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Thursday, 10 May 2018

Being a bigger woman doesn't necessarily mean big birth risks.

The Birthplace Study continues to publish interesting analyses, this one about the birth risks associated with larger BMI (over 35 kg/m2).  

https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.12437

Multiparous women with BMIs over 35 appear to have a lower risk of adverse events than primiparous women with BMIs within the 18 to 25 range, and to generally have fewer problems associated with birthing their children than we may have believed.  Of course, primiparous women generally  have a lot of meddling with their labours and births and only a minority have straightforward births without interventions, so the comparison is not without its problems.  However the data does show that higher BMI in women who have given birth previously is probably being over-played as a "risk" factor.  

Perhaps consultant midwives and Birth Centre managers in the UK will be able to get the criteria for Birth Centre care altered to reflect this evidence.

While I am on the subject of bigger mothers, here is a link (will also post in useful links section) to the blog of The Well-Rounded Mama and her previous excellent website.  Lots of information here and a positive approach to birth and mothering with a well-rounded body!

https://wellroundedmama.blogspot.co.uk/p/about-this-blog.html 

http://www.plus-size-pregnancy.org/firstindex.html



Saturday, 31 March 2018

The contemporary bullying and adversarial culture of UK midwifery and Jane Greaves RM

Update: Jane Greaves reinstated!!  AND the story is covered by today's Sunday Express.

https://www.express.co.uk/news/uk/946014/jane-greaves-midwife-petition-job-sacking-unfair-dismissal-wakefield 


What is going on in midwifery in the UK?  Weekly UM hears of a midwife who has been sacked or suspended, or who has been forced out of the profession.  If these were careless, uninterested, uncommitted, lazy or rude midwives, that would be one thing.  But almost without exception, the midwives involved have a long history of woman-centredness, commitment to their profession, kindness, and standing up for services and colleagues.  

The UK is chronically short of midwives but many managers show little sign of wanting to retain those they have.  Contractual hours, policies, shift times, shift lengths, lack of study opportunities, inadequate responses to legitimate concerns and complaints from staff, favoritism and the nurturing of cliques, all combine to make the lives of many midwives very difficult, and result in a huge percentage of midwives working part-time or "taking a break" from the profession.  

Many (not all) senior posts in UK midwifery are filled by those who fit the corporate blueprint, show themselves to be loyal to the business (and Foundation Trusts are businesses run by managers and accountants from non-clinical backgrounds), not rock the boat, accept cuts sorry transformation and persuade their staff to work harder sorry smarter.  If you challenge this model of healthcare organisation (e.g. want choice for women that may require more staff, reject shoestring continuity models, oppose the downgrading of a birth centre etc), then promotion will not come your way. 

Malicious or unnecessary referrals to the NMC are made to settle scores and to consolidate power.  Threats and lies are common.  One Head of Midwifery in a northern English city recently told a midwife that she might be sued, not over clinical malpractice or neglect, but because another NHS Trust was annoyed by something she had written.  As her writing expressed an honestly-held opinion and accorded with the scientific evidence, this was palpable nonsense.  So why say it, if not to instill fear and dread, in other words to bully the midwife? 

Another midwifery manager (again in a northern English Trust, but it is happening all over the country) has sacked a midwife called Jane Greaves.  Jane has an excellent track record for caring for women and defending the service, but the manager, citing her sickness record, feels the service doesn't need her, despite the midwifery shortage in the area. A petition started by a friend has attracted over 30,000 signatures in a week.  UNISON, the union involved, appears to be hanging out the Trust to dry in the local media and this is a welcome change to the Royal College of Midwives (RCM)'s common approach of stay quiet, say nothing.  

You can sign the petition for Jane Greaves' reinstatement here:
https://www.change.org/p/mid-yorkshire-nhs-trust-support-nhs-midwife

And view the local paper article here:
https://www.yorkshireeveningpost.co.uk/news/wakefield-midwife-fired-over-sickness-record-after-suffering-kidney-infection-claims-no-time-for-trips-to-loo-due-to-hospital-understaffing-1-9075856

Needless to say, the friend has come under pressure.

So why are midwifery managers so drawn to the unkind, adversarial, and punitive approach and outcome rather than one that is solution-focused, trusting, and compassionate?  UM feels it is basically an issue of skills and knowledge as well as one of misplaced loyalty and deficient understanding of the wider picture.  

Midwifery is a global profession with a history as long as the human story and its current connection with the NHS in the UK is a minuscule part of that history and this planet, and even tinier is its shackling to the pseudo-market-orientated NHS of the 2010s.  I don't think that anyone enters midwifery to be part of the latter, we become midwives to be part of the ancient and universal energy of women and birth.   The health of that connection is shown by actions not words.  Yvonne Rowlan, the Head of Midwifery who may have personally sacked or was involved in the sacking of Jane Greaves, gave this vacuous statement to the Yorkshire Evening Post:

"We are dedicated to providing excellent patient care and supporting our staff to do this.  In every aspect of our work we adhere to a set of core values which underpin not only the care we give to our patients but also the care and respect we show to each other as members of staff."   


Fine words but empty ones in the face of loss of livelihood, vocation and workplace friendships.  Empty in the face of anxiety, stress, mental ill-health, suicidal thoughts, and depression caused by heavy-handed approaches to common and manageable workplace differences and challenges.  Empty in the face of no staff loo.

are dedicated to providing excellent patient care and supporting our staff to do this.

Read more at: https://www.yorkshireeveningpost.co.uk/news/wakefield-midwife-fired-over-sickness-record-after-suffering-kidney-infection-claims-no-time-for-trips-to-loo-due-to-hospital-understaffing-1-9075856
“We are dedicated to providing excellent patient care and supporting our staff to do this. “In every aspect of our work we adhere to a set of core values which underpin not only the care we give to our patients but also the care and respect we show to each other as members of staff.

Read more at: https://www.yorkshireeveningpost.co.uk/news/wakefield-midwife-fired-over-sickness-record-after-suffering-kidney-infection-claims-no-time-for-trips-to-loo-due-to-hospital-understaffing-1-9075856
“We are dedicated to providing excellent patient care and supporting our staff to do this. “In every aspect of our work we adhere to a set of core values which underpin not only the care we give to our patients but also the care and respect we show to each other as members of staff.

Read more at: https://www.yorkshireeveningpost.co.uk/news/wakefield-midwife-fired-over-sickness-record-after-suffering-kidney-infection-claims-no-time-for-trips-to-loo-due-to-hospital-understaffing-1-9075856

Read more at: https://www.yorkshireeveningpost.co.uk/news/wakefield-midwife-fired-over-sickness-record-after-suffering-kidney-infection-claims-no-time-for-trips-to-loo-due-to-hospital-understaffing-1-9075856
The RCM is currently more part of the problem than part of the solution, having a schizoid relationship to its members: it appears to be most comfortable with those at the top of the NHS hierarchy spending time befriending, liaising with and hobnobbing with them at all sorts of dos and events, but like a rabbit caught in headlights when confronted with the multiple problems of the thousands and thousands of its members who are not senior managers, but on whom it depends for the bulk of its subscriptions.

The position of shop-floor midwives trying to get proper representation is also often invidious.  Those who become RCM workplace representatives generally have two mutually exclusive reasons for doing so:
Either they want to climb the slippery pole, get close to management, and show how compromising they can be;
Or they want to represent and serve their colleagues and challenge injustice and unfairness in the workplace.
The latter group often become subject to the same investigatory and disciplinary processes that they have helped others through.  The RCM, often as thick as thieves with midwifery managers (whom it often mistakenly refers to as "midwifery leaders"), appears uncomfortable with its dual role as a trade union, recruits full-time officers from its own stewards rather than from a TU background, and often fails to stand up for its members as strongly as it ought.  The RCM line is all too usually to advise repentance and to show remorse and accept the punishment.

UM suggests:
  • If the RCM is serious about representing midwives, it has to pull its finger out and join with  those who are fighting to heal the toxic culture of contemporary midwifery in the UK.  The Caring for You Campaign is not biting deep as the RCM's own report shows (their December 2017 Evaluation of the CfY Campaign showed an increase in workplace bullying in services signed up to it).
  • Midwifery managers need to stop indulging in mutual self-congratulation on their various get-togethers but get down to some serious work of self-scrutiny and objective criticism.  They need to rediscover (or discover) midwifery and public service values and kindness and solution-focused approaches to their differences with midwives. 
  • There should be a complete moratorium on malicious referrals to the NMC.  
  • Midwifery managers should stop threatening and bullying their staff and stop promoting their acolytes over those whom they know are the better midwives.  They need to turn their attention from those in the corporate offices to the women they serve and the midwives who care about serving them.
Postscript
Before you all go away thinking the north of England is the midwifery pits, UM would like to pay tribute to Airedale Hospital Trust and its midwifery managers for the solution-focused approach it has taken with Yorkshire Storks Midwifery Practice to address the independent midwives indemnity insurance issues. 

Saturday, 24 February 2018

More reasons to be cautious about paracetamol-use during pregnancy and labour


https://www.medscape.com/viewarticle/892824?nlid=120841…t_obgy&uac=45732BX&spon=16&impID=1566858&faf=1#vp_1 24/02/2018, 08O25





In case you can't access the article I am quoting it below:

"Acetaminophen Use Alters Sex Hormones, May Cause Birth Defects?
 

Acetaminophen (paracetamol) use has been linked with a depletion of sulfated sex hormones in a large metabolomic study, and the findings suggest that fetal exposure to the drug could even be linked
with risk of male urogenital malformation at birth. Acetaminophen has been used for over 50 years, and more than half of women take it for pain relief while pregnant, but recent data, including animal-model and human-epidemiologic studies, suggest it may have some unexpected side effects.
 

"The current work identifies depletion of sulfated sex hormones as a potential mechanism" for genital malformation at birth in boys, say Isaac V Cohen, a PharmD candidate at the University California, San Diego, and who works at Human Longevity, in San Diego, California, and colleagues, in an article published online February 1 in EBioMedicine.  "The surprising thing that we observed in people who were taking acetaminophen (paracetamol) was that all of them had a peculiar profile in hormone metabolites," senior author Amalio Telenti, MD, from J Craig Venter Institute, in La Jolla, California, explained to Medscape Medical News.
 

The researchers speculated that they might find liver dysfunction with large doses of acetaminophen, "because that is normal toxicity," but surprisingly they found that acetaminophen was associated with
changes in certain hormonal metabolites.  For example, the effect of taking acetaminophen on pregnen-dioldisulfate was roughly equivalent to the effect of 35 years of aging, or the normal decrease in levels seen in menopause. However, the effect only lasts 2 days, Telenti noted. "Three days after you took the acetaminophen you would be back to your chronological age." Nevertheless, given "epidemiologists are concerned that the people with animal models are concerned, and now we have data saying [acetaminophen] does modify some of the hormones," Telenti said, "I would try to be cautious until we understand better."
 

"I'm not saying that there is a risk to taking acetaminophen because you have a headache," he said. However, "I would not like to take acetaminophen every day for 1 month during pregnancy."
 

Common OTC Painkiller, Reproductive Health Concerns
 

Even though acetaminophen is one of the most common pain medications used worldwide, there is a lack of consensus about its mechanism of action, and more recently, growing concern about possible adverse effects on reproductive health. Acetaminophen has also falsely elevated continuous glucose monitor readings by a large margin in some patients with diabetes, which is a cause for concern as these devices are increasingly being adopted.
 

In the new study, Cohen and colleagues enrolled 455 active adults age 18 years and older and performed an analysis of more than 700 metabolites in 208 participants to establish a metabolomic profile. They then tested the training model in the other 247 participants. They found that 19 of the 208 participants were likely taking acetaminophen based on the presence of acetaminophen and its
seven metabolites, and this use affected a unique subset of sulfated sex hormones. The model was validated in 1880 individuals of European ancestry in the TwinsUK cohort and 1235 individuals of African American and Hispanic ancestry from the Insulin Resistance Atherosclerosis Study. "Overall, our analysis of 3570 individuals (including training test, Europeans, African Americans, and Hispanic participants) confirm the generalizable effect of acetaminophen use on sulfated sex
hormone levels across human populations," they write.
 

The study also sheds light on how acetaminophen may ease pain.  "Individuals who took acetaminophen," they note, "had very low levels of neurosteroids such as pregnenolone sulfate and DHEAS [dehydroepiandrosterone], a mechanism that could synergize with acetaminophen's known mode of action in the central nervous system that implicates the COX [cyclooxygenase], vanilloid, and endocannabinoid systems."  Moreover, "the current work showcases the use of pharmacometabolomics to identify unexpected effects of a commonly used drug, acetaminophen, on hormone metabolism," according to the researchers. "Closer scrutiny of this commonly used medication is warranted," they add.  "These findings are significant for they showcase how the body is impacted by seemingly innocuous everyday medications like Tylenol," said Telenti in a press release by Human Longevity. "There are hundreds of other drugs that no one has done this research for. We delineate a general strategy that should be applied broadly in the study of medications in common use."
 

EBioMedicine. Published online February 1, 2018."

Tuesday, 6 February 2018

First rate paper exploring why Continuous Electronic Fetal Monitoring (EFM) is used despite its uselessness.

Thanks to Ruth Weston of Aquabirths for alerting me to this very interesting article exploring the widespread use of EFM (or CTG as it is more commonly known in the UK) in face of the evidence that it is not only useless but harmful.
https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-017-0060-2
The paper is not only interesting regarding EFM but also about the interfaces between health and law and ethics.  
The whole mad parallel world of Labour Ward practice is embedded in the premise on which EFM is based:  Surveillance and rapid intervention, not necessarily in that order.  The care and support of women and the safeguarding of the hormonal dance of labour plays second fiddle to that, and that is being kind about most labour wards, which are no places for birthing women.  In UM's experience and opinion.

Saturday, 13 January 2018

200 women freebirth annually in London (London Evening Standard 11.1.18)

It's not often the London Evening Standard publishes anything of interest (neo-liberal, property-price obsessed, consumerist, growth-addicted rag edited by George Osborne the previous Conservative Chancellor of the Exchequer) but this week it had a headline (p.13) "Mothers shun midwives for "free births"".
https://www.standard.co.uk/news/health/mothers-shun-midwives-for-free-births-at-home-a3737396.html
None of the 170 to 200 women who had freebirthed in London last year was interviewed, so whether midwives are being shunned or whether medicalised care or lack of continuity is being shunned, we do not know.  You may be glad to hear that Kenny Gibson, NHS England's head of public health commissioning in London is "not unduly concerned".  Perhaps Kenny may like to stop being so complacent, look a little deeper and commission the sorts of services that women want, before jumping to his conclusion that freebirth is just another choice for affluent women (see article). 

With the Standard's usual lack of logic, there is alongside this "shunning" story, another titled "2000 choose private help costing up to £5000".
https://www.standard.co.uk/news/health/women-choosing-private-midwives-with-price-tag-of-5000-a3737411.html
This tells us that continuity of care is hugely important to women (both a midwife and mother appear in this article) and it is very positive about Neighbourhood Midwives, a group of independent midwives working in London and across much of south-east England, who clearly aren't being shunned by mothers at all!
http://www.neighbourhoodmidwives.org.uk/

Thursday, 23 November 2017

The Daily Mail

The Daily Mail, for those of you outside the UK, is a terrible newspaper - reactionary, divisive, negative, horrible, and it will basically say anything about anyone to get a sale.  The level of journalism is dreadful and, whatever the aspirations of its journalists on entering their profession, they have kissed any vision of informing the public "goodbye".  There is currently a campaign to persuade major companies to stop advertising in The Daily Mail (and similar rags) called #StopFundingHate.  
http://stopfundinghate.org.uk/

This week The Daily Fail's hatred involved a midwife, Sheena Byrom OBE, a well-known British midwife who is a campaigner for women-centred services and continuity of care.  The level of vindictive crap in this article, which is no more than a long string of inaccuracies and misrepresentations, has outraged us all. 
http://www.dailymail.co.uk/health/article-5098885/NHS-trusts-promoting-natural-births.html 

Many birth activists, midwives and birth workers have complained to the Independent Press Standards Organisation and the Daily Mail have removed the scores of condemnatory comments that were left on the Mail Online website but not, so far, its scurrilous article.
https://www.ipso.co.uk/

Midwives and allies are coming together to end the bullying and harassment of those who speak up for woman-centred care and the importance of normal birth for the health and well-being of women and babies.  The on-line stalking of Sheena Byrom is disturbing, malevolent, and perpetrated only by those who think they know everything but understand nothing.  SAY NO TO BULLYING IN MIDWIFERY.  SAY NO TO THE BULLYING OF WOMEN WHO CHOOSE TO BIRTH UNDER THEIR OWN STEAM.

POSTSCRIPT
Well eventually UM got a reply from IPSO but no action.  Indeed IPSO's response reinforces the dial-a-quote-without-bothering-to-understand-the-issues school of journalism.  It's one quote from Kirkup that seems to trump all the other issues that led to the deaths there, and John Buckingham has himself latched on to it:

"I write further to our earlier email regarding your complaint about an article headlined “NHS still forces mums into natural birth even when C-section is best”, published by the Daily Mail on 20 November 2017.

On receipt of a complaint, IPSO’s Executive staff reviews it to ensure that the issues raised fall within our remit, and represent a possible breach of the Editors’ Code of Practice. The Executive has now completed an assessment of your complaint.

You said that the article was inaccurate in breach of Clause 1 (Accuracy) because it misrepresented the issues involved in the Morecambe Bay scandal, suggesting that it was a result of pursuing natural births ‘at any cost’.

We note that the report of the Kirkup Inquiry is at the following link: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf

We note that paragraph 4 of the Executive summary states that:
4. The origin of the problems we describe lay in the seriously dysfunctional nature of the maternity service at Furness General Hospital (FGH). Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth ‘at any cost’; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons.

5. Together, these factors comprised a lethal mix that, we have no doubt, led to the unnecessary deaths of mothers and babies….

Where these were the findings of the inquiry, we did not consider it was misleading for the article under complaint to note that the pursuit of natural birth “at any cost”, formed part of the circumstances in which there were 11 avoidable deaths at Morecambe Bay. This aspect of your complaint did not raise a breach of Clause 1.

We should explain that IPSO is able to consider complaints from an individual who has been personally and directly involved in the coverage, or journalistic activity, which gives rise to the alleged breach of the Editors’ Code of Practice; complaints from a representative group affected by an alleged breach where there is a substantial public interest; and complaints from third parties about accuracy. In the case of third party complaints, we will need to consider the position of the party most closely involved.

You also said that the article was inaccurate in the way in which it characterised the Royal College of Midwives’ decision to drop its Normal Birth Campaign. We noted that Cathy Warwick, chief executive of the college was reported to have said that the campaign had “created the wrong idea”. In any event, we decided that the alleged breach related most closely to the Royal College of Midwives. Having taken into account its position, we considered it would not be appropriate to investigate your complaint without its input and consent. Because of this, we were not be able to consider this aspect of your complaint further.

You also said that the article breached Clause 3 (Harassment) because it harassed Sheena Byrom, and Clause 2 (Privacy) because it disclosed her payment without disclosing what this was made for.
In these cases, the alleged breaches of the Code related directly to Sheena Byrom, and as you are not acting on her behalf with her consent and knowledge, we were not able to consider these aspects of your complaint further.

For more information about third party complaints, and why it can be difficult for us to take them forwards, this blog may be of interest.

You are entitled to request that the Executive’s decision not to take forward your complaint be reviewed by IPSO’s Complaints Committee. To do so you will need to write to us in the next seven days, setting out the reasons why you believe the decision should be reviewed. Please note that we are unable to accept requests for review made seven days after the date of this email.

We would like to thank you for giving us the opportunity to consider the points you have raised.

Best wishes,

John Buckingham"

Thursday, 2 November 2017

Oxytocin Measures - midwives taking a critical look at oxytocin regimes for induction and augmentation.

UM met a beautiful and strong midwife yesterday who is part of a small group determined that the maternity community, both in the UK and across the world, takes a long, hard, critical look at the way syntocinon is used to induce or augment labour.

This group have looked hard at the drug insert and what Novartis Pharmaceuticals, the main manufacturer of the syntocinon in use for labour acceleration, says, and have discovered that a huge proportion of women and their unborn babies are being subjected to off-licensed dosages, with potentially adverse consequences in birth experience and outcome.  They are determined to bring this to the attention of professionals, the public, and policy-makers.

Their website (still under construction in some areas) is here: https://oxytocinmeasures.com/ and they also can be found on Facebook https://www.facebook.com/profile.php?id=100015746618208  The website has a facility to sign up for updates on their work.

The group aim to produce information for women and professionals so that consent to induction can be informed consent.  Given the crudity of 21st century induction of labour techniques, having a group devoted to exploring this issue is a positive development.

Great work!

Saturday, 21 October 2017

The Osborne Kneeling Chair - a great bit of kit!

Margaret Jowitt, UK physiologist and long-term birth activist, has combined her skills to develop the Osborne Kneeling Chair for birth centres and labour wards everywhere.  All is beautifully shown on this short film.

https://www.youtube.com/watch?v=JlHHH31US3g

Margaret has been working on this project for a number of years and has refined her design to meet all infection control and other institutional requirements, whilst making sure that her basic idea of enabling free movement and facilitating upright labour and birth are not compromised.  The final product looks astonishingly simple but has taken hours, months, years of research, design, engineering and investment.  UM wishes her all the best with getting this superb product into birthing rooms across Europe and beyond.



Friday, 6 October 2017

New AIMS book on gestational diabetes

The Association for Improvements in the Maternity Services (for whom we all, mothers and midwives, give thanks in the UK) have published a new book on Gestational Diabetes available from http://www.aims.org.uk/

image of Gestational Diabetes book
The author has tried to make this complicated and increasingly ubiquitous issue of hyperglycaemia in pregnancy understandable, point out where decisions, choices and issues of consent arise, and give information around these.  The book covers all areas of pregnancy, birth and the postnatal period as well as longer-term issues.  There is a useful resource section and some lovely illustrations by Jennifer Williams.

Tuesday, 3 October 2017

Professor Soo Downe explaining in simple terms WHAT WOMEN WANT!

The link below is to a YouTube clip of Soo Downe, Professor of Midwifery Studies at the University of Central Lancashire in the UK, summarising what women want from maternity care according to research on this important area. 

Why are these findings important to hold before us in any discussion about the maternity services?  Because too many people - journalists, politicians, and general misogynists - have seen fit to pontificate in the UK press over the summer on their views of what women should want with absolutely no reference to the views or insights of women or any other experts in the field (user groups, midwives, obstetricians, doulas, hypnobirthing teachers etc).    

https://youtu.be/dZmR23_XxNg

Soo enumerates simply and effectively why misogynistic fantasies about risk-averse medico-techno-delivery will always miss their mark - women want their embodied experiences of birth to take place within a context of love, support and kindness.  The real risk of not having the latter trumps the putative risks of not having the former.  But UM doubts Jeremy Hunt and his cronies will get it, alas.