One in five: pain into strength – and new beginnings in maternity care

Screen Shot 2016-06-12 at 09.45.43 copyFlitting listlessly through my timeline, I was arrested and perplexed by this wall of interrogation on a red background. Turns out it’s the narrowed, pointed questions directed at the woman sexually assaulted by Brock Turner, during a harrowing rape trial.

If you’re not one of the millions (it went viral) who has read the powerful and graphic 7000-word statement she addressed to her attacker in court, I urge you to read it now. She starts:

You don’t know me, but you’ve been inside me, and that’s why we’re here today.

Having read and re-read it numerous times, I’m shaken and enraged on these 8 counts:

1. The terrifying assault. Horrific details of a 23 year old woman unconscious, wounded and naked, with abrasions and dirt in her vagina, being raped behind some wheelie bins in the middle of the night.

2. The appalling aftermath. Deeply saddened by the far-reaching impact of the rape on her whole being, her life and family.

I didn’t want my body any more… My independence, natural joy, gentleness and steady lifestyle .. became distorted. I became closed off, angry, self depreciating, tired, irritable, empty.

3. The paltry sentence. Juxtaposed with the victim’s devastation, the outrageous leniency of the rapist’s sentence: 6 months in a county jail – of which he’ll serve half – instead of a potential 14 years in a state penitentiary, despite unanimous guilty verdict. (Judge Aaron Persky feared a longer sentence would have a ‘severe impact’ on the promising athlete). This embarrassingly short sentence doesn’t fit with the seriousness of the crime. It gives the message that a stranger can be inside you without proper consent and he will receive less than what has been defined as the minimum sentence. It’s why so many men believe they can do whatever they please to a woman’s body without accountability. And why so many victims of sexual assault never come forward. Currently in the UK, it is estimated that of the 85,000 women raped every year, an estimated 15 per cent are ever reported to the police, and of those, the conviction rate is a deplorable 6.5 per cent.

4. The dad. Brock’s father wrote a letter to Judge Aaron Persky (excerpt below), in which he pleaded for leniency on the grounds that his son had already paid a steep price for the ’20 minutes of action’, alluding to it as an inevitable, ‘unfortunate result[s]’ of campus party culture. (And poor Brock can’t even enjoy a whole steak any more). Is there an attitude more likely to cultivate a rapist than a father who confuses drinking problems with forcibly having sex with someone? We desperately need men to show sons how to respect women, irrespective of beverages or clothing.

DL1.png

5. The victim-blaming. This woeful case is not as shocking as it should be. As a society we have some disturbing attitudes: Over a quarter of the public believe that drunk victims of rape or sexual assault are at least partially responsible for what has happened to them. Other ‘causative’ factors identified are: what she is wearing, her behaviour and how many sexual partners she has had. A third of people believe women who flirt are partially responsible for being raped (Amnesty, 2005). We need to stop blaming rape victims and start teaching people about consent.

And move away from this:  everyparentsresponsibility

6. Brock’s lack of remorse – Doggedly attempting to dilute rape with the suggestion of ‘promiscuity’ (as opposed to the absence of consent), he still doesn’t admit to rape, only ‘drinking too much’ and ‘making bad decisions’. Yet, perplexingly, this lack of self awareness and taking ownership of his actions appears not to have affected his sentencing.

7. The white male privilege: real and insidious. Turner undoubtedly benefited from his white and economic privilege. It helped him hire a powerful attorney, expert witnesses, private investigators and ultimately secure a lenient sentence. He reaped the benefits of a judge who simply couldn’t imagine this white star athlete, from a prestigious university, in prison – he didn’t ‘belong’ there. There is plenty of evidence of socio-economic and racial disparities in sentencing. Again, failing to send out the message that sexual assault is against the law regardless of background, race, class, age and gender.

8. The terminology. Brock Turner was convicted of sexual assault but not ‘rape’. What does that mean? Does it mean that sexual assault is a less serious crime than rape? The FBI defines rape as

penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.

Yet Brock was convicted of assault with intent to commit rape of an intoxicated woman, sexually penetrating an intoxicated person with a foreign object, and sexually penetrating an unconscious person with a foreign object. The distinction between rape and sexual assault feels dehumanizing to me. Whatever we call rape/ sexual assault, it can be intensely traumatizing with lasting impacts on a victim.

The UK stats

1 in 5 women aged 16 – 59 has experienced some form of sexual violence since the age of 16 (Rape Crisis UK); 31% of young women aged 18-24 report having experienced sexual abuse in childhood (NSPCC, 2011).

What could this mean for our maternity services?

I’m interested in how women carry this internal, unseen damage and how pregnancy and birth can be deeply traumatic for rape victims. For some, giving birth is a reminder of rape: vaginal examinations, contractions forcing the body out of control, being exposed, in positions reminiscent of the abuse, strangers touching without consent, watching, inadvertently using triggering language (‘just try to relax’; ‘open your legs’; ‘relax your bottom’; ‘just let yourself go floppy’; ‘the more you relax, the sooner it’ll be over’ and so on). Sheila Kitzinger, Penny Simkin and others have written extensively on the short- and long-term effects of sexual abuse on childbearing women.

‘Being so out of control of my body again, it made me remember everything. Then I started seeing his face throughout the labour; it pushed me over the edge

That’s why I’m very excited to see that St Bartholomew’s NHS Trust, is opening in July the UK’s first maternity clinic specifically designed for women who have been sexually assualted. Pavan Amara of My Body Back Project, consultant midwife Inderjeet Kaur, and obstetrician and gynaecologist Rehan Khan, have created a different birthing pathway to ensure women who have experienced sexual violence receive the sensitive and specific care they need. The maternity clinic will be offering the following services:

  • Antenatal classes
  • Pregnancy care and examinations
  • Care during labour and birth
  • Breastfeeding advice
  • Specialist advice on ensuring mental wellbeing during labour
  • Postnatal gynaecological exams
  • Postnatal mental health support
  • Pre-pregnancy support for women who want to conceive

I salute the woman who wrote the unflinching emotional statement to her attacker, Brock Turner, turning pain into strength. And I salute you Pavan, Inderjeet and Rehan for setting up this groundbreaking clinic, increasing choice and ensuring tailored, sensitive care is available for the 1 in 5 women that has experienced sexual violence, when seeking maternity services. I hope similar clinics and birthing pathways appear across UK and the world.

 

 

 

 

 

Mary Cronk: Language – how far have we come?

Mary sent me this letter today, asking me to ‘put it on a universal email on the computer’ for her sisters in midwifery to read.

A few words I wasn’t sure about, so Mary clarified over the phone what she intended to say. Here is a transcript in case the image is too small to read:

Dear colleagues,
Well I’m now totally wheelchair bound and last practiced 3 years ago when I helped as second midwife at the homebirth of twins in Brighton.
I am passing on a large archive of Midwives Chronicles dating from the 1960s. I was trying to pack them and of course started to read a pile from 1973 and I wanted to share with you the enormous change in the midwifery language in 40 years. “Patients” were “nursed” and nurses were employed and advertised for to work in hospitals which did a number of “deliveries” per annum and were expected to be SRN/SCM. How we have changed, and I think for the better! I was part of the change but did “deliveries” of “patients” whom I “nursed”. I must get on with reading 40 years of Midwives Chronicles and hope you can read [them] and continue to help women to birth their babies, and not “deliver” them.
It was lovely to be visited by Oli Armshaw and I hope she gets interest in the Midwives Chronicles
Lots of love to all
Mary

In preparation for moving house, Mary has cleared out  – and given me – Midwives Chronicles and other magazines, going back 40 years. I’m enjoying perusing them, especially the antiquated job adverts, and wondering how best to put this classic resource to use – any suggestions?

journals

 “Some labours may need some help some of the time”

Mary is passionate about using non-medicalised, woman-centred language that emphasizes caring and respect. Although we have surely come a long way since confinement for childbirth, and referring to patients, we still have some more evolving to do towards the personal empowerment of birthing women: Delivery remains the ubiquitous term in maternity for birth as babies are “delivered” by the provider, not “borne” by the mother. Failure to progress is also woefully current – “disempowering and pejorative words that emphasize the poor quality of the uterine “machine”, women’s inability to give birth” (Hunter, 2006).

Mary has always been adamant that women do not go wrong, or fail (see this 45s video from 2012) – just that we may need some help sometimes, and there’s nothing wrong with needing help. She feels sad that as women we immediately blame ourselves when labour doesn’t happen the way we’d wanted, we say of our birthing bodies: “I wanted a normal birth, but I did it wrong”; “it went wrong”; “my body wouldn’t../couldn’t…” and so on. Much has been written about the language of childbirth (Bastian, 1992; Byrom, 2013; Hewison, 1993; Hunter, 2006; Kahn, 1998; Wagner, 2001Wickham, 2002;  Zeidenstein, 1998) and how it may contribute to these feelings of inadequacy, deficiency and humiliation. 

While old habits may be slow to shake off, language is everyone’s responsibility, something we all use – and it matters. Let’s be mindful of the impact of the words we choose, when talking to, or about, the women in our care.

Mary_me

Bracklesham beach, Isle of Wight on horizon, 18 May 2016

Evidence, Experience and Safety: Letters to Editor

ST_1ST_2

Mothers-to-be may get right to home birth, wrote Sarah Kate Templeton in The Sunday Times, 11 October 2015 (who also brought us Women may get right to breastfeed in public in 2007)

Paternalistic, inaccurate headline and disdain for evidence aside, last Sunday’s article on the proposed NHS voucher scheme was disturbingly biased.

Essentially,  it fuels the ongoing ‘experience vs. safety’ debate-which-isn’t-a-debate, by not so subtly suggesting that choice – especially of place of birth – is just misinformed women being self indulgent and/or irresponsible.  Below is my letter to editor, (which regrettably there was not enough room to publish, as he had received numerous letters on the subject). Three other letters to editor – from Sam O’Brien (not published), Beverley Beech (published in part) and Dr Tracey Cooper (not published) – are also posted below.

Dear Editor,

I’m writing to redress the balance of Sunday’s Mothers-to-be may get right to home birth’ – a headline implying we don’t already have the right to home birth, which we do. The European Convention on Human Rights, Article 8 protects every person’s right to respect for their autonomous choice about private life, including the woman’s right to decide the circumstances and location in which she gives birth. A better headline could be ‘mothers-to-be may get respect for right to home birth’.

But not just the headline is problematic.

Templeton’s piece is angled to undermine the National Institute for Health and Care Excellence’s recommendation that healthy women with uncomplicated pregnancies give birth in community or midwife-led settings (NICE, 2014). It overlooks the compelling evidence base supporting a salutogenic approach to childbirth, optimising physiology, avoiding intervention and the contribution of midwife-led care to improving quality and safety in maternity (Sandall et al, 2015, Hodnett et al, 2013). Instead, the article is weighted towards the perspectives of Birth Trauma Association’s Maureen Treadwell, spuriously claiming “the safety of community birth is yet to be conclusively proven” (what about Birthplace, 2011, Blix et al, 2012 and the other studies in NICE, 2014?), Care Quality Commission patient safety advisor James Titcombe and “doctors who believe the experience of birth is being promoted at the expense of safety of babies and mothers”.

What childbearing women need and want for themselves and their newborn infants is to be healthy, safe, supported, respected and to give birth to a healthy baby that can thrive, after a positive and life-enhancing pregnancy and birth experience, whatever complications they may experience (Lancet, 2014).

‘Experience’ and ‘safety’ are intrinsically linked, and cannot be separated, let alone opposed, as suggested by Titcombe and Treadwell. High quality, safe maternity care includes – and goes beyond – measuring mortality and morbidity, to encompass multiple outcomes, of which women’s experience is one. A woman is prioritising safety of the mother-baby dyad by trying to guarantee the ‘experience’ of continuity of care and the place of birth where she feels safe and relaxed – and where the evidence base tells her it is safe to birth. Medicalisation is not necessarily synonymous with safety. Women are not sacrificing safety for experience when they make the informed choice to birth outside obstetric units, avoiding increased risks of iatrogenic harm caused by interventions. Women make these choices based on individual interpretation of risks and benefits – which are physiological, psychological, emotional, social, spiritual, and vary from woman to woman. Safe and compassionate maternity care needs to anticipate and reflect these risks and benefits for individuals.

Sadly, the article points towards the misogynistic and misguided notion that all this choice is just self indulgent and reckless, which it absolutely is not.

Sincerely,

Olivia Armshaw, newly qualified midwife.

Here are three of the other letters to editor on the subject. (If there are any more which didn’t make the cut, please post them.)

1. Sam O’Brien, (the mother in the photograph accompanying the original article) writes: “When fighting for safety in birth, the experience matters.. Never have I felt less safe than when I was on the receiving end of a violent blur of procedures”. Read Sam’s letter here, which the Sunday Times did not include, but which she emailed to me.

When fighting for safety in birth, the experience matters. Letter to Editor from Sam O'Brien

2. Beverley Beech, (chairwoman of AIMS) calls out the ‘safety’ propaganda: “If safety is truly the first priority, then the publicity should be alerting women to the risks of hospital birth..” Read Beverley’s letter in full here – it was published in part by Sunday Times (paywall).

Beech_letter

2. Dr Tracey Cooper, (consultant midwife) proposes NICE guidelines advice on place of birth are more appropriate for women than “outdated perceptions or scaremongering”. Click to enlarge Tracey’s letter which the Sunday Times did not include, but which she emailed to me.

Letter to Editor from Dr Tracey Cooper, Consultant Midwife

Other prominent voices commented on  reports  that NHS  England-commissioned  National  Maternity  Review  may  recommend  women  be  given  maternity  vouchers  to  enable  them  to  choose  their  care providers. “Women can and should make the decisions about where they give birth”, says human rights in childbirth charity Birthrights. See full statement here

I was also relieved to read Milli Hill’s comment in The Telegraph, decrying the oversimplistic ‘safety versus experience’ argument: “Home births are not just for mad maternity evangelists – thanks NHS”. 

To conclude this post, here is a reminder of the relationship between safety and experience as clearly defined in Birthrights’ letter to the NHS Maternity Review, which lights the way on autonomy, dignity and human rights in maternity care.

Excerpt from Birthrights' letter to the NHS Maternity Review, 16 August, 2015
Excerpt from Birthrights’ letter to the NHS Maternity Review, 16 August, 2015

Midwifery reflections on the Kirkup report

I’m still working my way through Kirkup’s Morecombe Bay investigation report – it’s a heavy read.

After the RCOG and RCM ‘professional body’ responses, I wanted to hear some midwifery voices on what the report means to us personally, and the care we provide on a day-to-day basis. So I asked some key figures in maternity these questions:

  • How do you feel about the report?
  • What are your thoughts on: “the ethos of normal or natural birth ‘at any costs’, which resulted in inappropriate and unsafe care” (p.13, 1.4)
  • What are the implications for maternity?
  • Have you any concerns/ insights?
  • What are your suggestions for a way forward?
  • Would you like to say anything else?

Here are responses from: (in alphabetical order) Sheena Byrom, Jenny Hall, Mary Newburn, Lesley Page, Rebecca Schiller and Shawn Walker.  Mine is right at the end. There may be more to come, so watch this space.

Sheena Byrom.  Midwife consultant.

Sheena Byrom, midwife consultant: “I feel great sadness and disappointment reading the report. Sadness for the devastating suffering of families affected by loss and trauma, and for the staff who were caught up in a broken system. Disappointment that organizational processes and pressures were undoubtedly the greatest influence over human action.

Protecting normal birth is a midwife’s core function, and many work hard to support and promote such an ethos where they work, often in difficult circumstances. Problems arise when there is a lack of mutual respect between professional teams, and a ‘them and us’ culture between groups of midwives. But I have honestly never met a midwife who compromised safety in the pursuit of ‘normal birth’ – in fact, on the contrary. In the main midwives err on the side of caution, and through fear will sometimes practice defensively and involve medical teams for reassurance.

A maternity services review is being planned, and is welcomed. This gives us the opportunity to articulate the need for improved leadership, midwifery representation on boards, greater focus on the need for improved attitudes, mutually respectful relationships and the importance of collaboration. We need to ensure there is a commitment to reduce the fear that initiates most of the actions taken in maternity services.

The report highlights organizational malfunctions in one Trust at every level, and includes faults of each professional body, yet the focus of attention in the report and in the media is mainly on midwives, which I feel is worryingly unjustified. Learning from mistakes is crucial, but must take place in a no-blame environment.

Improving safety means more than increasing risk management strategies. The quality of relationships directly affects maternity care and outcomes. Midwives and doctors need to be listened to, nurtured, developed and encouraged to maximize their potential to provide sensitive, compassionate maternity care.”

JH_pic

Jenny Hall, senior midwifery lecturer, Bournemouth University: “I’m shocked, saddened for the families involved.  So sad that this was going on in maternity service for so long without it being recognised or dealt with and was indicative of the way the NHS has been managed over the past 20-30 years. Cost cutting at all levels and burying heads in the sand- culture of power and people being squashed if they speak out.

I have not experienced the ethos of normal or natural birth ‘at any costs’ anywhere else. Usually it has been the opposite – a culture of medicalization or a culture of midwives and doctors working together for the wellbeing of women and their babies. This ‘ethos at all costs’ is highly unusual and against the Midwives Rules of practice. This was not just about the midwives but also doctors that were ineffectual.

We have already had some repercussions in the first change in Supervision since the 1902 act. The implications should be that we should examine ourselves and ensure this does not happen again but also to ensure we work closer with the medical profession.  The implications are around education and ensuring midwives and doctors remember accountability and that we become more transparent in our practice

As a high profile situation I am concerned that the midwives are the only ones vilified in this when it was clearly a wider situation of management as well. I am concerned that the midwifery profession as a whole will be kicked by this when it is evident that this is a small group in a poisonous culture. But the impact of this on families has been so devastating that questions have to be asked. We must learn lessons but also keep hold of the evidence of how GOOD midwifery care works.

Moving forward will require dialogue at all levels, no burying anything, facing up to the issues and ensure we make changes in cultures that are controlled by anyone is power-hungry,  ensure there is no conflict in any roles, women babies and families must come first and services must match this.”

Mary Newburn. Maternity activist and parent advocate.

Mary Newburn, maternity activist and parent advocate: “It’s tragic that there were 20 major failures of care at the Furness General during 2004-2013. These led to one maternal death and 11 deaths of babies that the Kirkup enquiry felt would have been prevented with different clinical care. It took too long for parents’ voices to be heard. What can be learnt? The investigators’ list of problems include ‘poor clinical competence, insufficient recognition of risk, and failures of team-working’. Does ‘inappropriate pursuit of normal childbirth’ rightly have a place there, too?

In my experience, leading advocates of normal childbirth are very clear about the need for clinical competence, good communication, understanding and mutual respect in the multi-disciplinary team and continuous assessment of risk. These are the secrets of success. The Furness General is geographically isolated with relatively few births. These kinds of services can struggle to attract and retain excellent clinical leaders and keep up with developing best practice.

I feel it is vital that those in positions of power do not to pillory ‘normal birth’ following Kirkup. Despite reforms, many women still feel that their pregnancy and birth are not their own when making babies, and their mind and memories seem to matter little. Good services are built on team work, with competent, up to date, questioning and responsive midwives and doctors who respect women and each other. Add in engagement with parents, as individuals receiving care and as advocates for shaping services, and services really flourish.

So, with some trepidation I welcome Kirkup’s call for a review of maternity care in isolated, rural areas. And give a resounding ‘Yes!’ to the call for a robust MSLC (maternity services liaison committee) for the Furness General, and all other units. Please note CCGs. The ball is in your court!”

Lesley Page. President of Royal College of Midwives

Lesley Page, president of Royal College of Midwives: “I feel so sad about the grief of the families who suffered, grief compounded by the fact that nobody listened and failure of response and justice. Determined to learn from it.

The press has picked up on the report’s emphasis on “the ethos of normal or natural birth ‘at all costs’ at the unit which resulted in inappropriate and unsafe care” (Kirkup, 2015, p. 13, 1.4.) I searched carefully to find out what was the basis of this emphasis but couldn’t find much. I would have liked to have understood the clinical situations better. We need to support normal birth to improve health so such an ethos would not make sense.

We need systems of care and resources that help us give of our best. Morecambe Bay was an example of how to detract from humane, effective safe care. It will be important to ensure that we have strong midwifery leaders, working with others, supported to truly lead, in healthy cultures of care. In any unhealthy culture leaders may not stand a chance.

I’m concerned that response might be to increase, or allow an increase in the intervention rate and unnecessary interventions and to detract from the work of developing midwife led care and choice of place of birth for women. Avoiding unnecessary intervention is crucial to increasing safety. This needs skilled midwives and doctors, relationships within systems and pathways without rocks cliffs and boulders in them. It needs women to be involved in decisions about their care and user and public involvement in monitoring and developing services.

We must learn from the report. The maternity services review to be conducted by NHS England will be important. We need to recognise the evidence on what improves safety of birth and act on it. It will be important to use quality and safety improvement methodology in the health services.

Staff and all those who were part of what happened in Morecambe Bay carry a huge burden, this includes people at every level, government, providers, commissioners and regulators. Many will have been doing or trying to do their best. I hope any incoming government will take notice of the sheer disorganisation that comes from mismanaged reorganisation. Systems have people in them, those people are human, sometimes super human efforts are required to manage well amongst turmoil, there are few super humans. There was lack of leadership but I think the situation would have made it very difficult for leadership to flourish or be effective.”

Rebecca Schiller. Co-chair Birthrights, doula

Rebecca Schiller, co-chair Birthrights, doula: “The Kirkup report raises a series of valid questions and serious concerns about maternity care in England – many of which are applicable far beyond our national borders. It is now vital that we move forwards to answers and I hope that a national maternity review will be a step towards that.

However, in the wake of terrible tragedy, it is all-too-easy to be reactive rather than reflective. There is a risk of looking only to solutions to surface-level problems. It is crucial that this review does not only seek to fix the problems at the end of the chain of linked failings without looking back at the systems, structures, cultural values and resource-issues that cause clinicians to fail spectacularly in their duty of care. Genuine bad practice will sadly always exist. Systems need to be able to identify this and deal with it swiftly taking women’s feedback and complaints seriously and refraining from defensive and obstructive behaviours.

But bad practice is not the demon here. The overwhelming majority of clinicians want to practice safely, compassionately and professionally. They want to deliver care that matches women’s needs and expectations and there is an evidence base to draw on to show how this can be done. A thorough review of maternity services should identify where and why they don’t support health care professionals to offer this kind of care. Women have for too long been pushed through a system that doesn’t recognise their individual needs. This is unsafe and unsustainable. I hope that the tragedies at Morecambe Bay are a prompt for a genuine change in the models and culture of maternity care.”

Birthrights’ response is insightful on the Morecambe Bay midwives’ exclusion of obstetricians from the unit as ‘unlikely to have been principled adherence to evidence-based care’ and notes that ‘it is a sad consequence that the pursuit of well-evidenced maternity care has been conflated with their impropriety.’

Shawn Walker. Midwifery Lecturer, City University London.

Shawn Walker, midwifery lecturer, City University London. Breech Birth Network. “Like many midwives, I welcome the Kirkup report, though it was hard reading at times.

Very few women and midwives wish to pursue an ethos of normal birth at all costs. But a healthy desire for normality can become sick and twisted within a dysfunctional system, like a family plagued by unhealthy obsessions and addictions, in which everyone feels lonely, together. Sometimes one or a few individuals are able to make these dysfunctions work in their favour for a while, but inevitably cracks emerge. When one individual acquires an unchallenged amount of power by assuming multiple roles in the risk management process, the collaborative system of checks and balances characterising healthy organisations becomes unbalanced.

Used wisely, risk management and midwifery supervision are powerful tools, which enable organisations and individuals to change, improve, and grow. They can and should help health professionals to become aware of their errors, strengths, and developmental needs. These processes should be rigorous, transparent and welcomed. Insight should never be feared and avoided. The Kirkup report points the way to how health services can find health. It is not about natural birth or medical supremacy. Safety requires respectful, collaborative communication amongst all professions. Safety requires working environments where people are able to say, “I’m concerned,” without being overridden or overriding someone else’s concern. Only by being rigorous, compassionate and honest with each other can health professionals hope to provide care, which is all these things for the people who trust them with their lives.”

Olivia Armshaw. Student midwife

Olivia Armshaw, student midwife: “Treading carefully, respectful of the grief of those involved in the tragedies which distressingly resulted from substandard care… As a soon-to-be qualified midwife working in a busy NHS trust, alongside many highly competent, compassionate, careful, sensitive and emotionally intelligent midwives, I don’t recognise the picture reported at Morecombe Bay, thankfully the stories seem a world away from the care being given around me, and the feedback from women.

It doesn’t ring true that normal birth is pursued at all costs. Yes, we look for opportunities to bring normality and ‘low risk style’ care to those with complex needs, to humanise where possible. Yes, we offer homebirth to women who want it and for whom it’s safe. Yes, we have midwife-led birth units. But there is a collaborative approach to care with obstetricians, with weekly interprofessional meetings on delivery suite to review cases and discuss how care could be improved. We are not reckless or gung ho and never is there a cavalier attitude to normal birth. If anything, I think we could do more to maximise physiology and intervene less.

I witnessed how the Francis report demoralised midwives and some felt it became another stick to beat us with. I really hope the Kirkup report doesn’t have the same function, used by those how want to sling mud (or worse), and undermine the whole midwifery model of care. I hope we can extrapolate the learnings and work, mindfully and collaboratively so failings are not repeated. First we need to identify the lessons in a very specific, not a generic way that says ‘normal birth is bad’, ‘midwives are all reckless and unprofessional’, which are wrong and dangerous conclusions to jump to, with a whiff of an age-old witch hunt.”

I feel the Lancet midwifery series lights a way forward, supporting a shift from fragmented maternal and newborn care provision that is focussed on identification and treatment of pathology to a whole-system approach that provides skilled care for all. (Lancet, Volume 384, No. 9948, September 2014 )

Down the rabbit hole of ‘reasonable’

Before investigating whether vaginal birth is a reasonable option for women with a breech baby at term (for my undergraduate midwifery dissertation) I should really understand what constitutes ‘reasonable’. Or could I just presume a consensus understanding of the term and get to bed at a reasonable time?

You know you’ve fallen down a rabbit hole hole when you’re reading papers like Credo of a ‘reasonable choice’ modeler by A. Wuffle (1999) and Reasonable doubts about rational choices (Houghton, 1995) in theoretical politics and philosophy journals, alone in the hospital library at 00.00 hours. I guess this is the type of thing I should have defined upfront, before doing my meticulously methodical and transparently replicable (ahem) literature search.

Back to Wuffle.

According to political scientist, Wuffle, ‘reasonable’ and ‘rational’ are related, but distinct, theoretical bedfellows. He thinks that ‘most human behaviour is rational; some isn’t’ and in his highly original and entertaining paper he proffers ‘reasonable choice’ as a middle ground between the dogma of rational choice models that ‘explain’ all aspects of human behavior, and other political science work which suggests rational choice is utterly useless at explaining human behaviour.

Houghton (1995) too, considers some problems with rational choice or rational decision-making. He assumes that people want to make the best choices and that those choices ‘have to do with what will bring greater net benefit or have greater net value than any alternative course of action available’. Interestingly for my midwifely quest, he suggests that we are more likely to make the best choices if we make informed choices (informed choice being an essential tenet of midwifery) although he goes on to argue that the best choices need not and cannot be the best-informed choices. Houghton is intrigued by the nuances of decision-making and information gathering. He suggests that in order to arrive at decisions, the rational decision-maker would survey possibilities and rank them in order of preference, assessing the likelihood of each, considering all possibilities and outcomes – which is not possible as these would be infinite, leading to an unsatisfyingly inconclusive hole within a hole: that reasonable choices are essentially, unreasoned.

Curiouser and curiouser…

By wondering if ‘reasonable’ is essentially borrowed from law, I find myself in a common law part of the warren, where ‘reasonable’ is used in relation to behaviour that is seen as ‘uniform, foreseeable and neutral’.

Trying to get to the maternity department, I make a detour via the Equality and Human Rights Commission’s sensible discussion of what is meant by ‘reasonable’, this time in relation to adjustments made by employers to accommodate disabled workers. Although their definition of what is considered reasonable relates to workplace issues, I see how the concept is multifactorial and dependent on the individual situation. In the case of adjustments, what is reasonable ‘will depend on all the circumstances of the case including the size of an organisation and its resources, what is practicable, the effectiveness of what is being proposed and the likely disruption that would be caused by taking the measure in question as well as the availability of financial assistance’ (Equality and Human Rights Commission)

In order to apply this multifaceted approach to ‘reasonable’ in a maternity context – specifically breech decision making – I visit the US Department of Health and Human Services Consensus Development Program, which produces unbiased, evidence-based assessments of controversial medical issues important to researchers, healthcare providers, policymakers, patients, and the general public. They don’t have a consensus statement on breech, but their consensus statement on Vaginal Birth After Caesarean (VBAC) is gratifyingly enlightening, as VBAC is a comparable dilemma to breech for the woman, as well as practitioners, in which ‘benefits for her may come at the price of increased risk for the baby, and vice versa’ (NIH, 2010)

To assess if VBAC (read vaginal breech birth) is a reasonable choice, the NIH panel recommends using responses to the following 6 questions (especially 3 and 4) to incorporate an evidence-based approach into the decision making process and the woman’s preference should be honoured.

Medical-legal considerations add to the barriers to VBAC (read vaginal breech birth).

(For the purpose of my investigation into what constitutes a reasonable birth choice for women with a term breech baby, I have replaced ‘VBAC/trial of labour after previous caesarean’ with ‘vaginal breech birth’. The rest of the wording is unchanged)

  1. What are the rates and patterns of vaginal breech birth in UK?
  2. Among women who plan vaginal breech birth, what is the vaginal birth rate and the factors that influence it?
  3. What are the short- and long-term benefits and harms to the mother of attempting vaginal breech birth versus planned caesarean section, and what factors influence benefits and harms?
  4. What are the short- and long-term benefits and harms to the baby of vaginal breech birth versus planned caesarean section, and what factors influence benefits and harms?
  5. What are the nonmedical factors that influence the patterns and utilization of vaginal breech birth?
  6. What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?

This is an interesting framework for assessing ‘reasonable option’ as it asks about gaps in the evidence and non-medical factors as well as considering the existing and emerging evidence base. And it’s how I find my way out of philosophy and theoretical science, back to the outcomes that matter to women when making choices and to maternity in offering choices.

I now understand that ‘reasonable option’ is closely related to informed choice, the bedrock of our maternity system, which supposedly puts the woman at the centre of care, empowered to make decisions about her individual pregnancy and birth options, based on reliable evidence that has been presented in a balanced unbiased way, right?

Wrong. In reality options are presented in a way that belies real choice. I mean, when women with breech presenting babies at term are offered only ECV or planned caesarean section because no one is able (or willing) to support vaginal breech birth, could there possibly be a reasonable option missing? Is true choice being offered and delivered?

MIDIRS informed choice leaflets (2008) were an excellent resource for midwives and women for reliable evidence based information to support maternal choice and decision making, although sadly they are not being updated or republished. The breech leaflet clearly sets out options in a balanced way, taking into account some of the variables within the available information, including planned location for the birth and availability of skilled attendants. These variables are consistent with an evidence-based approach to decision making recommended by the NIH consensus statement on VBAC.

Decision Making in Midwifery Practice (Raynor, Marshall and Sullivan, 2005) could have been a more relevant place to start, but I’m here now, back on ground level, via theoretical science, philosophy, common law and equallity and human rights.

Blinking in the light, I emerge unsure if that was a useful exercise or just an excellent bit of procrastination. But at least now I can return to frantic colour-coding of themes in studies with highlighter pens, safe in the knowledge that I have investigated ‘reasonable’ to death.