in the Labour and Birth menu.