Podcast: Home Birth with Guest, Midwife Kemi Johnson

Home Birth with Guest, Midwife Kemi Johnson

Season 1, Episode 13

In this episode, Independent Midwife Kemi Johnson and I discuss all thing Home Birth. The benefits, what if’s, practicalities, everything you may want to know about having your baby at home.

Something important to consider, is that regardless of where you choose to give birth, if you go into spontaneous labour, at least part of your labour will be in your home environment. So understanding how birthing in this space is going to feel and going to work is important for most of us!

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TRANSCRIPT

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I know right now you have no idea what to expect from birth, what it's going to feel like, how it's going to pan out.

And so what you thought was going to be this glowing experience of pregnancy has turned you into a bunch of nerves.

Well, you were in the right place because I am here to hold your hand as you prepare for the birth of your baby, through the Birth-Ed online course.

The course that gives you the information you thought you were going to get from your antenatal appointments and didn't.

The Birth-Ed course opens your eyes to everything you need to navigate your pregnancy and birth choices so you can feel confident, informed, and ready to take back control.

Available worldwide for just £40 or $50.

Sign up now via the link in the show notes.

Welcome to the Birth-ed podcast, where we open up conversations about all aspects of pregnancy, birth and parenthood, so you feel fully informed, confident and positive about what this journey might entail.

I'm Megan Rossiter, founder of Birth-ed, and your host here at the Birth-ed podcast.

Birth-ed offers comprehensive, positively presented antenatal and hypnobirthing classes, both in person and online.

So if you like what you hear, be sure to come check us out on our website or social media.

Don't forget to hit subscribe so you don't miss any of our upcoming episodes.

Believe me when I say we will leave no stone unturned when it comes to preparing you for your pregnancy, birth and the postnatal period.

Before we kick off today, I just wanted to take a moment to tell you about the courses offered by Birth-Ed, because we are actually a little bit more than just a pregnancy, birth and parenthood podcast.

We offer in-person courses in the UK and an online course which is accessible worldwide.

The Birth-Ed course is totally unique in that it offers both a comprehensive antinatal preparation, so covering everything, all your birth choices, possible interventions, decision-making tools, your pain relief options, your birthplace choices, optimal positioning, kind of everything that you might want to know about having a baby.

But also included in that is a full hypnobirthing course, so giving you practical tools and techniques that you can use in labour to help you feel calm, to help you feel comfortable.

And ultimately, the whole course is there to get you to a place where you feel comfortable, where you feel confident and excited about giving birth.

Thousands of parents have accessed the birth-ed courses now, and time and time again, they're getting in touch to let me know that they had the positive birth experience that they set out for, in whichever way ended up being the right way for them and their babies on the day.

So if you're enjoying the podcast content, but you're thinking you might want a few more kind of practical ways to prepare for birth, then you can visit our website or drop me an email for more information.

Hi, everybody.

Welcome back to the Birth-Ed podcast.

Today, I am joined by independent midwife, Kemi Johnson, to talk about something that I'm very excited to talk about.

I've been very excited to do this episode for a long time, and it's something that I'm very passionate to talk about, and I know that Kemi is as well.

So, the focus of this episode is going to be homework.

So, Kemi, welcome.

Thank you so much for joining me.

Thank you so much for inviting me.

I've been very excited about this episode.

Fantastic.

It's going to be good.

So, before we kind of kick off, do you want to just quickly explain to everybody what an independent midwife is and how you work with women?

Right.

So, an independent midwife is a registered midwife trained in exactly the same way amongst the midwives that go to work in the NHS.

So, we all in the UK are trained by the NHS.

But as an independent, you then tend to go on to working one-to-one with families and not an employee of the NHS.

So, you're self-employed, and the family work directly with you, usually for the duration of their pregnancy, birth and beyond.

So, I tend to leave families between six and eight weeks.

Usually, with first-time birthers, I'll be there longer.

With people that have given birth before and are confident subsequent birthers, then I may be there less, but it really is up to the family how long they retain my services.

So, it's a private service, isn't it, that women pay for?

That's right.

We're not part of the NHS, so we are paid directly by the family.

So, whilst women employing the services of an independent midwife can still give birth anywhere, is it right in saying that you have quite a lot of experience with women who are choosing to give birth at home?

Yes, it does tend towards that.

We are usually working with families that are choosing home birth, but I try not to make them choose.

So, how we work, the midwives that I work with as well, is we tend to just prepare families for birth in any setting.

They usually do stay at home.

So, it's almost like the domino scheme that the NHS used to have, where you are just with the woman, you follow her on the journey, you make preparations for everywhere, and then when she's in labour, then she decides whether home continues to be the place that she would feel more comfortable, or whether she'd rather transfer in.

Yeah, fantastic.

Yeah, so that's how I work really.

I don't kind of, yeah, we don't choose.

We just prepare for anything, and then they usually choose to stay at home.

And so we'll kind of chat about home birth with an independent midwife, but most of it is going to be kind of transferable to the NHS.

So we'll touch a lot on giving birth at home within the NHS services as well.

Yes, absolutely.

And so I suppose the place I kind of want to kick off is the place that most people have reservations about home birth.

Yes.

The kind of thing that comes up most of all for people that don't necessarily know anything at all about giving birth yet is, you know, how could you possibly give birth at home?

Isn't it really unsafe?

Surely a hospital is going to be the safest place to give birth to your baby because that's where doctors are, that's where machinery is.

And so this is, I suppose, one of the big, big misconceptions about home birth, isn't it?

Yes, it is.

It's a massive one.

And it's really our whole society has fostered this idea.

You know, sometimes people say, oh, it's because of, you know, after the war when it was encouraged or where it was stated that there ought to be room for any woman that wishes to give birth in hospital, to give birth in hospital.

So up until that point, most births are taking place in the home.

And, you know, there are parents who welcomed that, you know, they really were happy to go into hospital to give birth.

You know, first, it was quite insanitary, overcrowded, et cetera.

And, you know, hand washing and sterilization of equipment wasn't as good as it should be.

So you did have some some infections that went rampant on wards.

But ultimately, when they got their act together, families were choosing it because they felt, yes, closer to doctors, et cetera, in case something went wrong, but also getting out of potentially insanitary conditions at home and outdoor toilets, overcrowding, et cetera.

So, you know, we all kind of worked towards this idea that hospital is safer.

But in actual fact, you know, this endless now research being conducted and published on the subject, and we now categorically know that in actual fact, home is as safe for children, the infants are born and safer for the person giving birth.

And the reasons are obvious.

At home, you have got the attention of the midwife fully.

She's not being asked to leave and attend to someone in another room or to assist in another room.

You know, you get the full attention of the midwife.

But also the kind of bacteria that is in your home, your body has already built a resistance to and antibodies to, and so has your baby.

So you're going to find that there's far less incidence of infection occurring when birth takes place at home.

Any kind of infection postpartum, or even if waters, say the amniotic fluid around the baby, the membranes have been breached, then there's much less likelihood of her developing an in-labor infection.

And the type of care that is received at home, because the midwife is able to basically concentrate on one person giving birth, they're able to determine the pace of the birth progress and where she might be at just by looking at her rather than vaginal examinations.

And if the vaginal examination is going to take place, it would only be one person.

So there's no confirmation VEs or any of those things.

So there's loads of reasons why, I can see why, you know, birth is as safe for the infant but safer for the woman.

You know, I mean, I'm rambling on because I do.

That's the thing, isn't it?

There's so many reasons why.

As soon as you understand the physiology of birth and you understand that what your body basically needs to give birth is to feel safe, to feel relaxed, to feel undisturbed and unobserved, you can go, okay, well, where I get all my clients to do, to basically go through their birth and think about if they were planning a hospital birth, when I'm at home, what could potentially stop me from feeling safe, relaxed, unobserved and undisturbed and nobody can do anything other than maybe the doorbell ringing or something.

And then we get to the hospital and the list just becomes incredibly long, so many potential disruptions basically.

That's right.

And as your body's got to let a baby out, we cannot minimize the effects of these interruptions.

And if you've got a list that's growing, longer and longer by the minute, you can think of, I mean, at least at home, you can hear the doorbell.

Yes, it will probably wake you up out of your oxytocin sleep state.

But at least you've got a warning that someone's about to enter your space, whilst in public spaces like birth centers and hospitals, there's no locks on the door.

So you have no warning.

Suddenly your door could be opened, you know?

Yeah.

And I mean, I don't know about you, but my doorbell never rings anyway.

So it's kind of a hypothetical thing.

Like occasionally I get an Amazon delivery, but I stick a sign on the door, so I can leave it outside.

So yeah, it's kind of considering those things as well.

Now, just for everybody's kind of reference, I've pulled out some of the kind of actual statistics around this because up until the kind of past couple of years, the best research we had into this was something called the Birth Place Study.

So that looked at 64,000 births of women with uncomplicated pregnancy, so kind of straightforward pregnancy, and the outcomes of their birth based on where they intended to give birth at the start of labour.

And all of the research in that, but one little bit, kind of confirmed exactly what you said, that the chances of having a straightforward vaginal birth are significantly more likely when you are either at home or on a birth centre setting in comparison to a hospital.

That research also showed that for the second time mums, it was much safer for babies.

Now, we have got more recent research than that into outcomes for babies.

So there was a paper, I think it was in The Lancet in 2018, which was a systematic review of tons of research.

So they pulled from not just that one bit of research, but lots and lots of research.

And what they said in this about outcomes for babies is that the risk of perinatal or neonatal mortality or morbidity, so that's difficulties or stillbirth in labour or around the kind of first few days to weeks after birth, was not different when birth was intended at home or in hospital.

And that was for both first and subsequent births.

And I love that, that they honed in, particularly on birth that was intended at home, because some of the studies, they bring in birth before the arrival of the birth attendant, like the midwife.

And you're going to get different stats of that because there's no preparation.

So, you know, I really do love the work that the Lancet did on this subject.

And I'm quite surprised that we still have many, many health care professionals that appear to be making recommendations without having looked at this systematic review.

Yeah, still quoting the old...

That's right, they're still saying, because for the general public to be saying it, you know, it depends on what they read.

I would understand them being misinformed.

But there are many, many health care professionals that are still singing a party line that is the opposite of what the Lancet have clearly shown.

And I'm shocked, really.

Yeah, and this is the biggest review, basically.

So I'm not talking about like a little tiny paper that showed something.

What it says is that it's the largest and most comprehensive meta analysis comparing outcomes of intended home and intended hospital.

So it really is the kind of the most up-to-date, the most reliable bit of research that we've got at the moment which is very reassuring, I think, if you're considering that.

It is exceptionally reassuring, because of course, home birth is midwifery-led, and The Lancet also have published papers on, or published in their journal, the fact that midwifery-led birth care has better outcomes than obstetric-led.

And they've even, I can't remember if it was The Lancet, but there was even an article that showed that midwifery-led care was better for even women deemed to have been of high risk.

Yeah, absolutely.

So I've pulled that as well.

That was a review, a sort of secondary analysis of some of the information from that birth place study.

So this is a review in 2015.

It was small in comparison to the birth place study and the meta-analysis one themselves, but it did show some quite interesting information, I think.

So overall, it showed that for women with more complicated pregnancies, now they weren't very specific about what this meant, but it seems it included things like a raised BMI, a pregnancy lasting over 42 weeks, a previous cesarean, advanced maternal age, I guess.

And again, they are all grouped together, so it's slightly harder to put that on to specific situations.

Comparing somebody with a raised BMI with somebody with a previous cesarean, those two things aren't necessarily like-for-like.

But as a group, basically, it did show that when you compare women with more complicated or what they like to call high-risk pregnancies, they did have more complications or worse outcomes when you compared them to low-risk women giving birth at home.

However, which is essentially a useless bit of information because you either have complexities of pregnancy or you don't, so you can't decide not to have one anymore.

When you compared a like-for-like group, so when they compared women giving birth or planning to give birth at home with complex pregnancies with women who were planning to give birth on the obstetric-led unit at the hospital, the price of price outcomes were better for both mums and for babies.

Goodness me.

I mean, I know it, but every time I hear it, I mean, I know it because independent midwives, people think that we're looking after just really healthy women carrying really healthy children, low BMI, perfect living conditions.

They think that's our client grouping, but actually the people we more likely see will be the ones that are vaginal birth after caesarean, vaginal birth after several caesareans, particularly.

Yeah, and they choose us, people with raised BMI.

So there are people that would choose us anyway because they understand that giving birth, feeling safe and unobserved is by far the best way that their bodies will open and let their children out.

But then you've got some people that end up choosing us because they're not finding the care that they need within maternity services, the NHS.

And so we know this already, but it's so wonderful that there's been a piece of work published that shows it.

Because it's enough for us to say, I wish it was enough for us to say, but it works, we see it, we see it all the time.

But I think more and more people are wanting to know the stats and I'm so glad a piece of work was done to show that.

Yeah, and I think it's a good indication that they need to do a bit more research into it and get even some harder figures around it.

But as a starting point for women who are thinking, I did record a podcast recently that was literally about accessing care out of guidelines, so thinking I want a home birth, but I had a cesarean where I had to access that.

So everybody, if you're listening and you fall into that category, have a listen back to that episode.

I think it might be episode 12 around that.

So I think we've covered then the research, the statistics behind it.

And I think that is hopefully going to reassure people to now listen to the rest of the episode about what a kind of home birth looks like, what it is practically, what it involves.

So let's just kind of talk about, other than the chances of having a more straightforward birth and it being kind of equally safe for babies, what are the kind of other benefits of deciding to give birth at home?

What would you say the kind of start, let's start with the kind of the emotional benefits of being at home?

The emotional benefits of being at home.

When, if you have a partner and you have prepared for this moment together, and then it takes place, your partner, it feels part of something amazing.

Your partner can be up close and personal with that thing that's taking place.

Because often when partners go into medical settings or other settings, because they're well brought up, they stand back a little bit.

They're not quite so involved.

They want to be polite.

They don't want to do the wrong thing.

They don't want to ask too many questions.

Whilst for something that you've created together, even with assisted conception, it's a choice that you made together.

It's a process that you went through together.

I think the togetherness, that oxytocin boost, the endorphin rush that you get from working together on something as precious as bringing another person into the world, I think that happens best in the home-like setting.

There's nothing to stop the kissing and the cuddling, the privacy.

The privacy is like, I think how I have enhanced my practice is becoming more and more aware of ways I can facilitate privacy.

So the rooms are getting darker.

They're getting quieter.

I'm getting further away from the action, literally.

Unless she wants me to be there to provide some reassurance, I will come forward.

I will remind her that I'm here and that all is well, and then I'll retreat, because it's actually what happens between her and her primary caregivers who actually, it could be her partner husband, sister, you know, doula, those people that have really journeyed with her and can come close and can cuddle and stroke her hair.

Those are the things that are going to raise the hormones that make birth happen best.

So the more privacy that I've provided in settings, the faster the births are becoming.

Not that I had speed as an outcome.

That's not what I was looking for.

I was actually aiming for comfort as being the primary goal that I was trying to achieve there.

But what has gone with that comfort is speed.

Their bodies are unfolding more efficiently, particularly the expulsive stage, down phase.

They're like minutes, they're not hours.

It's a whole different.

So with the home birth bringing with it additional comfort, privacy, efficient labor, you then have the knock ons from that, like babies gaining weight faster, breast milk coming in quicker, and if healing is required.

Some type of healing will always be required because you've let a little person out, a little human, but it happens better.

There's no transition from one place to another.

So being interrupted reduces, you don't have to think about car parking.

What happens when we get there?

Will the pool be available?

All these little spurts of anxiety that happen when you leave the house.

Who will I meet?

Will my favourite midwife be there?

You know, all of these things.

When you leave your home, you know, with the best intention, when units are created, they really try to design them to facilitate some privacy, but you'll always have a door that can never be locked.

You'll always have someone coming in to do fresh eyes.

They're now suggesting fresh ears on the obstetric units.

You know, there'll be so many reasons that somebody's being in your space.

Your hospitality, just coming to keep your room clean, so there'll be emptying bins, new, fresh bins, wiping down your ensuite, providing meals, cups of tea and everything else, but it's all little interruptions that you just won't get at home.

Yeah, yeah, I love what you said there, using the word caregiver, but about the birth partners, the people that are there.

We sort of assumed caregiver is the health care professional, but you're exactly right.

It's that actually the care and the care that's going to make the most emotional, maybe the most emotional difference, comes from the people that know you most intimately, and often that is whoever you've chosen as your birth partner on that day.

Yes, absolutely.

Absolutely.

And the thing with, you know, like when I say, because I absolutely have had years to really sit with this calling and why I do it.

And the idea is that even if health care needs to be given, that it's given with respect, tentatively, less is more, you know, that we don't take away the experience from the person giving birth just because we've maybe added a bit of assistance.

Almost that we assist without them knowing because ultimately birth is not a medical event.

So I don't know why we would, you know, give the role of primary caregiver to someone who's bringing medical expertise.

Yeah.

Because it's much bigger than that.

You know, childbirth is a natural event, occasionally has medical intervention, but even that should be given with respect.

It should be offered, you know.

I think because we've asserted ourselves as being, you know, the main act in childbirth, and talking about healthcare professionals of all kinds, we've kind of asserted ourselves as being the main act, you know, it revolves around us.

I think that's why it appears that birth isn't working.

The emphasis is in the wrong place.

The attention is in the wrong place.

Yeah, I completely agree.

And until there is a sign that a woman needs some kind of medical support, we don't need to be interfering ultimately.

Seriously not.

Seriously not.

Just going back to what you said about being undisturbed, I suppose, kind of at home.

I was chatting to the fantastic doula Natalie Meddings the other day, and she described this so well.

She said, do you know what, unless you have an induction or a cesarean, all births start as home births.

That's right.

And the vast majority of them transfer, I'm doing inverted commas here, to a birth centre or a hospital at some point.

And this is why actually this episode is really important, even if you're not planning a home birth, or even if you're absolutely not considering it, if you go into spontaneous labour, you are going to be in labour in your house, at home, in your home environment.

So everybody really needs to consider how they're going to use this space.

How are they going to be in this space when they're in labour?

Whether you're deciding whether to stay for the whole of labour and birth during labour, whether you've definitely decided that you're not going to be at home, or whether you know that that's where you intend to be fully, most people will be at home in labour.

And this is whenever I tell clients, it's always the biggest surprise.

In our heads, we go, yeah, I'm going to have to give birth in the birth centre.

So this is what my labour is going to look like.

And everything I'm picturing is in the birth centre.

Yes.

Yeah, I might watch a funny film when I'm at home.

But actually, even if you're giving birth not at home, you will be in really quite intense, powerful labour at your house.

Like you're not going in to the hospital or birth centre with mild surges and that are kind of coming every 10 minutes and they're totally manageable and you can chat in between.

You're going in at a point that labour has really developed and become powerful and strong and intense.

So you really need to start thinking about, okay, well, how am I going to do this at home?

What am I going to use to make me feel comfortable?

How is it going to make this a good environment, a good space for us to give birth in?

Yes, yes, absolutely.

It's so powerful that we're even having this conversation, because I'm quite certain that those listening will now suddenly be getting a better idea of what preparation they really need to make for their childbirth experience.

And perhaps we'll give more attention to what can be done in their home to make that experience more joyful and comfortable.

Then I would ask, how would you then feel comfortable moving in to the place where you want to give birth?

How much time is invested in that?

Do you wear dark glasses?

Do you wear earplugs or headphones?

And again, that's helpful to consider, even if you're planning on giving birth at home, in the instance that you potentially may decide in labour that transferring in is a good idea.

That's right, exactly, because that freedom for the birthing person to decide, actually, this isn't working for me, should be there for everyone, equally for those people that get really comfortable at home and then don't want to move in, but feel that they have to.

That's why I think there's a poverty in the education of society generally when it comes to preparation for childbirth, because it's so wonderful.

I mean, I knew we would be on the same page that we are.

The breadth of preparation that is required for families transitioning into having children or having more children.

If we really got that right, you wouldn't have people going in and out, you know, when they're in early labor, getting crushed with disappointment, you know, being misunderstood, being cold, being tired, being thirsty, and all of the other things that happened when people are not quite sure what they're doing, when and where, and the unknown really challenges them.

If we could get to this point where the unknown aspect of childbirth, we could get comfortable with that.

Because it's a certainty, it's a certainty that at some point, if you're pregnant, you are going to be letting this child out.

I think altogether, we frightened ourselves witless about childbirth.

And so for us, it's a great unknown.

I'm talking for society generally, it's a great unknown.

So you're having people that are pregnant, so inevitably they're going to need to let this child out.

Being confronted not only with their own unknowns, the unknowns of their family members, their loved ones, and the healthcare professional, who also is fearful, desiring to control things, because they're not sure of the unknown.

The healthcare professional, we've kind of brought it on ourselves, because we've interfered so much, that a large percentage of the births that we attend have some kind of complication in them.

And so we bring that fear into subsequent births, and on and on, and expecting the worst, and preparing for the worst, and all of that conversation around a subject that actually is just another event, it's another physiological event, women are beautifully built for, people that don't identify as women or having children are beautifully built for, they're being told all the time, no, this could go wrong, that could go wrong, and that's at the forefront of their minds.

So their bodies can't actually relax and let a baby out.

That's why there's such a tiny minority of people in this country that are giving birth in the home setting, because they honestly believe that something, there's a high chance of something going wrong at some point.

When actually, as these studies have all shown, the things that go wrong must be linked to something that was done, iatrogenic harm.

It must be, that's the only thing that could be making the difference.

Yeah, there's something isn't there that we call the cascade of intervention.

So the minute we interfere in labour or birth in some way, the chances of needing another kind of intervention kind of automatically go up.

Some people consider leaving the house to be the first intervention.

But it would be.

We can't even gloss over that.

It would be, wouldn't it?

Because you're no longer private, you're exposed to other bacteria that wasn't in your home-like setting.

Your safety and unobservedness has disappeared, even if it's temporarily until you settle in the new place.

So it's going to affect the way your hormones unfold.

So your birth is going to be less efficient.

So it could be longer.

So that means you and your baby in this transition period for longer.

So it's not surprising that leaving your front door is going to have an effect.

Yeah, absolutely.

So taking it back then slightly, we were talking about being in your home environment, whether that's for a home birth or whether that's for part of labour.

What do you find women find to be most comforting, to use as comfort measures?

How do they kind of use that space?

What do they bring to birth to help them?

Or what do you help them utilise to help them feel comfortable in that space?

Right, they tend to be using water.

So showers and baths will be employed an awful lot.

With baths, it's easy to include a few drops of essential oil, particularly lavender if that's something that you love because it helps you relax in all events, like emotionally, physically, you're able to just come down a few notches.

So I find people are using diffusers a lot or dropping oil in a bath.

Having their baths can be several baths in and out.

Crying, because it's like a release.

Cuddling, cuddling.

I see a lot of them.

There'll be a few parents that resist being touched, but most melt into a cuddle, melt into it.

So I think that physical company, that physical touch, the massage, music, I see them using music a lot.

The yummiest food, like food that raises your oxytocin, not food just to get by.

Yeah, so I've seen that.

I've seen hair brushing used, so wonderful.

I've seen gentle touching, touching of the breasts usually, but sometimes I've seen a woman employ clitoral stimulation for comfort.

I've seen kissing.

Yeah, that's what I've seen.

So anything that's kind of boosting that oxytocin production, really.

It is, but I know they're not thinking that.

They're not thinking, oh, I need to do this.

They're just instinctively reaching for these things, and it works beautifully.

And that's why I kind of said those things can work in any setting.

Now, some people say, oh, gosh, you know, touching of breasts and clitoral stimulation.

I think it's very poor of us as health care professionals who actually know how the physiology works to dissuade couples from doing that or to not make them comfortably enough to do that.

We're doing them out of a really effective comfort measure.

Yeah, absolutely.

And it's often for our own, we're feeling uncomfortable about something, but actually it's important to create a space where women feel free to do exactly whatever they instinctively need to do in that moment.

Fantastic.

So I think we've kind of covered all of the wonderful, incredible, amazing benefits, apart from obviously drinking a cup of tea in your own bed instantly after having your ova.

Well, as you got on to drinking, I cannot believe we didn't mention alcohol.

So I'm not, it's a touchy subject because it's not something that I would recommend during pregnancy.

But for sure, I know in labour events, parents are often given opiates for comfort.

So they might receive diamorphine or the fentanyl that's within the epidural mix.

So I don't hesitate to suggest that before we go to those levels using opiates, controlled drugs, why don't you try half a glass of wine to see if that gets you to relax a bit, or Prosecco to get you to relax?

Because your baby is already ready to come.

It's fully developed, it's ready to go.

And I feel there'd be far less, well, it's obvious there'd be far less effect on the infant of alcohol than there would be of her in derivative.

Yeah, well, quite.

I looked after a GP in labour and she drank half a bottle of red wine.

Half a bottle!

If the GP did it, then...

I don't think she was at any stage drunk, but throughout the first maybe kind of 8 to 10 hours of labour, just to chill out and relax.

But you're quite right to make the comparison with opioids, which are incredibly strong, mind-altering drugs.

I'm not sure there's any official research into a glass of wine and labour.

I was just thinking...

I was quietly thinking, who'd be brave enough to go and study it?

I don't know though, because if they're researching pathodine, diamorphine, epidurals, I mean...

I know, but I question the ethics of those.

But I question the ethics of those.

I'm just talking from the point of ethics.

I'm appalled by some of the studies that are happening at the moment.

So yeah, let's not go there.

So that's a whole other story.

If you're being put on to any trial with the word big baby in it, then be very aware.

Ah, don't go there.

I could have all podcast on my thoughts on that.

Okay, so the other question then that I suppose is an important one to ask, but it's also something that I know when we planned a home birth, this was something that was kind of on my mind a little bit and is often asked by women that I work with is, okay then, the what if situations.

What if you do need to transfer?

What if you do require medical assistance of some kind?

And so I've pulled out again the statistics which are coming, but as far as I can see, the most up-to-date statistics we've got about transfer in Labour are still from this 2011 birthplace study, which was a huge, huge study, but we are nearly kind of 10 years past it.

So anyone who's listening and they know more up-to-date ones, do let me know.

And what this kind of showed is that the transfer rate, let me see if I can pull it up, so the transfer rate for women who are having their first baby was 45% for planned home birth.

Meaning 55% of women who plan to give birth at home do give birth at home.

And for women having second or subsequent baby, the transfer rate was about 12%.

Now, I don't know about you, but I think the provision of home birth services in the past nine years has developed quite considerably, certainly locally to me it has done.

And so if you are hearing these kind of statistics, I would encourage you to seek out the statistics for your local trust.

So for example, the statistics from my local trust, which is Kingston, the statistics they had from last year, they had a 2% caesarean rate, a 9% overall transfer rate, and a 100% breastfeeding initiation rate.

So incredible.

And that as far as I'm aware is one of the best in the country.

Definitely one of the best, definitely one of the best, outstanding, honestly.

I mean, I published, I'm not a published, forgive me, I shared a picture, an image, an infographic that was created by the Angus Home Birth Team, who had equally impressive, amazing stats.

But I also am aware that there are teams around the country that have got a 60% transfer rate.

So I think there's lots of work to be done.

Yeah, so I'd say that's definitely helpful in understanding what provisions are like for you locally.

But also, would you say important in, if you're somewhere that's got a 60% transfer rate and potentially challenging some of the reasons for the transfer?

60% of women?

It wouldn't even be a challenge really, because each parent makes their choice, and no matter what they choose, it has to be supported.

I think sometimes those of us that work providing care, medical care, we're not always aware of that, and sometimes feel that just because we're uncomfortable is something it means that we want not to support the choice of the parent.

But you say, for instance, the area where they've got a 60% transfer rate, I've tried to explore and ask questions as to why.

Primarily, it will be about policy and the midwife adhering to the policy, even if it means her breaking her nursing and midwifery code.

So it's about the care provider, the face-to-face, the actual midwife giving the care.

It really is in their hands.

Do they let them, divide them of the policy but without coercion, so that the parents can make a choice about whether actually their policy is really applicable for them.

Because I think if more parents questioned, I mean, back to what you said, but just expanding on that bit, if the parent is aware that they don't have to do as they're told, then perhaps they would decline.

They don't have to challenge, they just decline.

And then it would bring down the rate.

But if the parent isn't as well informed as they can be, to be honest, when you're very heavily pregnant or giving birth, you are at your most vulnerable.

So even the strongest parent might find it very difficult to push back at that point.

But if they've got support, if they've got the time, that quiet moment, you've got a doula around who they could buy them some space to just sit and consider what they would truly want for them and their child, then you might find that those transfer rates are better.

It could be the leadership of the home birth team.

It could be that, that maybe they're a bit pumped.

Or some areas don't have a home birth team, do they?

It's covered in a lot of areas.

It's covered by the community midwives.

The community provision, yes.

Yeah.

And so say if there isn't leadership there that will support the midwives, no matter what transpires because of decision made by the parents, then I think that would positively impact transfer rates in some areas as well.

Yeah.

So something worth, yeah, definitely worth exploring kind of on a more local level.

Now, from what I could pull, I've kind of come up with the three main reasons for transfer.

So even in these, whatever your local kind of statistics are in terms of the number of women that transfer, I think in our heads, we hear 45% of women potentially transfer, and we go, oh, my God, that's like 45% of them ended in disaster.

And the reasons for transfers, the vast, vast, vast majority of those transfers weren't for actually any kind of emergency situation at all.

So I wonder if I tell you what they are, I wonder if you could kind of talk us through what they mean, what your experience is.

And so the biggest reason was basically for labour becoming slow, a stall in labour, mum's becoming quite tired.

And that was the biggest reason by quite a long way.

Yeah, yeah.

So labour dystocia.

So the actual fact, there was considerable attention given to this by the World Health Organisation, when they released some Interpartum Care Guidelines at the beginning of 2018.

Yeah, it's about this ready classification for labour dystocia or slow to progress.

It's how quickly we move to that.

It's what we're using to measure what is efficient progress and the faults in that.

Us not recognising that childbirth isn't a linear progression through various stages.

Our idea about giving it first stage, second stage, giving these labels, birth does not unfold as simply as that.

Us attempting to measure how many centimetres per hour a woman might be dilating by doing a vaginal examination, not appreciating the role that the vaginal examination plays in reducing the progress of labour.

So it's such a blunt instrument to have a progress chart or an intrapartan, or partogram, forgive me, to measure the efficiency of someone's labour and then the subjectiveness of which calling that the progress is too slow to stay at home.

Yeah.

It's a travesty.

I find it, and especially as I don't see labour dystocia.

So the only reason why I can say I don't see it is because I'm there present at births, whilst it's happening and can see that progress is not linear, but can see the progress anyway.

And I don't interfere with the progress because I'm not doing vaginal examinations unless there's a reason to do them.

If you employ vaginal examinations as a routine assessment of progress, you're on to a sticky wicket because some people will be, you know, two centimetres, not that it exists because no one takes a measuring device up there.

The estimate of two centimetres and presuming that you're going to be there a few more hours is wrong.

I've seen it.

Not that I do the vaginal examinations, but I can come and maybe if I do a palpation, I can see the baby still hanging out on the left somewhere.

So I know they have not descended enough to do their rotation and to line up for birth.

So I know that we're still maybe before halfway dilated.

I won't confirm that with a vaginal assessment.

I don't want to do that to women unless it's absolutely necessary.

And then lo and behold, two or three hours later, we've got a baby.

So that doesn't fit with this linear progression through childbirth in its stages, does it?

But I see that so many times.

I see that so many times.

And I think that very occasionally, the transfer may be to do with a kind of positional thing of baby, maybe baby not kind of getting their chin down on their chest, but it's rare, particularly at home, where women feel able to adopt positions that they feel comfortable with.

Because if you've had Pepidin, that's going to immobilise you because you're not used to a Class A drug.

Most of us aren't.

So if you've been immobilised with Pepidin or with an epidural, that's going to change the way your baby progresses through to becoming born.

So by all means, I would expect to see some kind of hold up in the process outside of the home.

But the fact that we've got that many people apparently transferring in to what appears to be labour dystocia, I would question the parameters for labour dystocia.

Whether it's true labour dystocia, whether it's an actual reason, and I think sometimes I know women who are just very, very tired.

But I always say that sometimes a slow in labour, is that not an opportunity for you to rest?

Has your body slowed it down so that you can go to sleep?

Does it mean you have to go in and 36 hours after 36 hours of being awake, give birth to a baby in a hospital?

Or does it mean actually, as long as you and baby are showing signs that you're healthy and well, can you sleep for two hours and wake up and things might pick up again?

Absolutely.

I mean, that is standard for those of us that went on to, you know, with our own education to become independent midwives.

The standard is, you know, the role that sleep can play in facilitating a really healthy birth.

And so we employ sleep as a, you know, basically a technique of childbirth in the early labour phase.

And definitely, if it comes to, towards the end of labour, and the parents seem to be going through a type of transition, and would be made comfortable to sleep then, we facilitate it then too.

Some of them are in the pool and not often in the pool.

We just make sure that they don't slide under.

You know, we'll just put a towel over the edge of the pool for a bit of friction, and they'll lay over that and have a snooze.

We know it happens.

And just like you say, we have to know that both mother and baby are well.

So our observations will be, you know, top drawer.

We'll make sure we're keeping really great notes and keeping an eye on the well-being of mother and baby.

But so many times we've seen the woman, you know, wake up from a lovely snooze of an hour or two, and then there's a baby in the pool within 30 minutes.

Yeah, exactly.

I've seen the same.

And so the next one, I won't touch on too much because it's kind of fairly self-explanatory, but it's women who are requesting epidurals.

So having been at home and decided actually, I would like to have an epidural.

Obviously, you can't have an epidural at home.

So that requires transferring in.

But again, it's not, there's nothing urgent or well, urgent in that you should be able to access whatever pain relief you want, but there's nothing in terms of health of the baby or mum that means that it's an emergency.

And the third biggest one was meconium in the waters.

So that's baby's first poo in the water.

Yes.

Another controversial chat.

There's Midwife Thinking.

Sorry, we're talking over each other because it's a hot potato.

Midwife Thinking, Dr.

Rachel Reid has got two great articles.

Well, let's refer to the one, the meconium staining.

Let's go after that because there are grades of meconium.

Here in the UK, we've changed our mind about how to grade them a number of times.

I'm not sure what the current language for it is at the moment.

I've told it's significant and insignificant.

I very rarely see it.

I'm thinking, and the thing is, most of the women that I have been looking after have given birth in the 41st week and onwards.

Occasionally, you'll get them before, but mature babies pass meconium.

Yes, they do.

They clear up their own meconium because they filter it.

That's what they've been doing the entire time, drinking in the amniotic fluid and then peeing back out the clear fluid, the straw-coloured, and that's what they're sitting in.

So the timing of meconium release, the release of meconium, then a few hours later, they'd have cleared it up.

You've got clear water again.

If membranes rupture and the meconium is still present, then an assessment is made.

We can't make up our mind about whether midwives can be trusted to make the assessment and then just make the information known to parents, make a decision together and go on, or whether they have to observe a policy of transferring in with the presence of any kind of meconium.

It seems to change from trust to trust and unit to unit, and the response to that policy changes from midwife to midwife.

So, you know, occasionally, when I was working in maternity services, I'd see, you might see thin meconium, and then when the baby's born, it's thick.

So you can, like, it's kind of lots of meconium produced towards the end of the labour.

So it starts off thin and then becomes more.

I must say that when I saw that, there were other things happening.

The people were in obstetric units.

There was lots of vaginal examinations and people on their backs and things like that.

So to compare with all that I've seen at home, there's been one instance of thick meconium.

That was the baby that was beyond 42 weeks, but that's not why it was there.

I think it was malposition.

So the way the baby was presenting and processing, the labour was taking longer and longer, and the baby was pooing accordingly.

So we went in.

So basically, they were pooing faster than they can clear it up.

And you might just point out what the concern is with meconium.

Yes, I will.

If meconium is thick, we call it particulate, so there's little lumps in it.

It's, you know, gloopy.

When a baby is born, if they have their mouth full of this gloopy meconium, and then they're born, and they're caused to gasp at birth, because these are all very rare situations.

If they're caused to gasp at birth, then the chances are that, because you've got one pipe going down, then you've got a flap basically that, if lifted, contents of what's in that pipe will go into the trachea, the bits where the bronchioles and the lungs are, or go straight down into the stomach.

So the hope would be that it would go straight into the stomach.

But if the baby gasps and that flap doesn't move quickly, and it does end up in the respiratory area, then that can cause problems.

It can cause an infection, difficulty in breathing, etc.

As you say, a tiny, tiny chart of all the babies born with meconium, the number that that happens to is incredibly small.

It's so small.

And then if you've got a baby that is having, you know, like a hypoxic or low oxygen events in utero, then there's a chance they could gasp in thick meconium as well.

But it is very, very rare.

But the chances are that if there is a presence of thick meconium and the midwife expresses this to the parents, the chances are that the parents would want to transfer in.

So that's where those figures come from.

The controversial thing is the presence of thin meconium and the transfer in, because we have no concerns about thin meconium.

It's the thick one that we're concerned about.

But unfortunately, I have seen occasionally that you think it's thin and then when the baby's born, it's thick.

Yeah, it's a tricky one.

I will link to the Rachel Reed article as well.

It's a very helpful thing in understanding meconium.

So just to finish us off, the final thing that people want to know is, we've covered the main reasons for transfer, which are not emergency situations, and they take up the vast majority of those.

But in the very, very small number of cases, that there is a complexity either at birth or after birth, and you are at home, such as bleeding or baby needing help breathing or tearing.

Do you mind just talking us through what happens in those situations from a midwife perspective?

So let's start with baby needing help breathing after birth.

Well, fortunately, the independent midwives that took me under their wing broke me out of the habit of thinking that you needed to clamp and cut the cord to help a baby.

They said I had to learn that quickly, just in case the situation could arise, because I could end up further compromising the baby by doing that.

So that's the first thing.

I would never, ever, ever dream of separating a baby from their only source of oxygen to help them.

So keeping the cord intact, so that they don't need to stay close to the mother.

And then offering some breaths with using our bag and mask.

So all midwives attending births, you always have one or two, and we'll always have them to hand.

We'll get them nearby around the time that birth is imminent.

When we do that, we just make sure we dry the baby first to make sure they're warm, make sure that there's no kink in their airway, so we position their heads properly, so that when we do administer feats and breaths using a bag and mask, that we can inflate the lungs and you can see their lungs inflating.

And then it only takes a couple, I've only had to do that twice in my whole independent midwifery career.

And the babies took over basically, you know, I saw Natalie mentioned the other day, you know, was it Natalie, was somebody else mentioned?

The babies try and push you away.

They're good, they're good, you know.

So it's wonderful.

So we'd have already determined that they still had a good blood supply, and we'd know that.

We'd have been listening when they were inside and when they were outside.

You can just feel the pulsing of the umbilical cord and you know that they're doing good.

If you've got time, you listen with the stethoscope as well.

So we know what to do, and midwives know what to do everywhere.

The only issue is in obstetric units, they were very, they're neonatologists and obstetricians and midwives that have that way of thinking are clinging to the idea that you need to clamp and cut the cord and take the baby somewhere.

That's, well, that's been shown.

The Nepalese study last year showed graphically that that was absolutely not the right way to conduct helping a baby out who needs a few breaths.

Absolutely.

And it just even just on a scientific level just makes so much sense to leave them attached to their supply of oxygen that's potentially going to be going for minutes more.

That's right.

So a couple of other things then that may happen at home.

So I suppose that I should point out about that.

And also the next thing to talk about is bleeding.

The first response way of dealing with any of these things is the same wherever you give birth.

So whether you're at home, on a birth center or a labour ward, you're not getting different care initially in any of those places.

I would hesitate to agree that only because seriously, I'm hearing because I do a lot of debriefing and birth afterthoughts, et cetera, that babies are being whisked away from their parents if they need some breaths.

So on the birth center, I think they do the same as we would at home, but definitely I'm hearing of such units, they're taking the babies away.

Yeah, absolutely.

But in terms of the apparatus itself, the equipment that you carry, is it the same?

Oh, yes, it's exactly the same.

Yeah.

And so the same with if a woman was to bleed heavily.

Again, the research that we have shows that the chances of bleeding heavily are less when you're at home or in a birth center.

But in the instance that somebody was to bleed heavily, how is that treated for a home birth?

Yeah, absolutely.

I mean, there were very interesting reports at the moment of people using some placenta in the cheek of the woman because she's got very thin, or she's got good access to her blood vessels in her cheeks.

But I have never tried it, but I'm seriously interested in how well that's been working.

And some people are using herbs for that scenario as well.

What I am always prepared for is to give an injection of an oxytocin.

So we start probably with some tosinol.

If that's not helping, then we'd go for centimetrin.

If that's not helping, we've got ergometrin.

Yeah, and say again, exactly the same wherever you are, the same drugs are carried.

Yeah, absolutely.

The same drugs are carried.

We also were all trained in bimanual compression, which is a mechanical way to reduce the size of the uterus, and so the site where the bleeding is coming from, so to reduce the bleeding.

We're all able to suture.

As I say, if the source of bleeding needs suturing, if it's something like a tear, then we can do that.

Most of us carry fluids and cannulation equipment, so we can do some fluid replacement if that's necessary to stabilize a woman if we're going to be transferring her in as a result of the bleed.

We all assess bleeding in the same way.

I admit, weighing, I mean, I've hardly seen a hemorrhage.

Weighing is something that some, we have to make an initial estimate before we can get around to weighing to see what the loss was.

That's kind of after all the dust has settled for an accurate recording of the loss, we would weigh maybe an hour after after the woman's been settled.

But at the time, we just need to make an assessment of what the loss is and whether it's going beyond that that she can manage.

And that's something that we would be able to do everywhere.

We all know the signs of collapse.

We all know what observations to take.

Many of us carry oxygen, not all of us, but many of us carry oxygen.

Although oxygen needs to be titrated, we're still quite comfortable with giving some to help maintain a woman whilst we've called the paramedics for the assistance and everything else.

When the paramedics come, we don't always transfer.

They will do an assessment.

They will sit with us whilst we all work together, looking at the woman, seeing how she feels, asking what she wants.

It's smoothly done, no matter where the setting is.

Yeah, fantastic.

So I think, just to point out one more time, that those things that we've covered at the end there are incredibly rare and are even rarer in a home setting than in an obstetric-led setting.

I hardly see it whilst, on the odd occasion, sometimes I might go in with a family to the obstetric unit.

Usually it will be, possibly the first birth they had, had a lot of challenge in it, and so they're both traumatised, and so they book an independent to keep them safe the second time.

So I might end up on a unit with, you know, an obstetric unit with them for that.

And I will be hearing the buzzer go off numerous times during my stay there because of someone's hemorrhage.

So it's not that there's an intention in any way, shape or form for women to bleed, but I think the combination of circumstances that are occurring on obstetric units, the cascade of intervention, the driving of labours of synthetic oxytocin, is just meaning that the heavier blood losses are more likely, and the research shows that.

So it's not that, you know, people think, oh, they've got a load of complicated cases on that ward.

That's why it's not that.

It's the path of labour not being smooth, not being efficient.

Most of those leads are not coming from a vaginal tear.

They're coming from uterine atony.

So there's just no tone in the uterus to complete the third stage.

And so the bleeding occurs.

So, you know, it's a difficult one because no one wants to cause harm.

But sometimes, you know, the cascade, at the end of that cascade is harm that may not have happened had we not had the cascade.

Yeah, yeah, absolutely.

And I think that's a kind of good place to kind of wrap up is that ultimately what home birth seems to do for ultimately for any woman that feels safe in that environment is that it really does just support the physiology of birth.

And when we're able to support the physiology of birth, number one, we can be sure that intervention is only happening if it's really, truly, truly needed, which I think is most women's, not all, but most women's want for their births.

And I suppose the final thing just to highlight for the last time is that giving birth at home for almost all women and almost all babies in almost all instances is a safe thing to do.

Yeah, I have to agree.

That's what I've seen.

So I have to agree.

Yeah, fantastic.

So I mean, I think we're running over an hour already, so I think we could literally talk for ages on this.

I cannot believe it.

It feels like 25 minutes.

I know.

So I really could just keep chatting about this, but I think probably best to wrap up here.

So Kemi, I'll ask everybody one question before they go.

And if you were to gift a birthing person one thing, what would you give them?

I have to say, because I know from my experience that childbirth is an event that most of us are built for and can perform beautifully.

I think what I would give every birthing family is a doula, because the most important thing is that the parents feel comfortable, that they're around someone who knows them, that they feel warm and safe, that they're nourished and hydrated, and that they're facilitated to sleep and do all the things that help a physiological process.

To unfold beautifully.

And I think doulas are the key for everyone to have a better birth.

Fantastic.

Well, thank you so much for joining me.

I hope everybody has found that incredibly insightful.

I will link to all of the studies and articles and things that we've mentioned, if you want to read about it further.

But yeah, thank you very much.

Thank you.

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