The Demise Of Midwife Led Units

Trigger Warning: This blog post talks about baby loss in the context of midwife led units and the latest publication of the MBRACE-UK report last week (MBRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK).

Why are all the freestanding MLUs in Northern Ireland closed?

Well, that's easy!

It’s because of Covid, isn't it? 

Remember that lil’ phrase: 'Cause of covid?

...remember Covid?

Why can’t I get loo roll?

Pasta?

Eat out?

Have a pint?

Travel to Germany?

See my GP?

All because of Covid!

And now it's as though none of it ever happened. 

One of the many casualties of C19 were Freestanding Midwife Led Units, or at least the ones that were still standing when Covid came (by 2020 I had already witnessed the birth and the gradual demise of Northern Ireland's first Freestanding MLU). 

They are all still closed today. Now it's 'staffing'. 

Only that story didn’t get nearly as much attention as the loo roll which, in case you hadn't noticed, is now freely available again.  

Childbirth generally doesn't make for great headlines. The type of birthing that goes on behind the closed doors of everyday MLU life is so simple and mundane that it doesn't provide nearly as much drama as the horror induced by the thought of not being able to wipe oneself clean.

And by now it should be blatantly obvious to everyone that Covid was just a welcome scapegoat for closing our Midwife Led Units.

Midwife Led Units in Northern Ireland and the UK as a whole never stood a chance of remaining a constant feature in our birth world. Our birth culture won’t allow for them to flourish and midwives who are fully invested in supporting women giving birth in midwife led units or at home are exposed to the modern day witch hunt currently taking place in our maternity systems. Those midwives are vulnerable because, inevitably, there will be a day when the unforeseen happens. A tragedy can strike at the high tech labour ward of a Consultant Led Unit just as much as it can in an MLU or at home. Only when it happens outside of the hospital, it will be implied that that is the reason. Despite a massive body of evidence pointing to the fact that the type of physiology informed approach that many midwives set out to practice is protective and statistically safer than medicalisation, isolated incidences are used over and over to support the narrative that interventions assure the safety of mums and babies. And because those isolated incidences generally *do* make for great headlines, this is the narrative that sticks, even with those people who should know better.

The people you depend on to provide you with unbiased and balanced information are scared of physiology because it is always easier to justify to have done *something* than it is to have done *nothing*.

Supporting freestanding Midwife Led Units should be second nature to every single member of maternity staff, the evidence supports it. And if your care providers were fully informed, *fully* informed (!), and honest, they would advise you against most of the things they do routinely. But that’s not the case. Only a few midwives and doctors even know what an undisturbed birth looks like or are willing to support you in trusting your physiology. MLUs don't have the backing they need from any level of midwifery and medical staff. In order to thrive they would need the commitment from maternity leadership at large and they don't have it. National guidelines are written by people who are blatantly ignoring the body of evidence that supports a hands off approach. This approach would be best for most women. The majority of our ways of 'managing risk factors' are based on no evidence whatsoever. Hospital guidelines are usually drafted around the recommendations in the national guidelines and so bad practices spread. This lack of understanding of birth physiology and over representations of the potential benefits of interventions runs all the way through to the courts and women and babies are suffering as a result.

Women and babies are suffering so that maternity services can continue to chase the pipe dream of saving every single family from the potential hardship and grief of losing a child. And of course this is a delicate issue, because I can't imagine a more devastating reality than being bereft of a child. And, as I am writing this, it is baby loss awareness week. So again, when I talk about these issues I am trying my best to be sensitive to those of my readers who have suffered such a loss. 

If this is you, you have my heartfelt sympathy.

When we talk about baby loss, I think it is important to discuss the wider implications of it, too. In an environment where we are not generally comfortable with talking about the fact that some babies will not get to stay with their parents, those issues are very difficult to raise. Each baby death, particularly if a baby dies during birth, has the potential to permanently impact not only her or his own parents but all parents via policy and due to the experiences of those providing the care. There's a ripple effect. Every birth impacts every single future birth and therefore the kind of advice that parents receive and the choices they are presented with. And these changes are not always for the better. Sadly, despite many additional risk factors and a move towards more and more medicalisation, we are seeing an increase in baby deaths in the latest MBRACE-UK report for the first time in almost a decade. It is in our human nature to want to find the reason for a tragedy and to then exclude the possibility of it ever happening again. Coroner's courts are the places in which medical and midwifery practices are examined in order to find those 'reasons' and the verdicts are not always coherent with the current evidence base and often they are damning for physiology informed care models and those parents who would like this approach for their pregnancy and birth in the future.

A recent coroner's verdict here in Northern Ireland ruled that a baby's death that occurred due to an emergency situation in a midwife led unit had been 'foreseeable and preventable'. The verdict hinges almost entirely on the fact that a woman's body mass index had been recorded wrongly. Her actual body mass index would have streamed her into consultant led care by a margin. The complication was a shoulder dystocia. In truth, there is no evidence to suggest that a body mass index of over 30 is an indicator for the likelihood of a shoulder dystocia. There is also no evidence to imply that shoulder dystocia is more likely to be fatal when midwives are in attendance than it is when doctors are. There have been fatal shoulder dystociae in obstetric labour wards where doctors were first attenders and yet the verdict claims that the baby's death 'would have been prevented' had the mother been transferred to consultant led care. To me it is immoral to tell a family that the life of their baby depended on a minor discrepancy in a height and weight measurement and that this death most certainly would have been prevented in the hands of doctors instead of midwives. Nobody can know this for sure. Nobody! And then there is the question of whether the calculated body mass index can actually make any kind of prediction about pregnancy outcomes.

Dr Sara Wickham's new book 'Plus Size Pregnancy' is hot off the press last month and in it she quotes evidence that states that a higher BMI is NOT an independent risk factor for shoulder dystocia and, most importantly, she states that no study has ever been able to adequately predict which babies will have a shoulder dystocia (p. 70). A shoulder dystocia is never 'foreseeable' nor is it ever completely 'preventable' in a physiological birth.

But this verdict doesn't just say that the shoulder dystocia was 'foreseeable and preventable', it goes as far as saying that the baby's death was. But, how could it have been predicted? When it comes to death directly associated with shoulder dystocia it is very difficult to come up with a statistic. It is rare and to my knowledge there is no study providing such a statistic. There is some data referring to the risk of a baby who was exposed to shoulder dystocia having a severe life altering injury. The Royal College of Obstetricians and Gynaecologists (RCOG) parent leaflet on shoulder dystocia states that severe brain injury happens in ‘a very few cases’. In their Green-Top Guideline for doctors and midwives on Shoulder Dystocia the RCOG give the following data:  'permanent nerve injury is associated with 0.1 - 0.2 per 1000 births'. The same guideline also states that 'Risk assessments for the prediction of shoulder dystocia are insufficiently predictive to allow prevention of the large majority of cases'. 

The RCOG offers no statistic of the chances of a baby dying due to shoulder dystocia and I couldn't find a reference anywhere else. The only reference we have for trying to predict the chances of a baby dying in birth is the MBRACE-UK Report. The latest report states that in 2021 in the UK, 0.25 out of 1000 families lost a baby in labour between 37 and 42 weeks of pregnancy. A further 0.66 out of 1000 babies of this gestational age passed away shortly after they were born. These are the most likely statistics to capture the chances of a baby dying from shoulder dystocia. The Royal College of obstetricians - 'the doctors' - collectively state that shoulder dystocia is not predictable so it beats me how a court ruling can suggest that it was in this case on the basis of this mother's BMI. 

The ruling states that the family were not given the opportunity to discuss in detail their options for place of birth and that this discussion should have taken place with a consultan obstetrician given the BMI of over 30. According to the guidelines for admission to Midwife Led Units in Northern Ireland effective at the time of this tragedy this is not the case. These guidelines were taking into account that BMI is not an individual risk factor for predicting additional risk to a baby and the BMI margin that would have prompted a referral at the time would have been a BMI of 35. This was not in line with NICE guidelines but it was a thoroughly evidenced and very welcome regional guideline for midwives operating in Freestanding and Alongside Midwife Led Units. Here is the summary of it. Sadly it is now withdrawn until further notice. This creates many additional referrals from midwives to already overrun obstetrician's clinics.

The verdict mentions that some of the guidelines contradict each other, and again, this is true as you can see and it is one of the systemic problems that midwives face in today's climate. There is also mention of the baby's estimated weight plotting above the 90th centile and this is another complex subject on which the evidence in favour of interfering is not clear. 

I read in one of the local papers that, given the choice, the family would have opted for consultant led care and that they didn't feel safe in the midwife led unit. That is the main issue here, the main learning point to my mind. Every parent, regardless of their 'risk factors' should be offered to explore openly all options for place of birth. Feeling safe is one of the most protective factors for the unhindered unfolding of birth physiology and if you feel safest in an obstetric led unit, even in the absence of any risk factors, then that is where you need to be. On the other hand, feeling safe in a Midwife Led Unit or at home even in the presence of 'risk factors' has the same potentially protective effect and it should be easy for you to find support in making a plan around your personal situation. 

Despite this verdict it is my opinion that we will never know if this poor family would still have lost their baby had they given birth in an obstetric led unit, I just wish they had been on a labour ward instead of an MLU. At least they would feel that they were in the best place for them even if their little baby had died in the same way. I wish them healing and resolve on their journey through grieving the loss of their baby.

I also wish that the midwifery community as a collective can heal from this ruling and that the doctors can have perspective when advising parents around this issue of shoulder dystocia. This ruling appears to be based on opinion and bias. It is not rooted in an evidence based approach and, as I see it, it serves no one; Not the parents of this poor baby and not any other future family. And it won't prevent future baby deaths either, it only perpetuates further a harmful narrative. It causes harm because it is undoubtedly part of the reason we are seeing so many caesarean sections here in Northern Ireland.

If you are interested in why this high caesarean sections rate is an issue and why people like me are speaking out about the overuse of caesareans, I highly recommend you listen to a recent conversation between midwife Blyss Young, Raquel Elise (a HBA3C mum - she had a homebirth after three caesareans) and Dr Stu Fishbein. Dr Fishbein is an obstetrician who admits that in his early years of practice he simply didn't know that a large percentage of the caesarean sections he was doing might have been 'indicated' but were completely unnecessary. Apart from countless women feeling robbed of their birth experience without good reason (yes, this is a valid reason to keep your scalpel in your pocket), there are implications on the population at large. Babies born by caesarean sections are more likely to develop early onset childhood diabetes to name just one of the effects. And while those are marginal shifts in our population for now, they will accumulate over time and the impact on the individuals are massive. Besides, there would be an outcry if we were performing a large number of unnecessary surgeries in any other context. Not only is it costly, but surgery takes time to recover from and you introduce a whole set of new risk to a situation that could have resolved on its own.

And this brings me full circle to why we need Midwife Led Units and Home Birth teams who are committed to physiology informed midwife led care; they have the lowest caesarean section rates! We also need practitioners, midwives and doctors, who are committed to exploring a physiology based approach with women who want it and have 'risk factors'. We need this because this increases the rate of physiological births and it reduces childbirth related trauma. Lovingly supported physiological birth helps the mama/baby relationship and it supports breastfeeding physiology. And while it is never a personal failure to have a caesarean section or to formula feed, ever, as a collective of birth professionals looking after the population at large, we must take the long view and acknowledge that the physiological pregnancy, birth and postpartum continuum is preventative for overall public health. We must support midwives in operating in settings that support this and we must allow them to beat the drum for physiological birth without fear.

Oh, and staffing Midwife Led Units really shouldn't be an issue. There are around 1300 midwives in Northern Ireland.  The problem is that most of these midwives are employed as obstetric nurses and shortages, so far, have led to midwives being pulled out of midwife led units in order to stuff holes in obstetric led units.

Why is that?

Midwives need to keep practicing midwifery because not only is it evidence based and safe but it could become a lost art. Just like breech birth was lost to poorly evidenced guidelines, physiological birth will be, too, if we don't support it. We need to up our game fast because women are starting to walk away from maternity services to give birth on their own or attended by family and friends. 

References:

Blyss Young Instagram chat with Dr Fishbein

https://www.instagram.com/tv/CyKMeP4pW5v/?igshid=MzRlODBiNWFlZA%3D%3D

MBRACE-UK report:

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://timms.le.ac.uk/mbrrace-uk-perinatal-mortality/surveillance/files/MBRRACE-UK-perinatal-mortality%20surveillance-report-2021.pdf

RCOG (2012) Green-Top Guideline no. 42, Shoulder Dystocia:

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.rcog.org.uk/media/ewgpnmio/gtg_42.pdf