The First Drive Through Maternity Hospital

Trigger warning: 

This blog post talks about baby loss in the context of 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).

Working in the same hospital for almost two decades meant that I got to know it intimately. All the corridors, wards, the lecture theatre, obstetric theatre, canteen, the file room, the liaison and directorate offices, social services office, the shortcuts, secret staircases, all of it. A hospital is like a living organism and inside the bowels of our maternity building there was forever movement. Not just the daily wheeling of meal trollies, linen trollies, baby cots and beds (with or without passengers) but also the movement that is caused by rearranging services and departments according to the directive given from above.

Close x-amount of postnatal beds, move this ward here and that ward there. Close down this department, establish such and such a service, close it down again.

And so it goes on. 

The hospital I worked in had absorbed a smaller maternity unit by the time I first stepped foot in it. I've only ever known it to be too small for the amount of people moving through it. There even was a consultation document in the library when I was a student midwife that advised against this amalgamation of the two services on grounds that the hospital didn’t have capacity for the amount of births it would have to accommodate.

The hospitals had been merged regardless.

Shocker!

When I started there, the service accommodated around 3500 births per year. Now this number is closer to 5000, same building. Turnover of beds has to be fast and the hospital has been bursting at the seams for years now.

But I loved it for its imperfections.

I loved it for how ugly it is. I loved its grubbiness. I loved the old part of the building.
I loved the extension that was at some point ‘modern’ (but hasn’t been in a long time).
I loved the new fixtures that were installed at regular intervals in an attempt to hide the undeniable fact that the building has seen its day. 

We’ve been waiting for the ‘new hospital’ for about a decade now, many deadlines have been and gone.

In my early days at this hospital I felt a true sense of belonging. It was like a second home to me. There’s something truly special about a place that never sleeps. I loved being there at night, my colleagues and I awake especially to see new life into the world. We were like family and we had a Head of Midwifery then who encouraged us in this, she knew that strong relationships among staff make for better care. Midwives, doctors, kitchen staff, maternity support workers, social workers, domestic staff, clerical staff, we all knew each other’s names, all shared in each other’s family lives and we all felt part of something. And even though there were days when things were hard, ultimately it felt like we all loved being there in service to women and their families, or at least most of us did most of the time. 

Or at least that’s what I saw.

In my early years it felt as though true advocacy for women was still easy even though there was a definite bias towards medicalised birth. There were enough midwives who celebrated women in their choices and there were some true advocates among the medical team, too. One of the labour ward sisters introduced waterbirths there in the late 90s. I remember she phoned me when I was pregnant with Lena because she had heard that I transferred care to another hospital because they had been the only ones to offer waterbirths up until then. I decided not to transfer back and I didn't ever get near a birth pool owing to a swab positive for Group B Strep. I have often wondered if I would have gotten a waterbirth in her care having witnessed her commitment to it and to 'normal birth' in the years of working with her (she was committed to other practices that I wouldn't have liked, too, though). 

Who knows.

It's not the same anymore now. Though there still is a sense of companionship and solidarity among staff (and I did love working with my former colleagues until the last day), there seems to be a real disconnect between the narrative of what midwives supposedly represent and what they really do in their day to day interactions with women. And it’s not surprising that this is happening.

The throughput is so much faster than ever before. Since the initial amalgamation another smallish consultant led unit was closed and, recently, yet another. Centralisation of services, apparently for the benefit of women and babies - to pool medical expertise in the one place. There are many challenges in this. Space is an issue. 

I am still waiting for the drive-through hospital and the four bedded discharge lorry I once dreamt up for satire. The fast discharges, the scramble for space and being robbed of time to spend with women I was caring for left me with cynical ideas at times. Double bunks, drive through maternity hospitals, discharge lorries to drive you home in and do all the discharge stuff with you and your baby right at your doorstep. I come up with this kind of stuff stone cold sober if I'm pushed. 

Staffing is also an issue and staff get assigned here and then there. Midwifery model of care services are the casualty of the maternity shuffle. They get dismantled to relocate staff. All of our freestanding midwife led units have fallen victim to this, ‘The pandemic’ providing the perfect scapegoat. But we *are* trying to establish continuity of carer services. It's proving difficult in a cohort of midwives who favour shift work over on-call work. If there was an attempt made to recruit for continuity teams at university level it hasn’t been successful.

And then there’s the current climate here in Northern Ireland - we are sporting the highest rates of everything when compared to elsewhere in the UK. Inductions of labour, caesarean sections and stillbirths. According to the latest report on stillbirth in the UK, the rate here in 2021 was 4.09 per 1000 births compared to 3.54 per 1000 births overall in the UK. Thankfully by far the most likely outcome is for a family to be spared the tragedy and pain of losing their baby regardless of where in the UK they happen to live. Stillbirth is unlikely but possible. It's important to also note that the weeks that parents are most likely to get swayed towards accepting interventions are also the weeks when the risk of stillbirth is significantly lower than previously in the pregnancy. The rate of 4.09 per 1000 describes the overall risk of stillbirth from 24 weeks onwards. Between 37 and 42 weeks the chance of this happening is 1.19 overall in the UK (I couldn't find the data for Northern Ireland) and yet late pregnancy loss is the number one reason there is a drive to induce labour when you have crossed the 40 week mark. Loosing a baby in labour is less likely again. In 2021, 0.25 out of 1000 families lost a baby in labour who had completed between 37 and 42 weeks of pregnancy in the UK and a further 0.66 out of 1000 babies of this gestational age passed away shortly after they were born.  

If you are reading this having lost your child at any stage in pregnancy or after, please know that I don't see you as a statistic, I see you as a bereaved parent with an extended family who is also grieving and I see you with love and compassion. The reason I am stating numbers specifically related to losing a child in labour or shortly after is that very often shoulder dystocia is the number one reason women are being told they need an induction of labour for a 'big baby'. These overall statistics capture babies who may have died from this particular complication. 

For you to decline an induction of labour or caesarean section in late pregnancy and to decide to trust in the process of birth instead is not such a far out choice if it feels right for you. The choice of induction of labour can be a reasonable choice, too, if it feels right for you. 

When it comes to why there is a higher rate of stillbirth in Northern Ireland, there may be many factors at play. Regardless of what the contributing factors may be, I am making the point that we have higher intervention rates compared to elsewhere in the UK but we also have higher rates of stillbirth. 

The induction of labour rate was consistently over 40% (sometimes closer to 50%)  in 2021 in the hospital I worked in compared to a national average of 34%. Our emergency caesarean rate is currently around 40% (marginally less in 2021) compared to a national average of around 25%. The overall caesarean section rate (emergency and planned combined) has been scraping 70% in places this year. 

Given the disadvantages of interfering to the individuals and to the service itself - families need to be in already crowded hospitals for longer through inductions of labour and caesarean sections - it beggars belief. The narrative that our interventions ‘save lives’ does not hold up to scrutiny. I think it is entirely reasonable to at least ask the question if the opposite may in fact be the case. 

Not all of the components that contribute to the experience of the women and families we serve are obvious at first sight when you move through maternity services. Policy makers, direction from the department of health, regional events, the pharmaceutical industry, bed availability, national events, coroner’s courts, the press; all of these shape public consciousness and therefore the attitudes of families and care providers alike. Routine practice is not always based on best available evidence, it is often based on opinion instead.

It takes strong midwifery leadership to represent midwifery models of care and that is what I think we are lacking these days. Leaders seem to be less prepared to stand up for midwifery than they used to be when I first started out. When I say ‘midwifery’ here, I mean the type of approach embodied by iconic midwives like Mary Cronk, Jane Evans, Dr Rachel Reed, Dr Sara Wickham and many many more. To me it looks as though midwifery leaders are more inclined to take direction from medical directors than they have ever been. This tendency is modelled by our royal colleges. The Royal College of Midwives and The Royal College of Obstetricians and Gynaecologists seem to be singing from the same hymn sheet and the tune seems to be set by those who embrace the risk based approaches inherent in industrial maternity models. That’s how interventions like routine symphysio-fundal height measurements have come to be implemented by midwives. Check out last week’s blog ‘Midwife Goldilocks And Her Measuring Tape’ to read what I make of this intervention.

It seems that many midwives are seeing birth as hazardous and precarious. Not so long ago a former colleague of mine suggested that telling women to trust the process of birth and to trust their bodies was spreading and supporting a ‘dangerous narrative’. There’s a clear distrust of birth physiology among midwives and it's not surprising. Physiological birth barely ever takes place in our maternity systems anymore. Most women have at least a membrane sweep.

Doulas who advocate for women who decide to decline routine interventions can find that they are seen as a hindrance by midwives trying to operate within policy and guidelines. I understand the apprehension because midwives are held accountable in a different way than doulas. Our Nursing and Midwifery Council has fully embraced the medical model, too. And, no, I don't think regulating doulas is the answer. Look where it has taken midwifery! Supporting physiology has fallen victim to ‘action bias’. Humans are generally biased towards doing something in an attempt to control the unfolding of important events. *And*  ‘doing what you could’ looks better in court than ‘doing nothing’ even if the evidence supports the decision and even if the woman chose to ‘do nothing’. (Check out Dr Sara Wickham speaking about this on the Down To Birth Podcast recently). 

Our collective experience is shaped by culture and there has been a very definite culture shift since I first set foot into midwifery school in 2005. Student midwives may never see an undisturbed birth during their entire training and that is far from ideal.

But its not all doom and gloom! 

There are a few beacons of light in maternity care in Northern Ireland. Those clients of mine who opt for homebirths, have the best experiences by far (and there's a team that clearly stands out from the rest). 

There are some amazing consultant midwives, too, I hear the same names repeated over and over by my clients. 

And, the Doulas of NI are in the process of training a group of new doulas! I hope that down the line the important contribution doulas can make, not only to a family’s journey through their pregnancies, births and early days of parenting a newborn, but also to guarding and witnessing birth physiology will get recognised. I hope that doulas can move from being tolerated to being respected by more and more members of the medical team. 

And we are getting a review of midwifery services in Northern Ireland. The review is being conducted by Professor Mary Renfrew. It is aimed at improving the situation for midwives and their clients. Let’s hope the recommendations Professor Renfrew makes will help maternity services overall. 

It’ll take time, the machine moves slowly.

The pieces of the puzzle continue to be moved. The next reshuffle in the hospital I used to work in is likely going to be the move to the new maternity building. Perhaps the extra space, the review, the extra birth pools and the genuine desire for positive change among many of my former colleagues will lead midwives back to trust.

Maybe we can find perspective and put this era of the highest intervention rate we have ever seen in Northern Ireland behind us.

Maybe this is our rock bottom.

Here's the link to the 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