Making the case for independent midwifery: The Baby's Coming by Virginia Howes

Virginia Howes's book The Baby's Coming - A story of dedication by an independent midwife was published this week, just as the Department of Health announced that the government would not support independent midwives' proposed insurance solution, which means that when new EU legislation is implemented later this year independent midwives will become illegal. To anyone who has had any involvement, however remote, with independent midwifery - even if they've done no more than watch Virginia on TV in ITVs Home Delivery - this must seem like total madness: independent
midwives are highly skilled and offer choice and high-quality care to women with a wide variety of needs, relieve the pressure on an over-stretched NHS and save £13 million per year in costs to maternity services. You can read more about the situation facing independent midwives in this article in the Express, this blog by Angela Horler on the Huffington Post, or on the Independent Midwives UK website.

Reading The Baby's Coming this week, then, means that I have read it with an eye on the wider picture too. And, having read it, it couldn't be clearer to me that if independent midwifery is outlawed then we will have lost something of immense value, and outcomes for the women who would choose independent midwifery if they could will be less favourable as they are forced to birth in circumstances they wouldn't have chosen - either within the NHS or alone and unsupported.

Although the book is in many ways an entertaining read, packed with wonderful birth stories, moments of humour and everything that birth junkies like me love to read about - it's also profoundly political, stuffed full of clear demonstrations of where there is room for improvement in our maternity services. In a climate where choices in childbirth are becoming limited within the NHS, due to the suspension of home birth services, the closure of stand-alone midwife-led birth centres and fear of litigation - and all this despite a European law that enshrines a woman's right to choose the circumstances of her birth - it seems to me that we need independent midwifery more than ever.

I'm involved with the Positive Birth Movement, and at meetings we share positive experiences of birth and discuss how women can make their own choices and work with their caregivers to ensure their needs are met; in the process we often hear how difficult this can be and debrief previous experiences. Virginia's book, it seems to me, could be seen as almost a manual for mothers and their caregivers for how respectful, woman-centred maternity care should be delivered, whether in home or in hospital, within the NHS or outside it. There are 'scripts' in its pages that mothers (and midwives) could use to great effect and that's a real strength of these stories - they are an antidote to the 'am I allowed'/'will they let me' position that so many women find themselves in and they show how, even in difficult circumstances, you always have a choice about your care and your informed consent should always be sought.

I had all three of my children at home - with NHS midwives - and I love how the book, again through real-life birth stories, gives a truly realistic picture of what home birth can be, both when all goes well and when there are complications. (I absolutely loved the story of the parents who planned a home birth, went into hospital for monitoring, found all to be fine, then dashed back home again to have the baby in the pool as planned!) Parents considering home birth can read the book and get a sense of the 'back up' that's in place, whether the care is independent or NHS, and feel reassured. On the whole the book is immensely reassuring; it's a long way from the 'drama' of birth on television shows like One Born Every Minute. Even through the (admittedly very unusual!) story of a breech birth that took place in a moving ambulance in a snowstorm there is never a sense of panic, more a sense of wonder that birth can often unfold spontaneously even in the strangest of circumstances. I also relished the moments where traditional (yet evidence-based!) birth wisdom - so easily overlooked in more medicalised births - was in evidence: Virginia describes how something as simple as getting out of the pool could slow down labour enough to give her time to arrive to be with a nervous father worried about having to catch the baby, and how labours that are progressing well can be stalled by people coming in and out and talking to the mother, or turning on the lights. She often talks about the subtle signals women give about what is happening in their labours, without the need for vaginal examinations or calculations of 'rates of progress'. There's valuable knowledge here that we would all do well to take note of.

It's probably clear by now that I loved this book (I've ordered a few copies for my mobile book stall so I'll be spreading the word...) And I'm with Virginia in hoping that it doesn't become a historical document in the near future: if you can join in the campaign to save independent midwifery, please consider doing so. You can go to the IMUK website and take it from there - lobby your MP, donate to the fighting fund, sign the petition.

Finally, I wouldn't be an editor worth my salt if I didn't flag up the fact that there are a few proofreading errors in the book, and that some of the dialogue sounds a bit clunky (that's down to the fact that someone decided not to use any contractions - strange, given the subject matter! - so instead of 'I'll' 'I'm' or 'We're' these are spelled out in full). These are minor niggles, didn't spoil my enjoyment of the book and can no doubt be corrected in future editions (of which I hope there are several, revised and updated to include many future birth stories!)

I received a review copy of the book from Headline; my opinion of it is, of course, my own!

Positive Birth, home birth, choices in childbirth

I've been mulling this piece over for several days since I attended the first meeting of a new Positive Birth group in Derbyshire on Saturday. I've delayed writing it because I had reading to catch up on. First I read about the changes to the home birth service at Homerton Hospital in Hackney (where the team that supports home birth has been cut so that it can no longer provide a 24/7 service, without consultation and leaving women already booked for home deliveries in the lurch). More about that here (and do sign the petition, which has nearly 1,000 signatures already). In support of that campaign, this post has plenty to say about the illusion of choice in childbirth. Then I saw this article in the Daily Mail about the reality of working as a midwife in hospital today. And then, just as I was about to start writing, I read Louise Carpenter's important article in the Observer about the Freedom for Birth movement and the importance of the ruling in the European Court of Human Rights (Ternovsky vs Hungary) which upholds a woman's right to choose the circumstances of her birth. You can read the father's perspective on one of the case studies cited in Carpenter's article here.  Finally, I at last got round to watching the free abridged version of Freedom for Birth - A Mothers' Revolution, a film about women's maternity rights around the world. Phew. Have I got anything left to say?

I want to draw out a few threads from all this discussion. As someone who's involved with birth at a personal, local level (I've had three NHS home births in the last six years, and work with mothers postnatally as a volunteer breastfeeding peer supporter, often debriefing birth and breastfeeding experiences) and at a wider level as a publisher of birth and breastfeeding books, interacting with our authors and readers, it's fascinating to see how the 'big picture' and real women's lives intersect.

What I hear from the women I meet and talk to about their experiences of birth and breastfeeding is that, although it may seem as though we have choices about our maternity care in this country, the reality is that those choices are constrained. Almost every woman I've ever spoken to has said that at their first antenatal appointment, or 'booking-in', they were asked 'which hospital will you have the baby at?'. Right from the outset there's a presumption that women will birth in hospital, which shuts down further discussion and information-sharing. Just consider how differently that conversation might go if the midwife instead asked 'have you had any thoughts about where you might give birth? If you want to explore some options you could go along to this group that meets monthly, or look through these booklets, then come back to me with any questions'. (Similarly, women might feel differently about discussions of infant feeding at antenatal appointments if instead of being asked 'are you planning to breast or bottle-feed?' they were asked 'have you given any thought to feeding? If you'd like to explore some options you could go along to this group where you'll get plenty of information to help you make a decision.')

Inviting women to share what they already know, and directing them to accessible sources of accurate information and support that can increase their knowledge and help them make their own decisions, is surely at the heart of woman-centred care. This is where Positive Birth and other antenatal groups, both free and paid-for, can really come into their own - by meeting with other mothers, and sharing information and experiences, women can become aware that they do have choices - not just about where to give birth, but about everything to do with their pregnancy, birth and early parenting experiences. It's this same idea that underpins Lonely Scribe's publishing philosophy and our 'stories to inspire and inform' series, which already includes Home Births and Breastfeeding, is expanding next year to include Twin Births and Water Birth.

"Birth isn't something we suffer, but something we actively do and exult in." Sheila Kitzinger, Freedom for Birth.

The question of how you empower ordinary women to own their experiences of birth, feeding and parenting when the prevailing culture is one of deference to a medical model of childbirth and formula feeding is at the heart of all this. I've recently heard a midwife describe how readily women submit to interventions and examinations that may not benefit either them or their babies simply because they are suggested by an authority figure (midwife, doctor, consultant), even when no reasons for the procedure are given. (This was in specific reference to repeated vaginal examinations during labour.) Do women know that they can refuse vaginal examinations if they want to? If they don't know that they can refuse, can they give informed consent?

Another common complaint I hear is about risk and how it is presented. It's not something that is easy to communicate and health professionals struggle along with the rest of us in making sense of the facts and figures of scientific research. However, unless our doctors and midwives are to make our decisions for us - disempowering us in the process - they must learn to talk about risk in a different way. It is not ethical or accurate to tell a mother keen to avoid an induction at 41 weeks that she will end up with a dead baby unless she consents to the induction. Similarly, breastfeeding mothers are routinely misled about the risks of co-sleeping. Many health visitors condemn the practice outright - instead of acknowledging the beneficial effect on breastfeeding - and shut down the debate, leaving mothers unsupported and uninformed (see the UNICEF research on the topic here.)

Home birth is a topic close to my own heart and one that throws up many more ways in which choice can be constrained. I've met and talked to many women who've planned home births, whether they eventually gave birth at home or not. They almost all have stories to tell of how their choice was belittled or overridden and how they had to fight just to be 'allowed' to book the home birth they wanted. And that's within a system that theoretically supports women's choices! I regularly hear of women open to the idea of home birth being discouraged by midwives who say 'well, there might not be a midwife available on the day. If you ring and no one can come out to you, you'll have to go to hospital anyway.' The implication is that it isn't worth booking a home birth because you might not get one! Women understandably don't like the idea of being all set for a home birth only to find that no midwife is available, so they book for a hospital delivery 'just in case'. I find this situation unacceptable. A home birth service needs to be fit for purpose. It's a woman's right to choose to give birth at home and the NHS has a duty to support that. I heard recently of a case where a woman chose a home delivery of a breech baby. The hospital could not provide a midwife with the necessary experience, and in the end paid for an independent midwife to attend the delivery. That's great, and I'd like to hear that sort of story more often, particularly as independent midwifery is under threat (another way in which choice may soon be limited).

Another example that I have direct experience of is to do with access to water birth. I visited the new delivery suite at Derby Royal hospital before the birth of my second child (I went with a pregnant friend, I'd already booked my home birth!). We saw the huge, well-equipped pool room. I admired the filling system that fills the pool from a ceiling tank in minutes. Someone asked what happened if you wanted a water birth and the room was occupied? Our tour guide simply shrugged. I've since met many women who've had water births in Derby Royal, and many who could not, because the room was occupied. You do not really have a choice about whether you use water for pain relief or to give birth in - it's a lottery. And this at a newly-refurbished, flagship baby-friendly hospital.

I blogged recently about the Infant Feeding Survey and what it showed about the influence of place of birth on breastfeeding rates. Women who had home births had the highest rates of breastfeeding, both initially and in the early weeks (women who used birth pools and TENS machines also had higher rates than average of breastfeeding). I've been thinking about why this is. The report's authors suggest that it may be explained by the 'profile of mothers' that fall into these groups and to an extent I agree with this and understand what they mean: not all women have the means or the opportunity to arm themselves with the information and confidence they need to choose home birth, or water birth, or breastfeeding in today's society, and those that do tend to be in certain social groups. However, what really interests me is whether through activism - groups, blogs, discussions, information, support - we can empower more women, across society, to become active participants in their own care during pregnancy, birth and early parenthood.

There are those who will say that it is all very well engaging in this discussion, but the NHS is under strain and there's no way we can justify changes to maternity care. I bring up again a point I made in my blog about the UNICEF report that showed that programmes of breastfeeding support were cost-effective and showed a quick return on investment: a time of financial difficulty is a great time to be examining what the NHS does and where it could improve services, improve health outcomes, and save money. We've seen the report about breastfeeding. I'd love to see what would happen with a modest increase in home birth nationwide, both in terms of cost-effectiveness and longer-term health outcomes (tied in with the increased rates of breastfeeding associated with home birth). This study does some of it, but was published before the UNICEF report. I wonder whether, in time, research will show that Positive Birth groups, the Freedom for Birth movement and other grassroots initiatives will improve the lives of mothers and babies. I think they will. 

Infant feeding survey 2010: a closer look

The publication of the full results of the Infant Feeding Survey 2010 on 20 November prompted a slew of articles in the press, with the BBC, Telegraph, Independent and Daily Mail all covering the story. However, in my view the most interesting points arising from the figures are not those that have been widely reported so far.

Last month I blogged about UNICEFs report into the cost-effectiveness of breastfeeding support programmes and how they directly impact maternal and child health in the UK. The full Infant Feeding Survey 2010 reinforces many of the arguments the authors of that report made in their assessment of the state of breastfeeding in our society. The survey is a lengthy document and there is so much information to be gleaned that it would take more than one blog to cover it all - so I'm going to mention a few points for starters and hope that others do the same.

Formula milk
If I were a formula company executive, I'd be pretty pleased about the results of this survey. British babies are consuming a lot of formula. They're also getting plenty of follow-on formula (a product designed entirely to circumvent the tight regulations covering the marketing of infant or first-stage formula). At Stage 3 of the survey, 69% of all  mothers had given their baby follow-on  formula, an increase from 53% in 2005. 31% of mothers did not understand the difference between infant formula and follow-on formula. All those adverts must be doing something! Some 89% of mothers report seeing adverts for baby milks on TV, radio or in the press, and 79% said these were adverts for follow-on formula. Rates of exclusive breastfeeding (which is recommended by WHO and the UK Department of Health up to six months) are much lower than the headline figures for breastfeeding initiation: 69% at birth, 46% at four weeks, 23% at six weeks. So by six weeks, more than three-quarters of UK babies have been given formula, water or solid foods. At six months just one per cent of babies are exclusively breastfed.

What's going on here? My feeling is that at least part of the explanation for these figures is the lack of confidence mothers have in themselves and their milk; a cultural doubt that breastfeeding really works. (The fact that mothers of second or later babies are more likely to exclusively breastfeed, and for longer, adds weight to this idea: experience brings confidence.) The survey itself concludes: "These findings illustrate the fact that the main reason why so few mothers follow the recommendation of feeding exclusively until six months is due to the introduction of formula, either to replace or supplement breastmilk." Elsewhere in the survey, where the incidence of feeding problems is discussed, the figures reveal that the highest levels of feeding problems are reported by mothers who are combination feeding. It's certainly my experience as a peer supporter that once formula has been introduced, and mothers' confidence in breastfeeding eroded, the road back to exclusive breastfeeding can be tricky. All this is surely an argument for supporting mothers for whom breastfeeding is working well not to reach for the formula in the first place, and a tightening of the restrictions on the marketing of infant formula (to health professionals) and follow-on milk (to everyone).

When mothers were asked their reasons for using follow-on formula, the most popular answer (20%) was that they thought it had more nutrients or was better for the baby. This is not true of either breastmilk, which is by far the best milk nutritionally for babies of any age, or infant formula.

Less than half (49%) of mothers are making up formula bottles according to the latest guidelines (making one feed at a time, within 30 minutes of boiling, water in bottle first, then powder). This may be a substantial increase since 2005 when the figure was only 13%, but it flags up (to me) the fact that mothers who choose to use formula are either not getting the right information or choosing to ignore it. In my experience a lot of mothers who stop breastfeeding are given no information about bottlefeeding at all. This is a missed opportunity, particularly when we know from the figures that so many mothers are using bottles and formula: surely these mothers deserve accurate, unbiased information that will promote the health and safety of their babies? Mothers need to know how to prepare formula safely, and during those conversations support can be offered that might lead to them offering expressed breastmilk instead, or adopting practices (such as paced bottlefeeding) that will benefit their children. Breastfeeding supporters cannot opt out of discussions about formula entirely, and if they do so they leave mothers unsupported and reliant on the formula manufacturers for information.


Breastfeeding and returning to work
In Chapter 2 of the survey, which deals with initiation, prevalence and duration of breastfeeding, there's an interesting section about the impact of mothers returning to work on breastfeeding rates. This is one area where it seems that clear progress has been made: in 2005 mothers returning to work before six months were more likely to stop breastfeeding, whereas in 2010 "There was  no clear relationship between the age of the baby when the mother returned to work and duration of breastfeeding, which suggests that returning to work per se did not have much bearing on mothers’ decision to stop breastfeeding in 2010." This is evidence that nine months of paid maternity leave and up to a year of leave in total has had a positive impact on breastfeeding rates. It's interesting to consider this in the light of the recently-announced changes to parental leave that will allow parents to share leave and perhaps encourage mothers to return to work earlier once again, and adds to what we already knew about breastfeeding rates being higher in countries with generous maternity leave arrangements (Norway, Sweden).


Information and support that mothers are given
Following on (!) from the points made above about mothers' confidence in breastfeeding, I found the following figures tough reading: "Just under half of mothers breastfeeding in the hospital, birth centre or unit (48%) were informed about how to recognise that their baby was getting enough milk and nearly two in five (37%) felt they were confident enough to recognise whether or not their baby was getting enough milk." There's a clear call to action there for midwives, doctors and breastfeeding supporters: all breastfeeding mothers need this information.

Home births, water births, pain relief
The 2010 survey is the first to include detailed information about where babies were born, with some very interesting results. Breastfeeding initiation is highest among mothers choosing a home birth (88% compared with 81% overall). This could be down to a variety of factors, including access to consistent support in the community, and predisposition of these mothers to breastfeed. However, these mothers also have the highest rates of continued breastfeeding in the early weeks: at one week 82% were breastfeeding compared with 70% overall, and by two weeks 81% of home birthers were still breastfeeding compared with 67% overall.

And as for the effect of pain relief on breastfeeding rates: "Mothers who used a TENS machine continued to have the highest breastfeeding rates after one and two weeks from birth (86% and 83% respectively, compared with 70% and 67% overall). Those who used a birthing pool were also more likely  than average to breastfeed initially (89%) and at one week (81%) and two weeks (79%).  However, these rates could be explained by considering the profile of mothers who used a birthing pool or TENS machine during the birth." Mothers who used pethidine had the lowest rates of breastfeeding initiation, 77% against 81% overall.

It seems there is important information here for women planning their births. My feeling is that the impact on breastfeeding of some of these decisions is often overlooked. Interestingly, mothers delivering in consultant-led units, and having complicated births, also had high breastfeeding rates, perhaps reflecting an increased level of support in hospital. That's information worth sharing with mothers too - a difficult birth does not, in itself, mean that breastfeeding won't work.

I've found reading the survey fascinating and there is so much more to come out of it - I've barely scratched the surface. It has highlighted for me the areas where breastfeeding supporters have the most work to do. Reaching groups that tend not to breastfeed has got to remain a priority, and supporting mothers throughout their breastfeeding journey is clearly important too - with good support tailing off as the weeks pass, mothers are left without information and many begin supplementing with formula unnecessarily. Antenatal information about breastfeeding needs to be realistic, practical and mothers need to know where and how they can access support once the baby arrives. Perhaps the greatest challenge, in a nutshell, is combating misinformation, which booby-traps mothers at every stage. Whether that's misinformation from peers, health professionals, formula manufacturers or the media, it needs countering with evidence-based information and good support. And at the same time, we all need to work towards making society more breastfeeding friendly too. It's a tall order, but not, I think, an impossible dream.