Giving Birth In A High-Intervention System, with Guests Sheena Byrom OBE and Professor Soo Downe
Rising intervention rates are changing what pregnancy and birth feel like, and we question whether the gains match the costs for women, babies, and staff. We explore how fear, broken trust, and tick-box care shape decisions, then map the practical steps that can rebuild safety through relationships, time, and real choice. In this episode we explore:
• The impact and reasons for rising intervention rates in a modern world
• Fear-driven practice and the unintended consequences of a zero-harm mindset
• Stillbirth, brain injury, and maternal mortality data alongside what gets missed
• Risk in maternity care and how this impacts care
• The long-term value of spontaneous labour and physiological birth
• Continuity of midwifery care as a proven route to better outcomes
• Trust between women and midwives and how media narratives damage it
• Learning from pockets of excellent care rather than endless new reviews
• Pregnancy circles, social support, and why community links affect physiology
• Practical advocacy tools
TRANSCRIPT
(AI GENERATED)
Speaker: 00:07
You're listening to the BirthEd Podcast, and I'm your host, founder of BirthEd, and handholder Extraordinaire, Megan Rosseter. The BirthEd Podcast is here to provide you with the in-depth conversations about pregnancy, birth, and parenting that you deserve to be getting in your antenatal appointments, but aren't. So if you're ready to take your birth prep seriously and take back control of your birth, but need a gentle holding hand to get you there, you're in the right place. Make sure you hit subscribe so you never miss an episode. So Sheen and I recorded an episode on physiological birth in the modern maternity system right back at series one of the BirthEd podcast, which I think was about eight years ago now. Um and if you haven't listened to that episode, I definitely still would. But we wanted to record another episode, not um only because I've written in my um notes, not only because online sound recording has approved, improved a lot in that time, but amusingly we're recording from um Sheena's in. Sheena, are you in Greece? I am, yes. Um, and so we're sort of currently um slightly uh stuck with Wi-Fi and stuff, but we are also joined by Professor Sue Down, who is a sort of close friend of Sheena, works very closely with her and another excellent mind in the world of kind of physiological birth and understanding the maternity system. So from one side, we want to kind of bring in that aspect of conversation. And from another perspective is just how much the maternity system has changed in the last decade. Um so, Sheena and Sue, welcome. Thank you so much for joining me again for a kind of repeat of this conversation that I imagine will take a very different shape to how it did almost 10 years ago.
Speaker: 01:51
Great to be here. Thank you for the invitation. Yeah, it's great for me to be here as well from a hilltop in Greece.
Speaker 1: 01:56
Oh, yeah, I'm very jealous. I'm just in a slightly it is sunny uh living room in uh Surrey. So um I listened back to the episode that Sheena and I recorded, and sort of out outrageously or amusingly at the time, we were both outraged at the fact that at that moment in time, 52% of women were going into spontaneous labour. Um and every year since we've had that conversation, it has been less than the majority of women going into spontaneous labour. So in the last 10 years, induction has gone from 25% to 33%. Plan Caesarean has gone from 13% to 25%. So thinking about the kind of past 10 years in maternity care, um, what has changed?
Speaker 2: 02:42
And and I'm not working clinically at the moment. So I'm speaking from the point of view of observing what's happened through research studies or through colleagues or you know, in the various networks that I'm in, where many clinical midwives and others and service users and um childbreaking women and and um birthing people are. And I think I mean the conversation about fear has always been there, and Hannah Darlene writes a lot about this, and if you're in maternity care always has, but I think it's become almost tangible now, in certainly in um UK maternity care. And I say UK advisedly, I think it's also true in Wales and Ireland and uh Wales and Northern Ireland and Scotland. Um, and that, and and it's also because the focus has become very, very laser sharp on one particular set of outcomes. So that, you know, probably, and and it may have been a bit longer than 10 years, but certainly over the last 20 years, the shift has been from understanding
Speaker 2: 03:35
there's a balance between um prevention and harm. You know, that some things unfortunately there will always probably in any area of healthcare be some things that go wrong and some things that don't work out the way that we hoped they would when we provide the treatment or support or whatever it might happen to be. But we now seem to be in a phase where no adverse outcome is acceptable. And every adverse adverse, well, well, specific adverse outcomes, such as stillbirth and neonatal death, well, actually, not even neonatal death, but such as stillbirth and um brain injury at the moment, are completely unacceptable. And that there doesn't seem to be a balance between understanding that that is really important to prevent those deaths and those those harms, but that there are unintended consequences of focusing only on those deaths and those harms and not and not on other on other aspects, and particularly not on the positive aspects of labour and birth. You know, the fact that labour and birth can be um life-enhancing and it can it can um it can support, or not even support, it can transform women and families if the process is positive, sometimes even from when they're in a bad space to a good space, not just that it's a good thing in itself, but it can be transformational and it also has long-term consequences as well for mother and baby. So that's a long answer, but I think for me it's that it's that is that the the tangible effect of that laser-sharp focus on the levels of fear for everybody.
Speaker 1: 05:01
Yeah, Sheena, anything that you would want to add?
Speaker: 05:04
Yeah, I agree with everything you said, Sue. And if you remember that day in our garden when we decided to edit the book for Behind the Silence, it was because of that. Um, and it seems to have, like you say, escalated beyond beyond all recognition, really. And I think from just to add that, what I've seen as well is that the fear has just gone, it's sort of it's it's it's deepened through the work of midwives too. So, you know, we're thinking about myself as a midwife and and liaising with midwives all the time and student midwives. What they're saying now is that they're not practicing midwifery and that they feel that their practice is basically uh trying to avoid harm, but it's being done by tick box exercises, um, which we could see coming in 10 years ago, but they've it's just escalated beyond belief that it's all around computer, that their skills are honing in on computer skills, having to know what how to how to uh use a computer well and how to tick box tick boxes as quickly as possible, and moving away from that holistic um authentic care where they can really treat women as individuals and deliver personalised care. It's mainly focusing on guidance, which is are seen as policy, and that no one must veer either side of that policy, which is completely wrong. And and the support mechanisms that were in place to help midwives and other birth workers to support women's choices have been stripped away. It's almost like they've disappeared. We used to have something called supervision of midwives, where there may have been problematic problems with that kind of mechanism, but it was also there to support midwives if they were providing care, what we now call out of guidance. It's always been there. There's always been the the fact that some women haven't wanted to have conventional care, they've wanted to have a a birth that's you know, sort of not seen as being the norm, and um, and we had a mechanism in place that's been completely stripped away. So I think it's multifaceted, the reasons why it's changed so much, which we can which we which we can talk about maybe during this session.
Speaker 1: 07:30
Absolutely. So for anybody kind of listening that maybe isn't familiar with what we're kind of talking about as a kind of baseline, is that in the last 10 years we have seen intervention rates in almost every way rise quite staggeringly. Um things like induction, planned caesarean birth, unplanned caesarean birth. But hand in hand with that, as Sue was talking about, the the kind of implications or side effects or sort of complexities that those things may have gone on to cause have also risen, things like um postpartum hemorrhage, um birth trauma, those those kinds of things. So they're not kind of benign interventions. So I suppose my question is with the rising intervention rate that we are seeing, is it is it working? Is the stillbirth rate coming down? Is maternal death rate coming down? Are we seeing the improvements that these changes have set out with the intent of improving, if that makes sense?
Speaker 2: 08:31
The stillbirth rate is going down, has gone down, I should say, uh, but nowhere near at the rate that the government has a target for. Um, and the maternal mortality rate is going up, so in the opposite direction. Um, and some of that is because of a rise in maternal suicide in the postnatal period. And that raises questions about the fact that if you focus so much on the intrapartum period, which is where a lot the focus is, and you don't recognise the fact that in the postpartum period women need support and they need periphery care and they need other kinds of care, um, then then we drop the ball. And that's what I mean about the unintended consequences really of this laser-sharp focus on what happens during labour and birth. Um, a brain injury has gone down slightly. It's gone down by about two in 5,000. So again, the question is uh over the last five or six, five, five years, I think, something like that. So the question is uh what is the in
Speaker 2: 09:24
in science in science or in or in applied health, we talk about number needed to treat and number needed to harm. So the question is, what is the number you need to treat, number of people you need to treat to get one benefit? And what is the number that you need to harm for the sake of that one benefit? And I think at the moment, as I said before, the balance between those two things is out of kilter. So we always used to understand, I mean, it used to be, if I remember rightly, Sheena, that if a risk was more than one in a thousand, it wasn't felt that you needed to necessarily discuss it with people because it was so rare. Well, you know, now in terms of induction of labour for late um for late pregnancy, the the ratio is something like if you if you offer induction, and when I say offer, and of course many women aren't perceiving this as an offer, but if you offer, as Alan, um, to women to have an induction in at about 41 weeks' gestation, you probably reduce the stillbirth rate by one in a thousand. So for the woman who's lost who would otherwise have lost her baby, that one in a thousand is 100%, no argument. But 999 other women and babies and birthing people are therefore exposed to that intervention for that gain. So I think I think that's the public conversation really that has to be had. Are we understanding all the consequences and are we putting them to people so they can understand that risk-benefit balance? Because some women will say, I'm taking that, I want, you know, I want that induction. Thank you very much. I'm not I'm not gonna, you know, I don't want that one in a thousand. And others will go, really, one in a thousand? Well, you know, I mean, all my family's always been healthy, I've been healthy, I'm you know, I'm really I'm not up for that because I think there are the consequences I don't want, I don't want to see. And for example, in terms of induction of labour, we uh with Hannah Dahl and another group and Lillian Peters and others did a uh analysis of a very large database in in Australia, and we looked at women who had no obvious risk factors for induction but were induced for late for uh later in pregnancy, um post-maturity. And we thought we look, we've we looked at the data for those kids up to the age of 16, and we found that there was an increased risk, among other things, there was an increased risk of hospitalization for serious infection in those babies whose mothers were induced with no obvious medical reason. And we there would there's other data which seem to suggest that you know spontaneous labour and labour, spontaneous onset labour birth seems to set the immune system up in ways that protects uh children against uh uh autoimmune uh problems and and immune problems. Now, you know, it's not a proven hypothesis, but it seems to be coming out in lots of different studies, which suggests it's not just that intervention might cause harm, it's that not intervention actually has positive benefits. And I kind of almost want to frame it that way around because I think for me, uh it's there's no good us talking about not doing intervention if we're not doing physiological labour and birth very well, because what option is there for women then? You know, so actually if women are having traumatic births that are called normal, or they're having adverse outcomes due to labor and birth that's called normal, then then we're not doing them any favours. So, you know, we I think we have to look to ourselves to say, okay, can we start to understand and recognise that there is a certain physiological benefit in the longer term and the emotional benefit of spontaneous labour and birth? And can we create the conditions in which that is safe and positive for all those women who want it?
Speaker 1: 12:43
And I think that's something that is influencing a lot of women's decisions today, is that a lot of the women, I would say in the last 10 years, kind of supporting families in their birth preparation directly, a big change that I've seen is fear has always been there. Ten years ago, women were afraid of giving birth, like the actual experience of giving birth. Now, I would say the majority of people that are saying I'm scared, it's that they are scared of the maternity system. They are scared of harm being done to them by intervention that they didn't want, potentially didn't need, didn't understand, didn't consent for. Like it's it's that that is shaping sphere. And it seems to have been like a really big and quick shift from from one to the other. So I suppose my sort of the the question is,
Speaker 1: 13:36
how do how can we get to a you know, let's let's go um real like utopia. How could we create a maternity system where physiological birth was was a genuine option for women? So a lot of the people that I will support, let's say for example, they had a cesarean birth in their first birth and they come to the birth second time, a lot of the time they will go, I'm choosing between a home birth or a planned cesarean birth because everything else in the middle feels dangerous to me. So I either want to be in the situation where the chances of physiology being supported are at their absolute utmost and being supported by people that really understand it, or I want nothing to do with it. And I want to have that feeling of kind of control and power in a way that I can't see myself getting from anything in the middle. So, you know, throw throwing it back out there, maybe Sheena, what do you what would you what would you like to see in terms of maternity care that really values the benefits of physiological birth? And is there anything that women can do to kind of reap the the best bits of that?
Speaker: 14:45
Oh, that's a great question. And uh if only we had a magic wand that we could have everything we wanted. And I guess that's you know, I think the best chance in England uh that we ever had was with better births. Uh, you know, the the policy, the first policy that came out that um that was that had been founded on listening to women and families and staff came out with the suggestion that we had continuity of care. Continuity of midwifery care really is, and we've we we've known this for for so long uh through the evidence and through anecdotal practice as well. But you know, we you're just providing gold standard care. Uh anybody would want to see the same person, I would say,
Speaker: 15:32
uh, rather than having the fragmented care that we have now. I'm speaking to uh families and and for midwives who are just not seeing the same person twice. So, how can that be safe in one in one respect, but also how can it be enjoyable and you know building relationships, relational care is probably the the key the key uh phrase that we could should be using in terms of what we should be having. Because if you have if you have ex well, if you have well-educated, well-supported, nurtured uh uh midwives with enough resources to provide continuity of care midwifery care carer, and they're working in a system that supports them to do that, then you I I can't see how there would be any any problems with with uh with outcomes. I think the outcomes would increase dramatically for both mother and baby, and job satisfaction for staff. And that's not to say that every midwife should work in that way, but I think that you know you want to see the same doctor, you want to see the same dentist. If you've got a problem, you want to go for the same hairdresser, if you like her, you know, and we know that the outcomes are just far superior, and uh all the uh disadvantages that we see now, all the challenges uh in terms of outcomes for mothers and babies that Sue's talked about would would would be minimized. So I think that that would be the first thing that I would I would suggest in terms of what works.
Speaker 1: 17:07
I know, and it's just devastating that it's been specifically taken off the list of recommendations at the moment. You know, we've we might see hopefully next month we'll see some renewed commitment to the very honest, obvious benefits of continuity. So anything that you would want to add?
Speaker 2: 17:25
No, I think I agree with Sheena, and of course, you know, a component of that is also time. And this is all this is again none of this science. You know, this this is true, uh, this is true for every area of healthcare, as Sheena says, for every area of our life, every other professional group that we we make contact with, it's just very, very bizarre that it seems to be resisted, you know, in in the maternity's system. And I suppose if we got to a point where midwives were trusted, that's another thing, we're actually trusted to be autonomous, not completely autonomous. Obviously, you don't want somebody going off the rails completely and doing something completely mad, but you know, autonomous within their professional capacities, um, then yeah, you and and and also I think in that context, you would get less of this notion, as Shina was talking about, of out of guidelines being something that's maveric and unacceptable. And instead it would be something which is more about individual variation, because we all vary, you know, none of us are standardized. So I think it is definitely the answer. The trouble is we tried it before it didn't work, but of course we tried it before during COVID. So that you know, in itself put a layer on it, and we also tried it before in a context which still kind of supervalued the Labour board. So, you know, midwives were taken from continuity teams and moved onto the Labour ward, so they couldn't actually do their continuity of care and it broke down as a in some places as a consequence. So I think in my ideal world, we would also have a kind of public recognition that you can do the best you can, but you can't always, you can't always get a good result. And in that system, I'd also want every single woman and partner and family that had an adverse, uh an adverse outcome to be fully supported in managing and dealing with that outcome, whatever it is, in the short and the longer term. So that so that you know people didn't have to be, I mean, nobody's gonna anticipate nobody's gonna want a bad outcome, obviously, but you know, to to feel that at least if it happens, you've got the support to deal with it would be something. And it might decrease the public fear about that potentially.
Speaker 1: 19:19
Yeah, and and something that you mentioned that I'd like to pick up on is a this kind of breakdown of trust that has happened from kind of within the system itself, so from management to midwives, from policymakers to midwives, between obstetricians and midwives. But and and this is something that I hadn't really kind of really acknowledged well until I had my own second baby. Um, and and kind of within that is the kind of breakdown of trust from the public to the maternity system. But the the bit that was missing for me that I hadn't realized just how important it was, was the breakdown of trust between midwives and women or birthing people. So I and I hadn't realized in in my first birth, I didn't feel like I trusted the people that were looking after me. I felt like I was doing it all on my own, kind of despite this trusting
Speaker 1: 20:12
relationship not happening. And then in my second birth, this midwife walked into my house, and within what was quite amusing is that I'd actually interviewed her for the podcast. So I knew who she was, but I hadn't actually met her in kind of real, in in like non-professional context. But she came into my house and within three or four minutes, uh, I knew that she trusted me. And it was like this revelation that I was like, oh, I hadn't realized that that was like the missing piece of maternity care. That if you say something as somebody that's in labor, you're gonna be believed, you're gonna be trusted, you're gonna be understood. And do you think the kind of lack of continuity of care is contributing to that, the lack of the relationships? What do you think it is that is making the mismatch of us as women, trusting professionals, professionals, trusting women, how do we get that back that is kind of the essence of good and safe maternity care?
Speaker 2: 21:11
Yeah, I mean, she might want to comment as well as but I'll just quickly say I'm like this this reminds me of you know, Anna, Sheena's daughter's uh PhD, uh, this notion of midwives being with the organization and not with the woman. So coming under this um sense that actually what matters most is that they abide by what the organization wants of them, and that when women want things that are not that, then the women become the enemy. Now, you know, of course, we're framing this in broad terms. I many women in many places around the country have good birth experiences with good midwives. But, you know, that notion I think is definitely there. Shiny, you might want to say some more about that?
Speaker: 21:45
Yeah, uh well, obviously I I just feel exactly the same, and that the tr I think that social media and the media has done a lot in relation to the decline of trust, I have to say, that there's been That you know we talked about fear, right, at the very beginning. Midwives are fearful of what the media is going to say about them, and they they also just want to stay out of it, stay out of any conflict whatsoever. It used to be that if if something went wrong or or if you didn't necessarily agree with something that was happening in your maternity service, you just got on with it. But now everybody talks about it online. It's become kind of everybody's business. And every day you see negative reports about midwives. So it's no wonder that I mean, I'm immersed in social media, and you know that because it's what we do, it's what our organizations kind of work with with the midwives and student midwives through social media a lot. So we we can feel it that that that we can see that you know that there's the demonizing of midwives, and it's it's interesting because one of the things I talk a lot about is and and it's hard for people to understand sometimes unless you're really seeing it, is that on one on one hand, midwives are being blamed for pushing an ideology of normal birth, for example. And you know, Sue and I have kind of lived and breathed that, and we we're being blamed for that, and the fact that things are going wrong because we're pushing that. And then on the other hand, we're being labelled as medwives because we're interfering too much in the labour process, a labour and birth process, and in every aspect of maternity care. So I I kind of can see both things going on because I'm in that space, and and it's baffling because you know, it's no wonder. First of all, it's no wonder women don't trust midwives anymore because they don't know what they're doing. And the second thing is that, you know, it's no wonder midwives are afraid because they're being attacked from all angles. Sometimes one angle of midwives can't really see the other side, they don't know that that's going on, actually. Um, so it's like these these two kind of parallel universes that are going on that that uh that and that and it's anti-midwife. And so, you know, we've got a lot to do to try to reclaim that trust. And you know, I think that that's one of our big objectives really is to try to work out how we can how we can nurture that relationship again, get back into that space because it's so important because we know we know from the evidence that midwifery care is is the answer, like it's the it's the answer. Good, good midwifery care is is the solution, not the problem. But at the moment it's not seen as that.
Speaker 2: 24:53
I agree. And I know the other thing I would say to that is, you know, in the end, this disadvantages both women and midwives, and of course most midwives are also so it does seem to me that, and and I I I was I had I had been getting a bit depressed about all of this, and then I saw um an obituary of a of a childbirth activist who's been around for a long time. Uh, don't know how old she was, but anyway. And in it, she said, and this, and I'd forgotten this, because I trained in the in the early 1980s. She said she was talking about how in the 1970s, 1980s, the induction rate for first-time mums was 70%, and the epesiotomy, it was kind of 100% when I started training. Um, no, and and nobody was asked about it. It was just like, you know, cut. We don't do that anymore. So actually, we have changed. We have changed, and we can change, particularly, I think, when women have good experiences with midwives or good experiences of physiological labor and birth. They really need to talk about it. And, you know, the thing that worries me is that lots of women say, Oh, well, I daren't talk about my positive birth because I'll get shot down on social media because everybody has to have a traumatic birth, otherwise, otherwise they're not kind of a real woman or something. I don't know what's going on. Where change change won't happen by midwives pushing for it because we're seen as we're seen as being biased. Change will only happen if if women really want it to happen and if they push and if they talk to their GPs, and if they say, actually, I had a great birth and it was really transformative, and I want all women to have that if they can, that's what that's how the change and their partners and their families, you know, that's how change will happen.
Speaker 1: 26:18
Yeah, and and I think so. Obviously, if if anybody's kind of reading the news in this area at the moment, there is um uh a massive investigation undergoing to hopefully create a another set of guidelines. I mean, you can't not laugh when you see how many versions of this have existed and nothing's been done, but to shift maternity services for the future. And to me, when I'm looking at it, the big the conversation that seems to be missing is we're looking at where everything has gone wrong. We're looking at the trauma that women are experiencing, we're looking at the poor care that people have received. But there are pockets of exceptional care that exist and that are working extremely well all around the country right now, today, this very, very moment. So why are we not going to those pockets of care and going, this is great. How do we replicate
Speaker 1: 27:11
this? How do we just copy paste? Like the answers are sometimes sitting right in front of us. All we need to do is just copy, paste, copy, paste it across the country, rather than sitting there trying to reinvent the wheel, you know, twiggle, twiddling our thumbs, going, oh, you know, how could we possibly improve outcomes for black women? How could we possibly reduce birth trauma? You're like, well, just look at the people that are already doing it and just copy them. Like it's it surely it's that surely it's that simple. Wouldn't you think?
Speaker: 27:39
Yeah, and we feel exactly the same, don't we, Sue? In fact, that's what we talk about. We have a it's worth us mentioning, Megan, that um Sue and I and others set up something called a midwifery maternity birth collective, of which we because we were just so tired of this kind of you know, sort of hamster wheel where there was no no and no one was speaking about the elephant in the room, it was just all about, you know, what's gone wrong, what's gone wrong, what's gone wrong. And yet Sue's involved, she's one of the leaders and Claire Feely in in a beacon site research study looking looking at exactly what you said, Megan. And we also feel that um if we come together as a collective of mothers, politicians, obstetricians, journalists, midwives, you know, all of us together, which we have done in this collective, at least we can talk about this and say, and then what we can do is lobby the politicians in a really cohesive way rather than A not knowing what B is doing. But you're absolutely right, we have the answers, we know exactly what works, and and yet we continue to spend all this money and all this energy and all this time on more and more reviews, more and more recommendations. Um, and I think it's I don't know whether you want to talk about uh about the foo about the Northern Ireland review and the the Wales that have used the same methodology, which has been doing what exactly what you're saying in their reviews, too.
Speaker 2: 29:08
Yeah, I mean it's supposed to be much more inclusive and much more looking at you know where things go right as well as where things go wrong. I mean, and and actually there's there are other things. So the Hamler Project in Leeds is uh is a continuity care, a mid-wiffer continuity care project, which is working really, really well. And interestingly, they did a review of that project and they found that there were two components. One was relationship-based care, which, you know, again is fundamental, and the other one, and they used a complicated term I can't remember, but really it was about linking women up with their community. So making sure that through the pregnancy, labour, and birth, the woman became the women became linked to their community resources, whatever they may happen to be, whether it was to do with homelessness or drug addiction or whether it's just like there's a park down the road from you or there's a toddler group up the road from you. So they they they they did this social support piece. And I think that's another thing actually that that is becoming stripped away from the midwives role. And actually, I'm increasingly thinking it's the most important piece of the midwives role. That, you know, as time is shrinking and as the pressures are growing on the clinical outcomes, and a bit like Tuna says with the computer, the midwives are being strongly directed down the, you know, the only doing the clinical bit stuff, the technical clinical bit stuff. And other things have been given away to, you know, doolers or maternity support workers or whatever, whatever, whatever. But the more I've looked at the literature on social support, the more I realize that it has fundamental physiological impacts on, you know, neurohormonal things like oxytocin or immune system, again, you know, on cytokines, which is which is what you get when you're stressed and it affects your immune system, or on natural killocell activity, which is what um suppresses infection. You know, there's there's a whole load of things that happen in the body when you get good quality social support that have important implications for things like baby growth. You know, feet that babies are bigger if you have good social support in pregnancy, you know, outcomes are better. Um in one of the one study they looked at with of midwife social support at the age of seven, women reported that the babies that were um had had the social support by midwives, so it's a specific group that only did social support, didn't do the midlifery piece, somebody else did the midifree piece, you know, clinical piece, someone else did that piece. Um they were, you know, they they were their behavioural levels were better, they were better socialized. This is what the mums reported. The mums enjoyed parenting better. You know, it it has an absolutely profound consequence. So if you can combine the clinical skills of midwives with the social support skills of midwives, that's midifree. But unfortunately, we're stripping away that second piece, which means that midifree won't be as effective. So, you know, I think the what the reviews are not doing at the moment is they're not recognising the mechanism of effect that underpins the successes. Well, A, they're not recognising the successes, and B, they're not recognizing that mechanism of effect. It's not just plonking out somebody with a middle free qualification in a space, it's actually allowing them to do that broad role. And um absolutely there's places that we could learn from about that and take it forward. I mean, at the moment we have uh something over 700 recommendations from the reviews, some of which contradict each other. So it's completely impossible to put them into practice. We just need, you know, in complex systems, they're usually very simple rules. We probably need three simple rules, you know, make sure people are properly trained and joined up, make sure they've got the time to care, make sure they can build positive relationships and are well looked after, probably something like that.
unknown: 32:25
Yeah.
Speaker: 32:25
And it's Could I just add in? Yeah, sorry, could I just add in? There's some there are there is something that's working that is exactly that at the moment, Sue, which is which is pregnancy circles.
Speaker 2: 32:36
Yeah.
Speaker: 32:37
So I, you know, there are midwives who are actually in touch with me, who are running them at the moment in the north of England, and they said it's keeping them going, it's sustaining them as midwives, and it's also the women and families are absolutely loving the fact that they're coming together to that. This is this is for anybody that doesn't know what this is. It's where you provide antenatal care in a group rather than just singularly but taking a taking a woman or birth in person into a room and and doing the antenatal care, you're actually doing it as a group. And the outcomes, I mean, we actually published an open access to a full journal of articles from that that were uh the the editor-in-trip was from the Netherlands, and this it's a global issue, and it's got it's full of articles, the evidence around the effectiveness of pregnancy circles. Now, are the reviews looking at those? You know, that that that is actually combining both things that you said, Sue.
Speaker 1: 33:34
Yeah, and I I actually spoke to a midwife that works in Cornwall and she said they were doing something very similar to that. And it had come about from a conversation around, I think I'd been I'd been speaking to somebody who was um the kind of very late stages of pregnancy about how at the moment, the way that maternity care operates, every interaction that a woman is having with the care provider is based on risk in some way. It's in in every single conversation that she has, we're concerned about the risk of this happening, the risk of that happening, we're testing to see if the risk of this is going, you know, that that is the sole focus of antenatal care at the moment, kind of universally across the country. Um, and picking up something you said earlier, Sheena, is that it in that becoming the focus is that we have removed the enjoyability of pregnancy. Like it's like nobody is allowed to feel proud of being pregnant or enjoy being pregnant or find the magic of being pregnant because we're just scared the whole way through pregnancy, everything. What am I going to find out today that's going to disrupt what I want, that's going to become a concern? You know, we're not, we don't start those appointments, you know, universally going, wow, look at how much you've grown in the in the like, haven't you done a fantastic job growing your baby? Oh no, you've grown the baby too much, you haven't grown the baby enough. Like, what how do we, you know, and again, it's it's relationships, it's time, it's midwives having, you know, space to come into those appointments refresh, but it is it's really sad that pregnancy has become a non-enjoyable experience in so many ways, or certainly the interactions with maternity care have.
Speaker: 35:17
And unless we do something fairly, fairly quickly um sustained around this, is that unfortunately, the midwives, this is in general, the student midwives who are qualifying, who've been trained in a system where that is the focus of you know, make sure that you monitor this, monitor that, monitor the other, tick the boxes for risk, and that is how they practice, that's what they've been shown. Um, we're not gonna, we're not gonna, you know, be able to change that unless we we train, not train because I hate that word, educate, support, nurture students and midwives in a way that's that's sort of leaning towards that that that way of care because we we're sort of losing it. Student midwives aren't seeing that type of care in general. I mean, they are in some places that you've mentioned, which we always have to come back to, but there are fantastic things going on in some places, but this is what we're we're hearing, you know, through through evidence, through surveys that are being done, and through listening to students and really qualified midwives, they're afraid of things that I saw as being sort of um you know fundamental and and really important in my practice that that's that's missing. And that's why Sue and I are invited to to talk, you know, about this, because unless we keep this conversation going and trying to move, and and and sadly, you know, we're we're it it seems to be going in the opposite way um because of the the media and certain people who are really trying to change education in that trying to lessen the amount of physiology that that students midwives are are are kind of uh exposed to.
Speaker 2: 37:12
Yeah, I I I agree that that's that is a risk. I mean, having said that, you know, I do talk to a lot of very positive dynamic midwives, you know. So so I think there are yeah there are people coming in who are very who are kind of coming in fairly wide-eyed. I mean, I think some of them are are still shocked, but you know, fairly wide-eyed because they've all experienced if you come into Midifri, having it having seen all the media that's going on at the moment, then it must be pretty determined, it seems to me. You know, so it it may be that we've got a cohort now that are um do know what they're facing and who could actually be kind of champions for the future. And I think that's something else that is worth thinking about in terms of how how MPs get lobbied, or as Gina says, you know, um, how we how we how we between us all try and change the conversation across the whole piece. Because and and how we bring together those people who are feeling that they want to make change. And as Sheena says, it's also bringing together, there are many obstetricians who feel the same way. You know, this is not a midwife versus obstetricians thing. There are many obstetricians who feel the same way, and and on neonatologists also, because they see the consequences on the babies. So actually, quite often it's been the neonatologist who've said, Do you really want to be doing, you know, this y, X, Y, and Z in pregnancy, well, in Labour particularly, because their neon ankle units are getting filled up with all these babies that are coming out as a consequence of some of the things we do. So it does seem to me that we need to be turning towards saying, okay, what is the solution and how can we work together towards it? And I do think, and maybe you were alluding to that, Megan, before, you know, that the Amos review is actually taking evidence from a very wide range of people in ways that the other reviews have not done.
Speaker: 38:54
Yeah, I I agree. And I think, Megan, when you said about uh Sue, about when you said about women and birthing people and midwives and obstetricians, everybody coming together, which is what we're trying to do with the collective. And I know that one of the things that um if if there are people listening to this podcast who are actually having a baby who are pregnant and thinking about, you know, and and I need to negotiate the system. I think we should think about that really carefully because I get asked that a lot. So a lot of my friends are having grandchildren now. So I'm that old is uh sort of so the grandchildren come to me and say, What would you do? What things well the first thing I say, and I'm not just I haven't even paid to say this, but the first thing I say is do your course, Megan. So you're the uh you know, you're the one, there's a very few people that I direct to, but it you're you're the one to do your antenatal, your antenatal course and to follow you on Instagram. And I can't wait to read your book. But uh I feel safe. I feel that people
Speaker: 39:59
are safe with you for the for the information that they're going to receive is evidence-based and thorough and great and non-biased. Um, but I I do think that we have to kind of think carefully about how we how we how we support families to make the right decisions. But I do think Hamptonatal education is absolutely key and to to um that's the that's the first bit of information that I would give. I don't know about you, Sue. What advice would you give?
Speaker 2: 40:28
Yeah, I agree. I I also think it's worth finding out because you can you could we can you can read the stats, but it's actually what happens in the the units that are closest to you. So find out what's really hap, really happening in the units closest to you. And you know, obviously the advice used to be, and I don't know if it's as good advice anymore or not, but it used to be book for a home birth because at least you get continuity, and then if you decide you want a hospital, you can go there later. But to be honest, the home birth services are under a bit of a strain at the minute, so that that might not work. But yeah, find out all you can, find out what your options are. Don't be too scared by the range of stories you hear and by what you read on online. I you know, I have heard a story recently, I don't know if it was with in a meeting with Yushina of somebody who was very upset because someone they were supporting in breastfeeding had been really, really traumatised by all the information she got that she felt she was doing it wrong around breastfeeding, and that made her feel very um unhappy. So, yeah, so treat social media with caution, have a clear idea of what you want, and you know, read around it, but treat it with be critical about some of the stuff you read. So I also want to, again, this is a this is a story. So this is a friend of mine whose daughter-in-law um had a baby a couple of years ago, and she really wanted a home birth and first-time mum, and um, towards the end of pregnancy, she she was told that she had certain things that were wrong with the baby on scan, and she was skeptical. So she asked me, and I asked an electrician friend, and he said, actually, this is fine, she's fine. So she carried on the pregnancy and she went into labour spontaneously, and she laboured at home with very good support from the midwives, and then after a while, it it was apparent the baby wasn't coming. So they all agreed that it's a good time to go to hospital. So they contacted the hospital. Hospital said, Great, come in. They went into the hospital, they got really good care in the hospital, she had a cesarean section, and she said it was a fantastic experience because she was she was treated respectfully the whole way through. She had the information, she understood the information, she made decisions about the information, she was then supported in her decisions, and then when she needed and wanted to have more intervention, she got it, and she got it in a respectful and caring way. That is what we need to set up. You know, it's not a failure if you need to have an intervention. It's a failure for us in the service if you feel you're a failure for having an intervention, because you know, we should set it up such that uh it's all, as you say, Megan, a joyful, uh positive experience. Uh and even when things go wrong, that it's as positive as it can be under those circumstances. So, you know, I think for women who are pregnant now, not necessarily um wishing, you know, not necessarily assuming harm's going to happen, but preparing for it, thinking, what will I do if this happens? What would be the ideal thing for me if this happens, and then relaxing back into you know, into a positive state of mind for where they are at the moment. So at least they've got a plan just in case, is what I would do.
Speaker: 43:12
Yeah, absolutely. Just to finish, just to finish, I'd like to say something around that is that I've been thinking a lot about this recently because you know what we say sometimes is that if you want to have a cesarean disease now, particularly in England, if you if that's your choice, you can usually get it. So that you know, you can make that choice and get that, and you and but you can't guarantee that if you want to have a physiological undisturbed birth, that you'll get it. So I know that sometimes uh people will contact me to say, What can I do? Because that's what I want, but what can I do? So, but as well as having the antenatical education, I would say to people So you go to talk to somebody in authority in the maternity unit that you are booked at, and you ask to speak to either a peer. A professional midwifery advocate, or you ask to speak to the head of midwifery or the director of midwifery, and you tell them what you want. Put it in writing, and this is what you want. And ask them so if you're having a cesarean section, you would need an anekhetist and a surgeon and a midwife. So if you want to have a physiological birth, tell them these are the things that I need. And obviously, through your course, Megan, they'll be able to know what those things are, they'll learn what they are. But I think that you know, we have to stop now thinking, oh, we might not be able to get that. So we should ask for it. If you can ask for an operation, a serious major abdominal operation and get it, you should be able to ask for something that you want. So I want the right environment, I want a midwife who understands this. But you wouldn't you wouldn't have an anaesthetist who didn't know how to incubate. So you say, no, I want a midwife who can do this. And I know that takes a lot of guts, but it also takes a lot of guts to ask for a cesarean. So we should be. I think this would be something for you, Megan, to take on board to say, you know, ask for it and go and make an appointment. Write to the chief executive, you know, write to them. I would write to them if my family member was was sick and wasn't being treated properly. So I think we have to we have to take the power back and just say, these are the things I want. And that would help midwives too.
Speaker 2: 45:27
So yes, you're right. It would help midwives, but it would also help the organization to understand that there is the demand because the organizations are responding to populism. You know, populism is driving some of the some of these things that are happening in maternity care. So if there's a shift in the populist conversation, there will be a shift in the response to that, because we are, you know, we're you know, we're highly sensitive to populism. So you know, I I absolutely agree, Sheena. I think that's right. And you know, write to your MP, write to everybody, write to everybody you can think of. And uh tell them that there is a whole bunch of women out there that really want something different.
Speaker 1: 45:57
Yeah, absolutely. And I and so much of the work that I do is helping people work out how to do that in a way that doesn't feel confrontational, that doesn't feel completely horrific to our people pleasing ways that we've all kind of grown up to have. And I think the kind of very, very baseline of that is just giving yourself, and if you're if you find it hard to do for yourself, for your baby, giving yourself the respect that you actually deserve. Because if you feel like it's too hard to ask for those things for you, then think of it as like the very first step of you know, a lifetime of advocating for your children. Um which is yeah, I think sometimes flipping that narrative a little bit can make it go, okay, actually it's not it's not just about me, it is about my baby. And yeah, and leaning into the the good bits of pregnancy, allow yourself to enjoy it, allow yourself to find the joy and the magic and the like incredibleness of what you're doing, growing an entire human, um, when that seems to be constantly torn away from us, whatever it is, throw the baby shower, throw yourself a baby shower and have a lovely bath and stroke your bump, what like anything that just yeah, brings back some of the the joy and the magic of offense.
Speaker 2: 47:13
Yeah, and and also be aware that you know the the things you're doing now are going to have consequences for your baby into the future. You know, it's not just that the baby's born and everything's healthy and that you breastfeed, which is all good. It's that actually it might have consequences when they're 10 and they're 17 and they're whatever, whatever, whatever, and for their own babies, you know, so you're you're building something there which is has very long-term consequences, uh, positive consequences, and that that's really important.
Speaker 1: 47:35
Yeah. And the responsibility of that can feel daunting and massive. Um, so yeah, go go gently with yourselves. But um, but it is it isn't it isn't one day that you're just gonna forget and then get on with life. It's forever. And so it's that's how worth it it is.
Speaker 2: 47:54
Definitely.
Speaker 1: 47:56
Amazing. Well, I mean, I could just keep quizzing you guys all day. So I really, really appreciate you joining me for this conversation. I'm very glad that our Wi-Fi sound situation has worked out in the end. Um amazing. Uh, if people would like to kind of find you or any of your work or hear more of your incredible wisdom, um, where would be the best places for me to direct them to?
Speaker: 48:22
Sheena? Well, for me it would be social media for sure. So I'm everywhere on there, and or my email address, which is Sheena at all for maternity.co.uk.
Speaker 2: 48:36
I I'm not so active on social media, so it would probably be my university webs uh website, which is at the University of Lancashire, to put my name in, or email sdowne at lancashire.ac.uk.
Speaker 1: 48:47
Awesome. Amazing. Thank you both so much. Thanks so much for listening to the BirthEd Podcast. I know you're already feeling how much of an impact these conversations are having on your own pregnancy and birth plans and parenting journeys. And I want that impact to be as far reaching as possible, but I can't make it happen without your help. If you've got two minutes now to five-star rate and review the episode or send it to a friend, this is what helps us creep up the podcast charts and into the ears of more and more parents to be. Together we really can change the face of birth as we know it.