TPM OCTOBER 2015

www.thepractisingmidwife.com The Practising MIDWIFE The best job in the world Volume 18 No 9 October 2015Women’s rights• Birth reflections service• Support for women with mental illness• Talking about obesity• GBS screening in Australia

* World’s first of its kind Pregnacare® trial published in British Journal of Nutrition Pregnacare® tablets shown to benefit the health of pregnant mums and their babies in major UK trial As widely reported in the national press, Vitabiotics Pregnacare® tablets have been shown to benefit pregnant women and their babies in a major UK trial1, carried out by the Institute of Brain Chemistry and Human Nutrition at London Metropolitan University and the Homerton University Hospital. “TO THE BEST OF OUR KNOWLEDGE, THIS IS THE FIRST REPORTING OF SUCH FINDINGS OF ANY STUDY PERFORMED IN THE UK OR THE DEVELOPING WORLD.” The lead researcher, Dr Louise Brough, commented: “This research highlights the concerning fact that a number of women even  in the developed world, are lacking in important nutrients during pregnancy.  It  also  demonstrates  the  benefit  of  taking  a  multiple  micronutrient  supplement  such  as  Pregnacare®.  It  is  especially  important  to  have  good  nutrient  levels  during  early  pregnancy  as  this  is  a  critical  time  for  development of the foetus. Pregnacare®, as used in the study, was shown to  improve nutrient status relative to placebo.” By the third trimester, mothers who took Pregnacare® were also found to have, relative to placebo, increased levels of iron, vitamin B1 and vitamin D3. Specially formulated by experts, Pregnacare® replaces a usual multivitamin and provides a careful balance of 19 essential vitamins and minerals. It includes the recommended 10mcg vitamin D and also 400mcg folic acid which contributes to maternal tissue growth during pregnancy. Plus iron which contributes to normal red blood cell formation and normal function of the immune system. Important: some pregnancy formulas do not include the exact 10mcg vitamin D,as recommended by the Department of Health for all pregnant and breast-feeding women. Before Conception Original Plus Dual Pack Breast-feedingADPRGTRADEP15-06-15E Pregnacare® is the prenatal multivitamin brand midwives * recommend most†, so you can recommend it with confidence. 1 L Brough, GA Rees, MA Crawford, RH Morton, EK Dorman (2010) Br J Nutr. 2010 Aug;104(3):437-45 † Based on a survey of 1000 midwives. For more information on this research, please visit www.pregnacare.com/mostrecommended * Nielsen GB ScanTrack Total Coverage Value and Unit Sales 52 w/e 25th April 2015. www.pregnacare.com

The ‘rights' battle The Practising MIDWIFE The best job in the worldC hoice is a cornerstone of women’s rights. Whilst childbearing women In this issue are promised choice, this is often limited to the confines of large consultant-led units. Women who understand that choice goes 3 EDITORIALbeyond this can find themselves having to battle for their right to choose. 5 VIEWPOINT Midwives supporting women’s rightsThis month TPM would like to encourage a review of some women’s rights Rebecca Schillerissues regarding childbearing experiences and midwifery practice. Engaging 6 NEWSwith the concept of women’s rights enables us, as midwives, to keep in mind 10 Reflection of a birth reflections midwife Meg Cooper describes running a birth reflections service in Bathour duty of care to the woman and her family; which can represent a conflict 14 ADVANCING PRACTICE Reflections on human rights as awith our professional duty to the service, our employer and regulatory body. reality for women and midwives Jo Murphy-Lawless reflects on the impact of human rights legislation and practiceAs a woman’s advocate, the midwife is ideally placed to be ‘with-woman’, 18 Mental illness in pregnancy: midwives supporting womento ensure her choices are informed and fully supported. Certainly, it is a woman’s and safeguarding babies Sharon Humberstone advocates team working for health professionals working with womenright to be cared for by midwives with appropriate education, registration and with mental ill-health and their babiesaccess to support and relevant resources. As the global push for more midwives 21 To stop walking on egg shells Stevie Walsh and Gillian Swinscoe describe a project to develop resources to facilitatecontinues, we must address the compassionate and effective midwifery care for pregnant women with high BMIongoing challenges and threats that 26 Antenatal GBS screening: an Australian perspectivemidwives face in their quest to offer Danielle Clack considers the challenges of facilitating informed choice regarding GBS screening in Australiacare tailored to each woman’s need. 30 Why women stop breastfeeding in the early days DeborahWhilst research evidence and Sharp and Francesca Entwistle make use of audit to understand why mothers stop breastfeeding exclusivelyinternational policy advocate for 34 Providing hope: midwifery teaching in Bangladesh Midwifemidwifery-led care, there continues Anna Kent travelled to Hope Hospital in Bangladesh, where she experienced teaching clinical skills to student midwivesto be criticism and scapegoating of 37 Women’s lived experiences of domestic violence duringmidwives and midwifery practice pregnancy Part 2 Kathleen Baird considers the role that midwives can play when there is a positive disclosure(Edwards et al 2011), affecting Anna Byrom, Editor 41 WHAT ABOUT NEXT TIME? I can be a midwife! Sarahmothers, babies and their families, Haddrell reflects on a very positive experience of using her knowledge and intuition to recognise a potentially seriousas midwives become fearful and increasingly ‘pressured’ to prioritise condition in a pregnant womanstandardised care pathways over individual women’s choice. 43 NEW! MIDWIFERY BASICS 1. Success at last! Kerry Taylor, Frances Webster-Benwell and Alice Tindall introduce theOur ‘rights’ battle then is to ‘avoid a rigid adherence to guidelines and 15th series of Midwifery basics on preceptorshipprotocols…over a response to the wishes and needs of individual women, 47 THINKING OUTSIDE THE BOX Pondering placentophagy Part 1 Sara Wickham looks at a recent systematic review andwhenever and wherever those women’s choices are not the same as considers the issues relating to placenta consumptionmanagement-defined ‘right’ choices’ (Edwards et al 2011: 5). 49 PROFESSIONAL DEVELOPMENTEdwards N, Murphy-Lawless J, Kirkham M et al (2011). ‘Attacks on midwives, 50 LAST WORD Fight for rights: a mother’s perspective Michelle Quashie asks why she had to fight for her right to aattacks on women’s choices’. AIMS Jour, 23(3). physiological birth Thanks to Anna Kent for this month’s cover picture: Providing hope: midwifery teaching in Bangladesh p34 The Practising Midwife | October 2015 3

Editorial advisory board CONTACT: 020 8313 9617 [email protected] Birt BSc (Hons) Midwife, Dudley University of South Wales Correspondence: 66 Siward Road, Bromley BR2 9JZGroup of Hospitals Foundation Trust Rebecca Knapp BSc (Hons) Midwife, Editor: Anna Byrom, BSc, PGCert, RM, SeniorDeborah Caine BSc, Dip HE Midwifery, Lancashire Teaching Hospitals NHS Midwifery Lecturer, University of Central LancashirePGCert (HE and supervision of midwives), Foundation Trust [email protected], RM Midwife, Lecturer and PhDstudent, University of East Anglia and SoM Joyce Marshall PhD, MPH, BSc (Hons),RM, Managing Editor: Laura Yeates RN, FHEA, PGCAP Senior Lecturer in [email protected] Crowther PhD, MSc, BSc (Hons), Midwifery, University of Huddersfield (editorial/author submissions)RM, Senior Lecturer (AUT UniversityAuckland NZ) and rural locum caseload Rachel McKeon-Clark LLB (Hons) News Editor: Mandy Gallowaymidwife BSc (Hons) RM Nurse Advisor, NHS Direct [email protected], 020 8313 9617Déirdre Daly MSc, PGDipEd, BSc (Hons), Mandy Renton RGN, RM, MSc Chief Advertising Manager: Margaret FloateRM, DipMid, RGN Lecturer in Midwifery, Nurse, Cambridgeshire Community [email protected], 01483 824094Trinity College, Dublin Services NHS Trust Publisher: Ian Heslop [email protected] Green MA, Bsc (Hons), BA (Hons), Katrina Rigby RM, MA, BA (Hons) SeniorDipHe, RM Midwife, Home birth team, Research Midwife and Team Leader, Facebook is a registeredBirmingham Women’s Hospital Lancashire Teaching Hospitals NHS trademark of Facebook, Inc. 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The views expressed in Viewpoint are those of the author and do notnecessarily reflect those of the editorial board of The Practising MidwifeViewpoint Rebecca SchillerMidwives supporting women’s rightsW omen’s rights activists are midwives and the women they care for are Education is key everywhere. Some lobby hard for driving it forward, using the conceptual and policy change, some work long legal framework of human rights to improve Dignity in childbirth education, designedhours in fluorescent-lit refuges supporting the world of childbirth; focusing us once again specifically for midwives and doctors, iswomen fleeing domestic abuse, others use their on the impact of this vulnerable time on increasingly in demand. A midwives’ guide tolegal expertise to counsel those whom no-one individual women. human rights (a collaborative project betweenelse is interested in. The more public-facing several organisations) is being launched thismake speeches, write books and deliver lectures. It is unsurprising, then, that this rights- autumn. It aims to empower and inspire theTogether they make the subtle changes that based approach is progressing hand in hand midwifery community to understand how thepublicly and privately progress the women’s with a feminist reawakening within the human rights legal framework impacts on theirrights movement. I’m grateful to know a few. midwifery community (Walsh et al 2015). work and how it can be used as a positive tool; Midwifery has struggled to find acceptance both for professionals and for women. But there is another group working hard for and congruence with the broader feministwomen who often get overlooked. Happily they project at times, and birth has not consistently Midwives as activistsnumber in their 10s of thousands here in the UK. focused large on the agenda of the reproductiveThey get up early in the mornings and spend rights movement. Increasingly, though, across The quiet work of midwifery, that which goestheir days and nights at the grassroots of professions, disciplines and campaign groups, on privately in the birth room, on the labourwomen’s rights. Advocating. Making options there is a shared recognition that if we can’t ward phone line and in research offices, isopen up where before there were none. They get it right in birth, the impact spills over into activism. Midwives are perfectly placed to bringoffer kindness and care in the form of tea, more robustly defended areas of the women’s human dignity and respect into the lives ofconfident eyes and a flannel on the brow. Not rights movement. often-vulnerable women. It’s time to startjust listening but really hearing. Cutting through framing their work in this way. tpma difficult system as best they can to make The need for respectspace for what they’ve heard. Treating each Rebecca Schiller is co-chair of Birthrightswoman as an individual, not an inconvenience. Inspirational work is being done around the UK charity and a doula in Ramsgate under a more explicit rights-banner. A 2010 CareHuman rights in childbirth Quality Commission (CQC) report into References maternity care at Barking, Havering andThey work quietly, often without recognition, Redbridge University Hospitals NHS Trust found Birthrights (2013). Dignity in childbirth: projects andand increasingly inside a system at odds with the all-too-common connection between perspectives, London: Birthrights.their mission. Many wouldn’t frame their work disrespectful and dangerous care (CQC 2011). CQC (2011). Maternity care at Barking, Havering andas women’s rights work; but for me, they are at Part of the remedy, led by midwife Felicity Redbridge University Hospitals NHS Trust, Newcastlethe centre. These activists are midwives and, Ukoko, has been the embedding of the White upon Tyne: CQC.given the right tools, they have the power to Ribbon Alliance’s (WRA) Respectful maternity Walsh D, Christianson M and Stewart M (2015). ‘Whymake great change. care charter (WRA 2014) in the mandatory midwives should be feminists’. MIDIRS Midwifery education of midwives and the obstetric team, Digest, 25(2): 154–160. The human rights in childbirth movement is to positive effect (Birthrights 2013). WRA (2014). Respectful maternity care - White Ribbongrowing in reach and recognition. Increasingly Alliance, Washington DC: WRA. The Practising Midwife | October 2015 5

News analysisMidwives must act to care for asylum seekersThe current European migrant Pregnant women who have been refused touch with ‘the authorities’ – representativescrisis has given added urgency to asylum faced a number of challenges trying to of the Government.”the Royal College of Midwives’ get the care they need, and healthcare staff(RCM) campaign to end the also face dilemmas in caring for these women While there was a clear need to lobby fordetention of pregnant asylum as they try to negotiate confusing and improvements to legislation, Ms Warwickseekers and to ensure that all obstructive bureaucracy, Ms Warwick said. urged midwives “to take direct action topregnant women receive ensure that women have the best chance ofappropriate care, regardless of “Immigration was the hottest topic and the getting the support to which they are entitled.their immigration status presentation of the impact of immigration was Any pregnant woman should receive a high mainly negative. The Government has standard of maternity care regardless of her Midwives have an obligation to ensure that responded to that rhetoric, with legislative country of origin or her status in the UK.pregnant women who are migrants or refused changes designed to limit the state’s supportasylum seekers have access to health and social for immigrants.” “Midwives have an obligation to help thesecare, information and support. women and simply must not allow themselves She stressed that pregnant refused asylum to be put in the position of ‘the authorities’. The This was the key message from Cathy seekers “are some of the most vulnerable NMC Code is clear about their duty to act inWarwick, chief executive of the RCM in her people in our society, and that those that partnership with those receiving care, helpingaddress marking the launch of the Maternity remain in the UK have no status, few rights, them to access relevant health and social care,Alliance’s briefing document, Housing and few resources and little reason to remain in information and support when they need it.”financial support for pregnant women whohave been refused asylum in September at a End detention of pregnantseminar entitled Pregnant and destitute. women, says RCM And in her blog, posted the same day, MsWarwick said: “The current refugee crisis is, I The Royal College of Midwives (RCM) has puts their unborn baby at risk as well. Theam certain, troubling many, many midwives. renewed calls to end the detention of pregnant women detained at Yarl’s Wood have a right toThe RCM shares your concerns and will be women following a damning report by the be cared for in a dignified and respectful way,continuing our long standing efforts to ensure Chief Inspector of Prisons on the Yarl’s Wood just like any other pregnant woman.all pregnant women and their babies, Immigration Removal Centre in Bedfordshire.regardless of country of origin, are treated “Home office guidance states that pregnantwith the humanity they deserve and receive The report found the centre to be a “place women should only be detained in exceptionalhigh quality maternity care. of national concern”, where conditions have circumstances and this guidance has not been deteriorated significantly in the two years followed. The centre was home to 99 pregnant “Achieving this aim is far more likely if the since the last inspection. Health care had women in 2014 and this is completelyRCM works with other organisations leading in declined most seriously, with severe staff unacceptable.this field.” shortages, poor access and quality of care and delays in giving medication. “Yarl’s Wood and other immigration Ms Warwick said it was “salutory listening removal centres are unsafe for manyto the 90 midwives attending and hearing Louise Silverton, RCM director for vulnerable detainees including pregnanttheir struggles to provide high quality care in midwifery said: “Once again the RCM asks the women and Nick Hardwick’s latest reportthe midst of faceless bureaucracy and complex Home Office to end the detention of pregnant proves this. Pregnant women are onlyrules and regulations. Often the only way to women at Yarl’s Wood now. supposed to be detained if their removal isprevent a mother and her newborn baby imminent and, at Yarls Wood, this is not thesleeping on the streets is to invoke the “Some pregnant women have reported case, which is most concerning.”Children's Act and even that is often receiving inadequate health care which clearlyunwieldy.”6 The Practising Midwife | October 2015

PROMOTIONAL ADVERTORIAL EXPLORING THE SCIENCE OF THE SENSES™ IN HEALTHY BABY DEVELOPMENTA strong body of existing and emerging research suggests thatmultisensory stimulation—or the concurrent stimulation of tactile,olfactory, auditory, and/or visual stimuli—benefits the social, emotional,cognitive, and physical development of babies.A baby’s brain creates up to 1.8 million new Multisensory stimulation—what a babysynaptic connections per second, and a feels, smells, hears, and sees at everybaby’s experiences will determine which moment—helps promote the long-termsynapses will be preserved.1 Stimulation survival of synaptic connections duringis essential early in development; within brain development.1the first 3 years of life, there is rapiddevelopment of most of the brain’s neural their baby’s ability to learn, think, love, quiet activities is a scientifically supported andpathways supporting communication, and grow. A simple ritual of bath time and simple behavioural intervention for improvedunderstanding, social development, and massage is an ideal opportunity to create a quality and quantity of sleep in babies.5emotional well-being.2 multisensory experience. Bath time provides an opportunity for increased skin-to-skin When bath time is part of an everyday Tactile contact (touch stimulation)7 and direct eye ritual, the benefits have been shown to help Stimulation contact,8 as well as the introduction of new generate a predictable and less stressful textures, sights, sounds, and smells that can environment for the baby and parents.5 Olfactory Bath Time Visual stimulate a baby’s tactile, visual, olfactory, and Stimulation Ritual Stimulation auditory senses. The sense of smell, in Bath time provides an ideal particular, is directly linked to emotional opportunity to create an enriched Auditory memory,9 a mother’s scent can help soothe multisensory experience. Stimulation a crying baby;10 while a pleasant scent during bath time is shown to promote relaxation in Although science has made advances inStimulating multiple senses sends signals both baby and parent.7 understanding the long-term benefits ofto the brain that strengthen the neural multisensory stimulation, there is more to beprocesses for learning. Through consistent A ritual that includes a warm bath followed by done to translate this research into everydaymultisensory experiences, research shows massage with a gentle skin moisturiser and practice. By encouraging parents to viewthat babies gain healthy developmental everyday rituals, such as bath time and massage,benefits, such as reduced stress in healthy Making Bath Time Part of a Ritual as opportunities for multisensory stimulation,and preterm infants3,4 and better quality and Improves Sleep5 experiences can be created that can contributequantity of sleep in healthy babies,5 as well to a lifetime of healthy development.as improved weight gain which led to earlier % Change vs Baseline 10%hospital discharge in preterm infants.6 6.2% For more advice and information, pleaseEveryday experiences in a baby’s life can contact [email protected] and stimulate his or her senses and 5% 3%provide parents an opportunity to nurture BROUGHT TO YOU BY 0% 0% -2% -1% -5% -10% Week 2 Week 3 Baseline Control Group Product based 3-step, before-bed routine Adapted from Mindell, et al. 2009This promotional advertorial was developed in collaboration with Dr Charles Spence, Head of Crossmodal ResearchLaboratory at the University of Oxford and sponsored by JOHNSON & JOHNSON. Prof. Spence received a fee forparticipation in this initiative.References:1. Eliot L. What’s Going On in There? How the Brain and Mind Develop in the First Five Years of Life. New York, NY: Bantam Books; 1999. 2. UNICEF/World Health Organization. Integrating Early Childhood Development (ECD)Activities Into Nutrition Programmes in Emergencies. Why, What and How [guidance note]. 2014:1-16. 3. Hernandez-Reif M, Diego M, Field T. Preterm infants show reduced stress behaviors and activity after 5 days of massagetherapy. Infant Behav Dev. 2007;30(4):557-561. 4. White-Traut RC, Schwertz D, McFarlin B, Kogan J. Salivary cortisol and behavioral state responses of healthy newborn infants to tactile-only and multisensory interventions.J Obstet Gynecol Neonatal Nurs. 2009;38:22-34. 5. Mindell JA, Telofski LS, Wiegand B, Kurtz ES. A nightly bedtime routine: impact on sleep in young children and maternal mood. Sleep. 2009;32(5):599-606. 6. White-TrautRC, Nelson MN, Silvestri JM, et al. Effect of auditory, tactile, visual, and vestibular intervention on length of stay, alertness, and feeding progression in preterm infants. Dev Med Child Neurol. 2002;44:91-97. 7. Field T, CullenC, Largie S, Diego M, Schanberg S, Kuhn C. Lavender bath oil reduces stress and crying and enhances sleep in very young infants. Early Hum Dev. 2008;84(6):399-401. 8. Farroni T, Csibra G, Simion F, Johnson MH. Eyecontact detection in humans from birth. Proc Natl Acad Sci U S A. 2002;99(14):9602-9605. 9. Herz RS. A naturalistic analysis of autobiographical memories triggered by olfactory visual and auditory stimuli. Chem Senses.2004;29(3):217-224. 10. Sullivan RM, Toubas P. Clinical usefulness of maternal odor in newborns: soothing and feeding preparatory responses. Biol Neonate. 1998;74(6):402-408.UK/JOB/15-4475 ©Johnson & Johnson Consumer Companies, Inc. 2015

NewsWarning on changes to registration renewalThe Nursing and Midwifery Council spring 2016, we are urging nurses and midwives and midwives found revalidation more(NMC) is urging all midwives to to take care to maintain their registration. straightforward than they expected, and thatkeep on top of their registration as the requirements built on things they alreadynew rules come into force later this “From November this year there will be no do in their day-to-day practice. The pilot gaveyear, or risk being barred opportunity for registrants to submit their us valuable insight and feedback on exactly documentation or pay their fee after their how we can improve the guidance for nurses Previously, members who failed to renew registration expiry date. and midwives so that every aspect oftheir registration (also known as annual revalidation, and its relation to the otherretention) before it expired could take “Going forward from then, they must have requirements, is more fully explained.”advantage of an administrative window that renewed (and retained) registration beforeallowed late submissions by couple of days. their due date or their registration will lapse.” Preparing for revalidation: I Sign up to NMC online – revalidation will However, from November anyone who Midwives have also been urged to make sureallows their registration to lapse will be taken that they start preparing for revalidation well all be done online, so it is essential to have anoff the register immediately. There is no longer ahead of its proposed introduction in April 2016. account, and this will show when the individual’sa grace period for late payment. Readmission revalidation date falls, so they know how longwill take two-six weeks. Continuing to work as The NMC council was due to meet on 8th they have to meet the requirements.a midwife while not on the NMC register is October to decide whether or not the fourillegal. It could result in suspension from work countries of the UK – and indeed, the NMC I Be aware that revalidation informationand difficulties with employers. itself – were ready to roll out revalidation, has to be submitted prior to the registrant’s after it was piloted earlier this year across 19 renewal date. Alison Sansome, NMC director of sites covering a variety of health care settings.registration, said: “In preparation for the I Read the provisional guidance, and lookintroduction of payment-by-instalment in Dr Katerina Kolyva, director of continued out for updates. practice at the NMC, said: “Initial findings from the evaluation show that many nursesShortage of midwives is the reason for highagency staff costs, says RCMHealth service regulator, Monitor, meantime, the existing workforce is the key... take on referrals from other trusts. Thehas warned NHS trusts to leave NHS trusts should authorise paying overtime Government has pledged an extra £8b of‘no stone unturned in a bid to find to existing staff...rather than spending more funding for the NHS by 2020. This is clearlygreater savings’ and told them to money to get staff from an agency.” money that is needed now, not in five yearsfill vacancies ‘only where essential.’ when it will be much too late. Clearly...trusts In a letter to NHS trusts, Monitor’s chief cannot wait that long for this extra money.” The RCM has expressed support for bids to executive, David Bennett, wrote: “As you know,control spending on agency staff, but points the NHS is facing an almost unprecedented Mr Skewes added: “One of the reasons forout that the current high level of expenditure financial challenge this year.” the spiralling cost of agency spending isis because of underlying staff shortages. Jon because of [the Government’s] ongoing paySkewes, director of policy, employment Monitor also suggests diverting patients policy. The cost of paying huge fees torelations and communications at the RCM ‘elsewhere’ when units experience staff agencies dwarfs the cost of paying a fair paysaid: “There is a shortage of 2,600 midwives in shortages, but Louise Silverton, director of rise to hard working midwives.England, so the solution to reducing agency midwifery at the RCM said: “The reality is thatstaffing is to recruit more midwives. In the for maternity services it is often the case that “We need an effective and sustainable neighbouring units don’t have the capacity to solution, not a sticking plaster.”8 The Practising Midwife | October 2015

NewsBosses hinder pregnant Midwives act to protectwomen from accessing their right to strikeantenatal care The Royal College of Midwives (RCM) has launched a campaign pack for its members in support of theA new report on discrimination against pregnant TUC’s Protect the right to strike campaign. Thewomen in the workplace has revealed that one in 10 campaign is calling on the Government to rethink itspregnant women is being discouraged from attending plans on the Trade Union Billantenatal appointments The RCM believes the Bill fundamentally undermines midwives’,The report, Pregnancy and maternity-related discrimination and maternity support workers’ and other workers’ right to protest againstdisadvantage from the Equality and Human Rights Commission and the unfair changes to pay, pensions and working conditions. It also affectsDepartment for Business Innovation and Skills estimates that almost unions’ ability to prevent job losses and cuts to services.half (45 per cent) of the 440,000 pregnant women in Great Britain Among the Bill’s proposals are plans to use agency staff to replaceexperienced some form of disadvantage at work, simply for being striking workers, and union regulation plans that threaten unionpregnant or taking maternity leave. It is also estimated that 30,000 (7 members’ privacy.per cent) lost their jobs. Cathy Warwick, chief executive of the RCM, said: “Frontline staffThe research found that: like midwives and maternity support workers are the most valuableI Around one in nine mothers (11 per cent) claimed they were either asset the NHS has. They should be listened to, not silenced, becausedismissed, made compulsorily redundant when workmates were not, or that is exactly what this Bill is aiming to do.treated so poorly they felt they had to leave their job: if scaled up to “When midwives took industrial action last year it was the first timethe general population this could mean as many as 54,000 mothers a in the RCM’s 134-year history. It was a last resort after a great deal ofyear consideration and it was a decision that was not taken lightly.I One in five mothers said they had experienced harassment or “I am deeply concerned that this Bill will unjustifiably restrict thenegative comments related to pregnancy or flexible working from their right to strike in the UK. This will undermine workers’ ability to organiseemployer or colleagues – equivalent to 100,000 mothers a year collectively to protect their jobs, their livelihoods and the quality ofI Ten per cent of mothers said their employer discouraged them their working conditions. Protecting working conditions is importantfrom attending antenatal appointments – because midwives’ and maternity support workers’equivalent to 53,000 mothers a year. working conditions are women’s birthing conditions.”Cathy Warwick, chief executive of the Jon Skewes, the RCM’s director of policy,Royal College of Midwives said: “It is very employment relations and communications said: “Wedisturbing that the rates of discrimination believe the Trade Union Bill will fundamentally damageagainst pregnant women are so high. It is employment relations and make it more difficult tovery worrying that the cases of women resolve disputes.being denied time off to attend antenatal “By imposing unnecessary and disproportionatecare are increasing. Missing antenatal rules, the Government is attempting to paint strikingappointments can increase the risk of workers as the villains. Politicians should be working tosmaller babies, premature babies, improve employment relations and helping both sidesmiscarriages and still birth.” resolve the dispute before it gets to the stage of takingThe RCM is calling on the Government industrial action.”to act to ensure pregnant women are not The campaign pack can be viewed and downloadeddenied their rights nor discriminated from the RCM website at www.rcm.org.uk/protect-the-against. Cathy Warwick, chief executive of the RCM right-to-strike The Practising Midwife | October 2015 9

Meg Cooper describes Reflection of a birth reflections midwiferunning a birth reflectionsservice in Bath SUMMARY: Supporting a woman’s emotional recovery following what can sometimes be a traumatic event is becoming an important part of postnatal care. That simple question, “How was the birth?” can be the first step in allowing a woman to acknowledge and voice her innermost anxieties around the birth of her baby, and put her on the right path towards feeling better about it, if need be. The birth reflections service has been running in our area for almost six years and its purpose is two fold: firstly it provides women with a safe environment in which to talk about their labour and birth, where they can become better informed about the birth and where they can express themselves freely. Secondly, it provides first hand feedback for the maternity service about the care that’s been given, enabling us to change practice for the better. Keywords Emotional recovery, birth trauma, anxiety, birth reflections service Author Meg Cooper, community midwife in Chippenham and one of the birth reflections midwives at Royal United Hospitals Bath NHS Foundation Trust By talking to a R esearch by Mercer et al (2012) talk to the women about the service, atmidwife who can offer indicates that women who reported a different stages of pregnancy and, postnatally, negative birth experience felt betrayed every woman is given a business card with a a professionally and unable to make sense of events for many contact phone number to enable her to book trained listening ear years afterwards, and said that the opportunity an appointment. As a result of all this and empathy, the to discuss their birth experience would have promotion, the service is very popular, with a emotional healing been welcomed. This is certainly in line with waiting time of around six-eight weeks for an process can begin feedback from women who attend birth appointment. reflections appointments even years after they’ve given birth. Mercer suggests that by How the session runs >> talking to a midwife who can offer a professionally trained listening ear and The service runs weekly, mainly from the empathy, the emotional healing process can consultant unit, with a satellite clinic in begin. operation every six-eight weeks from one of the local stand-alone birthing centres. This In Bath, getting the message across that the gives the women a choice of where they are service is available is key to its success. It is seen, especially if they don’t actually want to advertised on posters in antenatal clinics, return to the place where they gave birth. In children’s centres and GPs’ surgeries. Midwives addition to face-to-face meetings, we also10 The Practising Midwife | October 2015

VITAMINS & NUTRIENTS WHEN BREASTFEEDINGMaking it simple The powerfor mums of maternal nutrition whilstWhen baby arrives, mums often breastfeedingfeel overwhelmed and tired.They focus on caring for their Vitamin D helps buildbaby, but too often they do not strong teeth and bonesfocus on caring for themselves. in mum and baby4Educating mums about theimportance of key nutrients when Omega-3 (DHA)breastfeeding, and giving simple, contributes to normalpractical advice about how to get brain and eye developmentthem, is one of the ways of breastfed infants5PLGZLYHVFDQSRVLWLYHO\LQƮXHQFH {{the health and wellbeing of Vitamins B2, B6 & Folic acidmums and their babies. contributes to the reduction of tiredness6,7,8 Iron & Zinc contributes to the normal function of the immune system9,10Despite Department of Health recommendation of 10µg vitamin D during breastfeeding,mums are not supplementing dailyO Less than halfRIZRPHQWDNHVXSSOHPHQWVZKLOVWEUHDVWIHHGLQJ1O A third of women are not aware of the government recommendation of vitamin D during breastfeeding2Why don’t mums take supplements?They are confused. Less than a third of pregnant They forget. Approximately a third of women They make them sick.and breastfeeding mums were aware of the admitted to often forgetting or only sometimesrecommendation to take additional vitamin D taking their daily recommended supplements A third of women saythroughout pregnancy and breastfeeding.2 supplements have made during pregnancy and breastfeeding.2 them ill in the past.3nutrimum cereal bars replace mums’ daily tablet supplement, making it easy for them to fortify their diet in pregnancyand breastfeeding every day. One nutrimum bar (40g) per day helps mum meet Department of Health recommendations,providing 100% RNI of folic acid and vitamin D during pregnancy and 100% RNI of vitamin D during breastfeeding,as well as other key nutrients such as Omega-3 (DHA), iodine and iron.11The nutrimum pregnancy The nutrimum breastfeeding range provides continuedUDQJHKDVEHHQVSHFLƬFDOO\ nutritional support for mum and baby with 10 key nutrients.developed to provide 5 In addition to those included in the pregnancy range, it alsoimportant nutrients women FRQWDLQVYLWDPLQV%1DQGELRWLQ%WRFRQWULEXWHWRQRUPDOneed during pregnancy. functioning of the nervous system12,13 DQGYLWDPLQV%2DQG%(DFKFHUHDOEDUFRQWDLQV to contribute to the reduction of tiredness and fatigue400µg folic acid, 10µg, DVZHOODV]LQFWRFRQWULEXWHWRQRUPDOIXQFWLRQLQJRIWKHYLWDPLQ'RPHJD'+$ immune system.14iron and iodine. eln.nutricia.co.uk/midwife1References'DQRQH1XWULFLD(DUO\/LIH1XWULWLRQPDUNHWUHVHDUFK&RQGXFWHGE\0DUNHWLQJ6FLHQFHV2FWREHU1XWULPXPVXUYH\RISUHJQDQWDQGEUHDVWIHHGLQJZRPHQ-XO\'DWDRQƬOH2QH3ROO(DUO\QXWULWLRQVXUYH\VRIPRWKHUVPRWKHUVWREHDQGKHDOWKFDUHSURIHVVLRQDOV$XJXVW'DWDRQƬOH$KPHG6))UDQH\&HWDO5HFHQWWUHQGVDQGFOLQLFDOIHDWXUHVRIFKLOGKRRGYLWDPLQ'GHƬFLHQF\SUHVHQWLQJWRDFKLOGUHQoVKRVSLWDOLQ*ODVJRZ$UFK'LV&KLOG()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWR'+$()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWRULERƮDYLQYLWDPLQ%()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWRYLWDPLQ%()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWRIRODWH()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIDKHDOWKFODLPUHODWHGWRLURQ()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWR]LQF()6$-RXUQDOQXWULPXP3URGXFWV>2QOLQH@$FFHVVHG$XJXVW()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWRWKLDPLQH()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWRELRWLQ()6$-RXUQDO()6$3DQHORQ'LHWHWLF3URGXFWV1XWULWLRQDQG$OOHUJLHV6FLHQWLƬF2SLQLRQRQWKHVXEVWDQWLDWLRQRIKHDOWKFODLPVUHODWHGWR]LQF()6$-RXUQDO

Postnatal reflectionsspeak to women on the telephone, particularly helping women to transform subjective mental of staff who is recognised positively during aif they are desperate and feel they can’t wait images into objective facts; this, in turn, session is sent a letter of congratulations andfor an appointment, or if they are due to give promotes emotional recovery which is, of any areas of poor practice are fed backbirth again imminently. On occasion we see course, as important as physical recovery. through line management to be addressed onwomen in their own homes, in particular those an individual level.who are house-bound or too traumatised to Learning outcomesenter the hospital setting. Interestingly, it’s not always the cases one Information gathered from the birth would imagine that present for a birthTiming reflections session. Storksen et al (2013) reflections sessions is anonymised and fed back suggest there isn’t always a direct link betweenWe have seen women from as early as one to staff via a quarterly newsletter, to highlight obstetric emergency, negative birth experienceweek postnatally, although the typical time is what is done well and where improvements in and fear of future childbirth and this has oftenfrom six months to two years after the birth. care could be made. In addition, any member been the case with the women we haveAt the other extreme, one woman talked about supported through the birth reflections service.a birth that had occurred 18 years previously. Early discussion It is not unusual for a woman who, on paper,Often it is when women are in their second around subjective birth appears to have had the most straightforwardpregnancy that the issues from the first birth experiences may help birth, to be traumatised by the whole event.are brought to the fore, and that they need to alleviate the onset This may be due to feeling out of control; tothis service. Appointments last around an hour, being shocked by the level of pain; or becauseduring which the birth story is pieced together of PTS symptoms the midwife said something that felt unkind;to make a complete picture. or the midwife didn’t speak at all; maybe the mother felt no bond with the baby; or wasWriting a journal simply not expecting to feel the way she did. The list is endless, but the important thing isDuring the session, we discuss the benefits of that she feels listened to and supported in herreflective ‘journaling’, and this has proved to road to achieving a good emotional recoverybe a good way of helping women to express from her birth experience.the issues and helping them to achieve a betterlevel of emotional recovery than by merely It is fair to say that the sharing oftalking. information is usually very empowering for the woman, helping her to regain control andDiffering levels of support enabling her to take back ownership of her experience. Sometimes during an emergency itSome women attend the sessions with just a is difficult to explain what is happening andfew previously unanswered questions and some why, but most women understand this and dohave symptoms of post-traumatic stress (PTS). not expect a detailed explanation at the time.During the course of the session it soon However, even a few kind words go a long waybecomes evident if further support is needed and can make the difference between thein the form of professional counselling and we whole event feeling positive or negative.would refer them back to the GP for that. Astudy by Garthus-Niegel et al (2013) suggests Women value the support of midwives, andthat early discussion around subjective birth research by Andrews (2004) suggests that,experiences may help to alleviate the onset of although knowing the midwife in advance ofPTS symptoms. The evidence shows that the labour was seen as a bonus, it was actuallyprocess of listening and using labour notes to their manner during labour which was deemedexplain the events of labour may contribute to to be more important. Women just want to be12 The Practising Midwife | October 2015

Postnatal reflectionstold what’s happening to them and for in highlighting how the use of terminology awareness of complications that could occurhealthcare professionals to be kind during the during labour and birth can be misinterpreted during the birthing process.process, which seems like a reasonable request. and can cause anxiety: ConclusionWhat about birth partners? “I heard the midwife say that the baby was flat; I was scared to look as couldn’t bear to The birth reflections service is invaluable in ourSometimes we forget about the impact of see my baby looking deformed” trust and has helped hundreds of women tobirth on fathers and other birth partners. It feel better about their birth experience. Itcan be a tough task to watch someone you In addition to what is said in front of the facilitates empowerment, emotional healinglove endure what can be deemed as a parents, written documentation is equally and acceptance, and helps the women in ourtorturous event and feel completely helpless in important, as people may feel offended or care to move on mentally and emotionally. Formaking things better for them. One father upset by what has been written in the notes… the cost of one midwife, one day a week, itmade the following comment about his seems like a small investment for a very bigexperience in the labour room: “I was trying to stay calm but the notes return, is very easily implemented into the say I was OTT” maternity service and very quickly becomes “The midwife never looked at me or spoke something to be proud of. tpm to me…I felt invisible at my son’s birth” Managing expectation Meg Cooper is a community midwife in And another, whose wife had It would appear that antenatal perceptions of Chippenham and one of the birth reflectionshaemorrhaged after the birth, said: what to expect during labour and birth, midwives at Royal United Hospitals Bath NHS together with levels of fear, are shown to have Foundation Trust “I felt like I was taking part in an episode a direct impact on the birth experience. of Casualty: the midwife pressed the Elvander et al (2013) demonstrate through References buzzer and within seconds the room filled their study of over 3,000 participants, that up…I had no idea what was going on” women with high levels of fear antenatally Andrews A (2004). ‘Home birth experience 2: had more negative birth experiences and were births/postnatal reflections’. Brit Jour Midwif, 12(9): Studies show that with the right birth more adversely affected by instrumental and 552-557.environment, positive staff attitude and willing operative births than those with low levels of Elvander C, Cnattingius S and Kjerulff K (2013). ‘Birthpartners, it is possible to involve men positively fear. Therefore, care and education in the experience in women with low, intermediate or highin the birth process. Midwives are well placed antenatal period is paramount in preparing levels of fear: findings from the first baby study’. Birth:and indeed have a duty to ensure that men are women for what is likely to happen in labour Iss Perin Care, 40(4): 289-296.well prepared and included during labour and and, whilst the promotion of normality is Garthus-Niegel S, Soest T, Vollrath M et al (2013). ‘Thebirth (Kululanga et al 2012). important, it is equally helpful to raise impact of subjective birth experiences on post- traumatic stress symptoms: a longitudinal study’. Arch One grandmother said: The birth reflections Wom Mental Health, 16(1): 1-10. “I know everyone was concerned about service has helped Kululanga LI, Malata A, Chirwa E et al (2012). ‘Malawian the baby, but that was my baby going hundreds of women to fathers’ views and experiences of attending the birth through hell; I just wanted to hold her feel better about their of their children: a qualitative study’. BMC Preg Childb, and make it all better but I couldn’t” birth experience 12(1): 141-150. Mercer J, Green-Jervis C and Brannigan C (2012). ‘The This feedback has enabled us to make small legacy of a self-reported negative birth experience’.changes to our practice and, hopefully, Brit Jour Midwif, 20(10): 717-723.improve the experience for future women and Storksen HT, Garthus-Niegel S, Vangen S et al (2013).their birth partners. ‘The impact of previous birth experiences on maternal fear of childbirth’. Acta Obs Gyn Scand, 92(3): 318-324.Documentation and terminologyThe birth reflections sessions have been useful The Practising Midwife | October 2015 13

Jo Murphy-Lawless Advancing Practicereflects on the impact of Reflections on human rights as ahuman rights legislation reality for women and midwivesand practice on womenand babies around SUMMARY: We often speak of a woman’s right to choose the way she wishes to givechildbirth birth. This article discusses how ‘real’ that right is. Some of the legal background to human rights as they relate to childbirth is set out, centred on the 2010 European Court of Human Rights ruling in the home birth case, Ternovszky v Hungary. The limitations of this case point to why resorting to the law to achieve their rights about birth may not be the most fruitful remedy for women. Instead the argument is made for creating equality of voice in the clinical area to achieve a stronger collective voice for anchoring human rights in practice. Keywords Human rights in childbirth, law, power, collective voice Author Jo Murphy-Lawless, sociologist in the School of Nursing and Midwifery at Trinity College Dublin and member of the Birth Project GroupPractice challenge Introduction all the western European governments of the day. It was based on the 1948 UN DeclarationWhat part does human rights in Since the 2015 general election in the UK, the on human rights which itself appeared as achildbirth play in students’ topic of human rights has received an response of people and governments alikeeducation? Do you need to revise unusually large number of column inches in recoiling from the horror of mass warfare andyour understanding by setting up a the mainstream media. Much discussion has the mass extermination camps of Nazistudy group? focused on concerns about the abolition of the Germany and the gulags of Stalinist Russia. Human Rights Act (UK Parliament 1998), a Hope shone brightly that we had learned the Why might legislation on stated intention in the new programme of lesson about the importance of the universality human rights matter and government. Why might legislation on human of rights and freedoms for each and every how does it connect to rights matter and how does it connect to human being. In coming together as the United women, birth and midwives? Nations, countries sought to enshrine these women, birth and rights and freedoms in a document which midwives? The legal background to contemporary every national government undertook to understanding of human rights protect through its own national laws. This was a deeply idealistic undertaking rooted in events The original European convention on human which flow all the way back to the French rights (ECHR) was drawn up in 1950 by the Council of Europe (CE), which was made up of14 The Practising Midwife | October 2015

Human rightsRevolution and the Declaration of the rights of Practice challenge However, the ECtHR judges noted that thisman and of the citizen in 1789. ruling could not ‘be equated with liberalising Do you feel confident about how to home birth as such’ and went on to declare There are 17 principal articles in the ECHR. support a woman when she seeks to that such a decision entailed ‘balancing’ notAn individual can seek to take a case to the birth her baby normally, even only current medical knowledge about theEuropean Court of Human Rights (ECtHR) in though she falls outside safety of home birth which it stated isStrasbourg if she feels that one of her rights, standardised criteria for ‘low-risk’? disputed, but also issues such as the health ofas set out in these articles, has been ignored, Can you identify who you can turn mother and baby, appropriate health serviceoverturned or violated by the actions or laws of to in your unit or community team structures, and so on: ‘This is a matter wherethe state or official bodies in the state where she to gain backing for the preference the State has a broad margin of appreciation,’lives. She must first take her plea to her national the woman has expressed? stated the Court (ECtHR 2010: 12).courts and, if unsuccessful there, can apply tothe European court, so long as her country is a strictly illegal, the Hungarian state prevented The statement about not ‘liberalising’ homesignatory to the European convention. midwives like Ágnes Geréb from helping birth and the legal phrase about the state’sWithdrawing the 1998 Human Rights Act, women to have a home birth by subjecting ‘broad margin’ in balancing all the issues aboutwhich brought the UK fully into line with the them to legal sanctions, including prosecution. home birth, including resource issues, meansEuropean convention, would mean no further Thus if Anna could not be attended by a that the Ternovszky ruling had a considerableaccess for UK citizens to the ECtHR. midwife without that midwife facing hostile number of qualifications attached to it, state action, she had no substantial freedom to making it less a victory for a woman’s right toA right to home birth?: Ternovszky v give birth at home (indeed Ágnes Geréb was choose home birth (van Leeuwen 2015) andHungary subsequently charged with malpractice for more a reminder that her right is subordinate assisting home births and was imprisoned for to the power of the state.Many of us are familiar with the case of several months before being placed underTernovszky v Hungary (ECtHR 2010) which the restrictive house arrest until 2014; she is now The state and its ‘broad margins’ toECtHR ruled on in 2010. When Anna facing a re-trial). set conditions on birthTernovszky found herself pregnant for a secondtime, she knew that her midwife, the Backed by the Hungarian civil liberties This ruling lets us see how limited the notionobstetrician Ágnes Geréb, who had helped her union, Anna pursued her case against the of human rights is in practical terms in relationgive birth at home with her first baby, could Hungarian state. The ECtHR found in her to childbirth. Pursuing a human rights case is awell face prosecution and imprisonment for favour, ruling that Hungary discriminated difficult and lengthy process for the individual >>assisting Anna. While home birth was not against Anna through its arbitrary actions that constrained healthcare professionals from What should strike us is The Ternovszky ruling had properly supporting women wanting to give birth at home. Specifically, the court ruled that the major problem that a considerable number of Article 8 of the Convention, the right to a private and family life, included Anna’s right to both national sovereignty qualifications attached to choose where and how she became a parent, which also meant that she had a right to and international legal it, making it less a victory assume there was a ‘legal and institutional environment’ (ECtHR 2010: S24), that is, a state conventions pose to the for a woman’s right to regulatory system with clear machinery and protocols to regulate home birth (Eggermont pursuit of universal choose home birth 2012; van Leeuwen 2015). human rights The Practising Midwife | October 2015 15

Human rights Practice challenge ECtHR tracks a delicate path between the two, and distinctions only. These concerns are never deviating from the intricacies of law, heightened by recent highly technical Have you attended or can you find a even though the logic and the burden of truth instruments within the EU as a whole to do workshop where women and are most often on the side of the individual, with the ECHR which have given rise to legal midwives speak about their outside the scope of formal law. arguments that in time the ECtHR will be experiences jointly so that you can marginalised in its work by the European learn more of how to work Looking at current UK policies on a Union’s own Court of Justice, the CJEU (Butler together? woman’s right to choose her place of birth, it 2015: 106-107). A former ECtHR judge has is evident at once that this is a right observed that the ECtHR has already shiftedwoman who must undertake a complex action subordinated to the operations of the NHS. ‘its judicial policy from assertively protectingabout heavily contested issues surrounding her Under the Health and Social Care Act (UK human rights to becoming more timid’ (Butlerpresumed right to choose about her Parliament 2012), clinical commissioning 2015: 109).reproductive health. National machinery and groups with the responsibility for planning andlaws may reflect entrenched interests and commissioning maternity services, and NHS The problem of unequal power andbeliefs which do not accord with her needs trusts bidding to provide maternity services, ‘rights’and it is only on a point of principle, as with may use organisational models that do not inArticle 8 in the Ternovszky case, that she can fact prioritise the services women need most Beyond these matters lie still more complexproceed to the European Court. We have and which they would choose first. Thus, for arguments about who is free, who is equal andexperience of this in Ireland with the A,B,C v example, in spite of policies, in spite of who has the power to decide about theseIreland case which was first lodged in 2005 evidence, home birth may too readily become matters. Let’s go back to the 1789 Declarationand which the ECtHR did not rule upon until the preserve of those who can pay for it of the rights of man and of the citizen. What2010 (Irish Family Planning Association (IFPA) privately. It is within the power of the nation of the person who is not a ‘man’ nor a2011). It involved, amongst other matters, a state to name and apportion its laws, ‘citizen’? Has she any rights? Olympe dewoman’s need to access termination legally in institutions and resources: the ‘broad margin’ Gouges was a feminist French revolutionaryIreland for a pregnancy that threatened her which the ECtHR judges spoke of in their who asked this. In 1791, she published herlife (IFPA 2011). Again, the judgement, drawing ruling. The result is that in the contest Declaration of the rights of woman and theon Article 8, was hedged, with only C’s claim between the power of law and the power of citizen, at a time when women were unable tobeing seen as valid and then only partially so. truth, the latter frequently loses because of vote. Article X of her Declaration stated that ifLong before, C had been forced to go outside that issue of sovereignty and we end up with women have the right to ‘mount the scaffold’Irish jurisdiction to obtain her necessary human rights being observed by small degrees (many women had already been executedtermination. during the Revolution) ‘they should have the Under current UK law, right to speak.’ What should strike us is the major problemthat both national sovereignty and free NHS maternity care is Massive political struggles over many longinternational legal conventions pose to the decades finally forced the enactment of lawspursuit of universal human rights. As increasingly limited for which gave women formal equality as citizensimportant as the foundational principle is that within the majority of nation states (withwe all have rights; those rights are bounded by women without the much still to be fought for). That still leaves ussovereignty. Sovereignty is a formal way of with the rights and needs of the non-citizen,saying that the nation state can defend its requisite papers or legal be she called a ‘refugee’, an ‘asylum seeker’ orown powerful interests; interests which may a ‘migrant’: all finely measured legal categoriesnot be the same as those of all its citizens. The category which do not match the needs of 60 million people who are now displaced and stateless across the world. Under current UK law, free NHS maternity care is increasingly limited for16 The Practising Midwife | October 2015

Human rights Final practice challenge achieve better birth care. For all that each collective voice which creates the political experience of pregnancy and birth is unique to pressure to abolish boundaries (which are Having read this article, do you have the individual, we know the significant arbitrary) that the laws of sovereign power a clearer idea of how it might be pressures on the services which can impede us maintain to limit and deny the human rights of possible to bring human rights into in our response to that individual woman, right pregnant and birthing women. tpm your practice? then and there (Birth project group (BPG) 2015). Breakdowns in services, resulting in Jo Murphy-Lawless is a sociologist in thewomen without the requisite papers or legal harm to women and their babies, be it School of Nursing and Midwifery at Trinitycategory. In 2006, Doctors of the World set up Morecambe Bay or Portlaoise in Ireland College Dublin and a member of the Birtha free clinic in East London for people from (Murphy-Lawless 2015) or anywhere else, make Project Groupsuch backgrounds. When they surveyed their me wonder whose voice was not valued: anumbers for 2010, they found that of 66 woman; a student; a junior midwife; a junior Referencespregnant women who attended for the first doctor who tried to stand out against a clinicaltime, 40 were in the second or third trimester, setting, itself facing unbearable pressures BPG (2015). ‘Fear among midwives: qualitativewith the majority listed as either migrants or which were not spoken about? findings from an online survey show the extent toasylum seekers. They were from minority ethnic which midwives are practising in fear’. Midwives,groups, the very groups cited by successive We cannot solve the serious practice issues Autumn: 60-62.national confidential enquiries as most we face, let alone the dimension of human Butler G (2015). ‘A political decision disguised as legalvulnerable to maternal death (Ramaswami rights which surround childbirth in all their argument? Opinion 2/13 and European Union2012). richness and complexity, without starting from accession to the European Convention on Human where we are; with a clear plan to do the work Rights’. Utrecht Jour Int Eur Law, 31(81): 104-111. The Irish naval boat, LÉ Niamh, on duty in of thinking and speaking about what we must Eggermont M (2012). ‘The choice of childbirth is athe Mediterranean in July, rescued a woman put in place to truly support women, and we European human right’. Europ Jour Health Law, 19:from a shipwrecked wooden barge which had need to see this work as indivisible from the 257-269.set sail with many people fleeing from the war practical daily work of midwifery. When we ECtHR (2010). Ternovszky v Hungary, Appl No:in Syria, but many more from conflicts in take space to enable ourselves to discuss and 67545/09.Africa, fleeing via the Libyan coast. Soon after challenge the unacceptable circumstances we IFPA (2011). ABC v Ireland at the European court ofshe was taken safely on board, this woman see, as midwives, as mothers, as healthcare human rights briefing note, Dublin: IFPA.gave birth with the assistance of Irish naval practitioners, as birth activists, as citizens, as Murphy-Lawless J (2015). ‘Portlaoise Hospital andpersonnel. How are her needs, her voice, her non-citizens - all with an equal right to raise perinatal deaths: when ‘investigations’ and ‘reviews’rights, and those of her infant daughter not to our voices - we move closer to creating a fall drastically short of the mark’. AIMS Jour, 27(3): 4.be eclipsed by the ‘eligibility criteria’ of Ramaswami R (2012). ‘Why migrant mothers die innational and international laws which are Breakdowns in services, childbirth in the UK’. 50.50 Inclusive Democracy, 12really about dominant interests and power Jan.blocs rather than rights and needs and care? resulting in harm to UK Parliament (1998). Human rights act, London: Crown.Using human rights in clinical women and their babies UK Parliament (2012). Health and social care act,practice London: Crown. make me wonder whose van Leeuwen F (2015). ‘Milestone or stillbirth: anTo bring such matters back to where most analysis of the first judgment of the European Courtmidwives practise daily, we know the struggles voice was not valued of Human Rights on home birth’. In: van den Brink M,we face as midwives and birth activists to Burri S and Goldschmidt J (eds). Equality and human rights: nothing but trouble? Utrecht: Utrecht University. The Practising Midwife | October 2015 17

Sharon Humberstone Mental illness in pregnancy: midwives supporting womenadvocates team working and safeguarding babiesfor health professionalsworking with women withmental ill-health and theirbabies SUMMARY: The relationship between parental mental illness and safeguarding concerns is well documented. The role of the midwife in supporting women with mental health problems can sometimes be a balancing act, especially when perinatal mental health services are few and far between. The midwife needs to be able to remain objective with regards to safeguarding and be proactive in instigating early help assessments. There should be organised joint working within a multi disciplinary team including social workers and psychiatric nurses which addresses the needs of both mother and baby. This can lead to a less problematic handover to health visiting services. Continuity of care and an open honest approach will be instrumental in providing a supportive relationship that doesn’t lose sight of the baby. Keywords Mental illness, safeguarding, early help, joint working, continuity of care Author Sharon Humberstone, acting named midwife for safeguarding children at Scunthorpe General Hospital Midwives are in a Introduction born. This bond can become a balancing act, as prime position to it can be difficult to remain objective aboutsupport women and to In our ever-changing society, women accessing safeguarding when your primary aim is to safeguard babies, as maternity care include those with complex provide support. Serious case reviewsthey are often able to needs, including mental illness. Of the repeatedly highlight the reluctance of adult- build a trusting midwifery referrals to the hospital safeguarding centred care workers to share safeguardingrelationship before the team in Scunthorpe and Goole, 43 per cent information, yet these reviews also reveal that have mental illness as a primary concern. In an there are increased risks to the safety of baby is born analysis of serious case reviews, Brandon et al children if the parents have a mental illness (2009) found current or past parental mental (Department of Health (DH) 2002). Child illness in two thirds of the cases. Midwives are protection and the mental health of parents are in a prime position to support women and to entwined (Hall and Williams 2008) and, safeguard babies, as they are often able to therefore, the role of midwife is paramount in build a trusting relationship before the baby is18 The Practising Midwife | October 2015

Mental illness in pregnancyRUTH JENKINSON/MIDIRS/SCIENCE PHOTO LIBRARY Excellence (NICE) (2007), screening for mental illness should be included routinely as part of the booking appointment, and this can be the beginning of a supportive relationship. Midwives are in an ideal position to support women with mental illness antenatally in order Working together to safeguard their baby An early help assessment/common assessment framework should be encouraged and other not only supporting these vulnerable women although midwives should access the GP record professionals should be sought out as early as through their pregnancy and into motherhood, if they are able to do so. However women do possible, such as the GP, health visitor, but also in safeguarding the lives of their not always disclose the full extent of any past community psychiatric nurse (CPN) and social babies. medical history, especially mental illness. There worker. In order to promote the welfare of is still a stigma attached to this type of illness, children, providing early help is more effective Analysis and also the fear that the new baby may be than reacting later (Department for Education taken into care. Unfortunately this fear is (DfE) 2013). The midwife should take a Studies have shown that midwives often feel ill often realised, as support cannot be instigated proactive role, feeling confident enough to equipped to care for women with mental if the midwife is not aware of the problem. As seek out other professionals in areas where health problems. McCauley et al (2011) a result of the Centre for Maternal and Child joint working is not always common. Parents discovered that midwives felt ‘uncomfortable’ Enquiries (CMACE) report on maternal deaths who accept and respond to mental health and ‘unsafe’ when caring for mentally ill (2011) and recommendations from the treatment in the perinatal period are more able women. This is reflected in the findings of Edge National Institute of Health and Care to make changes in order to adequately parent (2011), who describes perinatal mental health their child (Ward et al 2012). It is paramount services as being ‘fragmented’ and ‘virtually Midwives also need to that any psychiatric specialist involved in the absent’ in some areas. MIND (2006) found in a develop an woman’s care is contacted without delay so survey that fewer than half of trusts have a that medication and the likely impact of its perinatal mental health service. It is understanding of the discontinuation can be discussed, as stopping unsurprising, then, that midwives feel out of role that social abruptly can lead to serious adverse effects their depth as there is relatively little specialist workers play in (Einarson et al 2001). The CPN will have more support, not only for the women but also for knowledge of the illness itself and should be themselves. To compound the problem, many supporting vulnerable able to advise on what to look for. They may seriously mentally ill women have other families also have built up a relationship with the ongoing issues such as substance misuse, woman and her family and so could have a poverty, domestic abuse and children in care. valuable insight on the effect of the illness on her daily life. Stigma As many midwives now take direct referrals The social worker needs to be involved from clients rather than through the GP there earlier rather than later, if there are any is a reliance on full disclosure at booking, concerns about safeguarding. Midwives also need to develop an understanding of the role that social workers play in supporting vulnerable families. In order to fully engage with the women and safeguard their children, there needs to be a shift in culture. MIND (2006) recommended that access to children’s >> The Practising Midwife | October 2015 19

Mental illness in pregnancyservices should be facilitated as part of a care to parenting in reality is often a tricky time for Sharon Humberstone is acting named midwifepackage rather than crisis management. It all mothers, regardless of mental health for safeguarding children at Scunthorpe Generalneeds to become common practice to involve problems, so it is important that the midwife is Hospitalsocial workers at an early stage, and any able to stay objective and able to support thereferrals should to be made in an open and mother as sensitively as possible without losing Referenceshonest way, with the full knowledge of the sight of the needs of the baby.mother (unless there are immediate child Brandon L, Bailey S, Belderson P et al (2009).protection concerns as, in this case, consent is Conclusion Understanding serious case reviews and their impact:not required). The named midwife for a biennial analysis of serious case reviews 2005-7,safeguarding can also be contacted for advice It is possible to support the woman and London: Department for Children, Schools andand support when dealing with complex cases. safeguard the baby but it requires a degree of Families. objectivity. In fact it is easier to safeguard the CMACE (2011). ‘Saving mothers’ lives: reviewingEach woman and baby’s needs baby if the woman is well supported. maternal deaths to make motherhood safer: 2006-An individualised care plan should take into 2008’. Brit Jour Obs Gyn, 118(S1): 1-203.account the needs of the woman and address Midwives need to feel confident enough to DfE (2013). Working together to safeguard children,the needs of the unborn/newborn baby. The seek out other professionals involved in the London: HM Government.underlying structure of the plan should be woman’s care and not wait to be contacted by DH (2002). Learning from past experience: a review ofbased on any local care pathway or guidelines others. They also need to take it upon serious case reviews, London: The Stationery Office.specific to the unit where the woman is themselves to provide an element of continuity Edge D (2011). National perinatal mental health projectbooking. Care should be co-ordinated as sub- to the woman’s care in order to assess the risks - perinatal mental health of black and minority ethnicoptimal outcomes could be the result of poorly accurately, wherever this is possible. women: a review of current service provision insynchronised decision making by health England, Scotland and Wales, London: Nationalprofessionals (McCauley-Elsom and Kulkarni Midwives need to be aware of the roles and mental health development unit, DH.2007). Although the fetus has no rights until responsibilities of other professionals, as well Einarson A, Selby P and Koren G (2001). ‘Abruptbirth, planning with regards to safeguarding as their own. Continuity of care and a discontinuation of psychotropic drugs duringshould be commenced early in pregnancy so proactive approach are especially important. pregnancy: fear of teratrogenic risk and impact ofthat there is time for appropriate assessments This allows the midwife to establish a counselling’. Jour Psych Neurosci, 26: 1.to be undertaken. relationship with the woman but also means Hall D and Williams J (2008). Safeguarding, child that she can communicate confidently with protection and mental health Arch Dis Childh, 93(1):Planning discharge other members of the team. Being a visible 11-13.Once the baby is born, the majority of the member of the team and not seeing midwifery McCauley K, Elsom S, Muir-Cochrane E et al (2011).work with regards to assessments should be as ‘temporary’ is also important. These are ‘Midwives and assessment of perinatal mental health’.complete. These assessments can then be used some of our most vulnerable women and Jour Psych Ment Health Nurs, 18(9): 786-795.to form the basis of planning for discharge. A babies and are therefore a priority. tpm McCauley-Elsom K and Kulkarni J (2007). ‘Managingdischarge planning meeting can be used to psychosis in pregnancy’. Aus NZ Jour Psych, 41: 289-discuss the support package for the parents Being a visible member 292.but can also revisit any safeguarding concerns of the team and not MIND (2006). Out of the blue? Motherhood andand ease the transition to health visiting. seeing midwifery as depression, London: MIND.Community midwives should always attend as ‘temporary’ is also NICE (2007). Antenatal and postnatal mental health:they will be able to use their skills to detect important clinical management and service guidance CG45,any concerns around parenting, but will also London: NICE.be able to provide support and communicate Ward H, Brown R and Westlake D (2012). Safeguardingto other members of the team. The transition babies and very young children from neglect, London: Jessica Kingsley.20 The Practising Midwife | October 2015

Stevie Walsh and To stop walking on egg shellsGillian Swinscoe SUMMARY: A collaborative project between a community midwife and midwiferydescribe a project to educationalist has developed a model of compassionate woman-centred care fordevelop resources to women with high BMI. The project aim was to test a model of care that would increasefacilitate compassionate midwives’ confidence in caring for women with high BMI. It was important that anyand effective midwifery new model should not involve what would be perceived as time-consuming activitiescare for pregnant women that would add significantly to the midwives’ workload. After searching the literature awith high BMI five-stage brief interventions model based on motivational interviewing (MI) theory was piloted with a team of community midwives in rural Scotland. Leaflets were developed containing information and activities based on MI principles providing women with a tool to work with. The Swinscoe-Walsh model has been well received and evaluated by both midwives and women and is being considered for wider implementation by public health services for pregnant women.. Keywords Maternal obesity, health inequalities, childhood obesity, pregnancy, maternal BMI Authors Stevie Walsh, midwifery lecturer at Robert Gordon University and Gillian Swinscoe, community midwife at NHS GrampianMaternal obesity has Background populations, 28 per cent of women are obesebeen identified as the (Richens 2008). There is also some evidence Prevalence that a high maternal body mass index (BMI) in biggest challenge Maternal obesity has been identified as the itself can result in obese children (Stadtlander facing maternity biggest challenge facing maternity services 2014), but even if that is inconclusive, parents today and, considering the prediction that 33 are role models so will influence a child’s eating services today per cent of girls will be obese by the year 2020 habits and approach to exercise (Payas et al (Glasper 2008), this is likely to be the case for 2010). As worldwide obesity has more than the foreseeable future. Maternal obesity also doubled since 1980, globally obesity is the new has implications for child health, as infants of malnutrition. obese mothers are less likely to be breastfed, which in turn increases their own chance of Contact with midwives >> becoming obese in childhood, as well as many As women can be more receptive to health other health disadvantages (Riordan and messages during pregnancy, midwives have Wambach 2010). Moreover obesity contributes long been identified within policy as being to widening health inequalities as, in poorer The Practising Midwife | October 2015 21

Caring for women with high BMIpublic health practitioners who can have a views also have an impact of families. The studypositive effect on women’s health (Centre for Many midwives think that healthMaternal and Child Enquiries (CMACE) 2011). Mixed methods research provides moreAnd for obese women who are otherwise promotion is giving information on risks (Lee sophisticated understandings of a problemhealthy the care they receive during pregnancy et al 2012), but a health promotion activity to (Howe 1988), so it was thought that combiningmay be their only sustained period of contact empower women to change behaviours is a quantitative and qualitative data would producewith health professionals unless or until their more effective strategy. Also midwives who a better understanding of the midwives’own health is otherwise impacted, but then adopt the role of expert when caring for obese confidence and competence. Post study thisthe opportunity has been missed. women will be detrimental to the change would also demonstrate more clearly increased process, so it is important that the decision levels of confidence. To obtain quantitativeFeeling awkward making or power is in the hands of the woman. measurements (a numerical score) of midwives’The small project was the result of the team of In order for this to happen a shift in beliefs confidence levels, we designed a Likert-stylecommunity midwives being involved in and behaviours is required. Women who have questionnaire to complete before using theresearch on obese women’s experiences of failed before to lose weight will have lower model we developed. Questions were askedmaternity services. The midwives identified self-efficacy and little confidence in about skills, competence and feelings aroundthat they lacked the knowledge and skills to themselves (Upton and Thirlaway 2014). It is discussing weight and giving advice on dietconfidently address the issue with women, in a possible that, using motivational methods, and exercise. Qualitative data were obtained byway that is effective, and this shortfall is women can be supported to develop an including two open questions about barriersreflected in the literature (Lee et al 2012). internal locus of control, increasing confidence that midwives face when approaching theMidwives find discussions around weight and strengthening their belief that their own topic. The results of this are shown in Figure 2difficult as they don’t want to risk ‘spoiling’ actions are key to their success (Rotter 1966). (on the next page) and initial data demonstratedthe pregnancy by bringing weight up (Powell that the knowledge, skills and confidence ofand Hughes 2012). It may also be that, as The aim was to develop an effective and midwives in the team supported the existingmidwives are likely to be represented in the sustainable model which would also support evidence. The midwives were asked to completenumbers of obese women, they feel they are in long-term health improvements. The five-stage the same questionnaire, with slightly differentno position to give advice, as their own issues brief interventions tool (as shown in Figure 1) open questions, after seeing and using the model.around weight interfere (Foster and Hirst was designed using motivational interviewing Figure 2 shows the total score obtained, before2014); obese nurses have identified that they techniques that are more likely to bring about and after using the model, by each of sixare conscious that they are not good role sustainable behavioural change. This type of midwives, from five questions around knowledgemodels (Brown and Thompson 2007). These model will result in women being able to take confidence in discussing weight managementfindings are mirrored in other primary care control of their weight management. with women with high BMI in pregnancy.professionals who are faced with managingobesity (Saeidi et al 2013). Figure 1 Swinscoe-Walsh model Social norms around weight have an 5 stage brief interventionsinfluence, and being overweight has, to some 1 Contemplationextent, been normalised. Overweight women 2 Preparationstill see themselves as healthy, so when risks 3 Actionmaterialise, many do not acknowledge that 4 Solutionsobesity contributed to problems encountered 5 Maintenanceduring their pregnancy (Keely et al 2011).Moreover in one American study, 79 per centof mothers of obese children did not see theirchild as overweight (Payas et al 2010); so these22 The Practising Midwife | October 2015

Caring for women with high BMI The model Figure 2 Scores six midwives gained, measur- midwives included: “The leaflets provide a basis ing confidence before and after using the for discussion and were easy to use”, “using The first intervention is ideally at booking, Swinscoe-Walsh model them gently sowed the seeds for healthy which fits with the Scottish Government’s 60 eating in pregnancy” and “using the leaflets ‘HEAT’ target: that early booking ensures helps with delivering the message, and created improvements in breastfeeding rates and other 40 more confidence”. Women said: “The leaflets important health behaviours. The principles of are helpful but not condescending” and “I the behavioural change models are that the 20 think the leaflets keep me motivated”. person must contemplate their situation, prepare for change, take actions, find their 0 Early days own solutions and develop strategies to 123456 maintain new behaviours. The content of the Before After It is early days for this model but it is being leaflets is based on these five stages, with activities and questions to complete in each. along with suggestions of ‘fit for life’ put forward as a part of a new health For example in the first leaflet there is a BMI behaviours. This a snapshot of the contents only. chart where the woman plots her BMI then promotion model for pregnant women in the thinks about and plots where she would like it The findings to be; she identifies what she has to gain by north of Scotland. Further education for losing weight and what might make it difficult. After using the model, as Figure 2 indicates, By the time you get to the last leaflet: there were marked increases in the midwives’ midwives is needed to enable them to deliver Sustaining new behaviours, planning ahead confidence and also positive feedback from and suggested activities are key. It is also here, women in their care. One was a student effective, sensitive and timely care. With the rather than in further discussion around risk, midwife who was herself doing a piece of workhpp_Latyhoautt t1he1b6e/0n9e/f2it0s1o5f a11h:e3a0lthPyaBgMe I1are identified, around obesity at the time. Comments from increased pressure on midwives’ time, a programme of brief interventions, based on motivational interviewing techniques, could be the most realistic and effective use of community midwives’ time with women who are obese in pregnancy. Moreover, even if pregnancy outcome is not affected, >> Maternal obesity increases health risks for both the mother and child during and after pregnancy. Supporting and advising pregnant women to eat a healthy balanced dietand undertaking moderate activity reduces the known risks associated with obesity in pregnancy and childbirth. Contact us for more information as we offer an NHS discount. Tel: 01252 843149 Email: thehealthyportionplate@ hotmail.co.ukThe Healthy Portion Plate is used by the NHS and is in national partnership with Change For Life.

Caring for women with high BMIpostpartum weight loss will improve future Gyn, 118(S1): 1-203. Powell J and Hughes C (2012). ‘Antenatal interventionspregnancy outcomes and health (Richens Foster CE and Hirst J (2014). ‘Midwives’ attitudes that support obese pregnant women’. Brit Jour2008). This may also result in long-term towards giving weight-related advice to obese Midwif, 20(5).behavioural changes that will improve the pregnant women’. Brit Jour Midwif, 22(4): 254-262. Richens Y (2008). ‘Tackling maternal obesity:health of families, and not just childbearing Glasper EA (2008). ‘Obesity: hidden costs to mother suggestions for midwives’. Brit Jour Midwif, 16(1).women (Powell and Hughes 2012). tpm and child’. Child Young Peop Nurs, 2(1). Riordan J and Wambach K (2010). Breastfeeding and Howe KR (1988). ‘Against the quantitative-qualitative Human Lactation, 4th Edition, Massachusetts: JonesStevie Walsh is midwifery lecturer at Robert incompatibility thesis, or dogmas die hard’. Ed Res, 17: and Bartlett Publishers.Gordon University and Gillian Swinscoe is a 10-16. Rotter JB (1966). ‘Genaralised expectations for internalcommunity midwife at NHS Grampian Keely A, Gunning M and Denison F (2011). ‘Maternal versus external control of reinforcement’. Psych obesity in pregnancy: women’s understanding of Monographs, 80(1): 1-28.References risks’. Brit Jour Midwif, 19(6). Saeidi S, Johnson M and Sahota P (2013). ‘The Lee DJ, Haynes CL and Garrod D (2012). ‘Exploring the management of obesity in primary care: a pilot study’.Brown I and Thompson J (2007). ‘Primary care nurses’ midwife’s role in health promotion practice’. Brit Jour Pract Nurs, 24(10). attitudes, beliefs and own body size in relation to Midwif, 20(3). Stadtlander L (2014). ‘Maternal obesity and the obesity management’. Jour Adv Nurs, 60(5): 535-543. Payas N, Budd GM and Polansky M (2010). ‘Exploring development of child obesity’. Int Jour Childb Ed,CMACE (2011). ‘Saving mothers’ lives: reviewing relationships among maternal BMI, family factors, 29(2). maternal deaths to make motherhood safer: 2006-08. and concerns for child’s weight’. Jour Child Adolesc Upton D and Thirlaway K (2014). Promoting Healthy The eighth report on confidential enquiries into Psych Nurs, 23(4). Behaviour, 2nd Edition. London: Routledge. maternal deaths in the United Kingdom’. Brit Jour Obs Looking for a new challenge in Western Australia? * Registered Nurse/Midwife – Maternity Services * Registered Nurse/Midwife – Neonatal Unit WA Health is seeking suitably qualified registered nurses/midwives with at least two years recent experience in the UK or Ireland. We want to hear from you if you have: 1. either UK/Irish nursing/midwifery qualifications, or current Australian nursing registration 2. a high level of verbal and written communication skills and 3. a well written, detailed CV (a CV template can be downloaded at www.wago.co.uk follow the ‘Migration >Opportunities for Health Professionals’ links) Competitive salary packages and sponsored Kununurra work visas are available to suitably qualified Broome nurses. Karratha To check your eligibility for registration go to Geraldton Kalgoorlie DOH-12814 SEP’14 www.nursingmidwiferyboard.gov.au Esperance If you meet these requirements, please Perth forward your CV to [email protected] Bunbury Albany www.wago.co.uk

Western Australia – fallin love with the place!Carla and Amanda have answCearrilnagPathriesecaanll dfoAr mmaonredamBidawthivheasvaetsPeettrltehd’s in nicely afterjoined our team – why agship hospital.don’t you?Midwives Carla Parise and Amanda Bath had a bit of giggle After working under supervision for their rst three months, asabout the weather on Perth’s rst day of winter. “It’s warmer required by the Australian Health Practitioner Regulation Agencytoday than it is back in Portsmouth” Amanda said. “I nish (AHPRA), the UK-trained midwives are now integral to the quality ofwork each day and walk out with a smile on my face when I care given to the mums and babies at Fiona Stanley Hospital. “Thesee how beautiful and blue the sky is” Carla added. supervision plan enabled a safe transition to working in another country and we were well supported,” Amanda said.The two took the plunge last year to make the move from Englandto work in the Obstetrics and Maternity ward at Perth’s newly “Midwifery here is very similar, woman-focused, and there areopened Fiona Stanley Hospital. As they hoped, they have found their lots of opportunities for British midwives to share their skills andnew work environment as fresh and clean as the brochures depicted. experience.”For Registered Midwife Carla Parise, her move to Australia has been Amanda’s quali cations and skills were obvious to those in charge,more circuitous than most. Born in Brazil, she moved to London to and she has been promoted within the system in short time. “Therefurther her studies and improve her English. While she had nothing are lots of opportunities for advancement, and I have no regretsbut praise for the NHS, the cold weather was something she never about coming over – the best thing I ever did” she said.entirely got used to. The lure of Perth’s sunshine enticed her and herhusband and two daughters, aged nine and 11 years, to migrate. Carla agreed: “There are more opportunities,” she said. “Perth needsCarla answered the call for nurses with specialist skills to come and midwives.”work in the Western Australian health system. To meet growing demand in the health system, WA Health is looking“The weather reminds me of Brazil, and the culture reminds me to recruit suitably quali ed and experienced nurses and midwivesof Britain, so it’s the best of both worlds,” she said. Carla says the with specialty skills in midwifery, neonates, community child healthbeaches are beautiful – as a Brazilian, she’s in a position to judge – nursing, school nursing, theatre, mental health (youth) and rural andand has enrolled her girls into the local surf lifesaving club to get the remote nursing.best for her children from the healthy lifestyle on o er. While wanting to encourage nurses and midwives to apply toFor Amanda, a highly quali ed Clinical Midwife Specialist, it was the work in Western Australia, WA Health advises against moving topromise of a better family life that clinched the decision to move. Australia without having your registration granted and a rm jobShe and her husband had previously holidayed in Perth and “fell in o er in place. WA Health will only o er employment to people wholove with the place”. have met the registration requirements and have the in-demand experience and skills.Her husband was working in Afghanistan, and she was a SeniorMidwife in Public Health and Management Leadership at While some nurses and midwives from overseas have experiencedPortsmouth Hospitals, and lecturing at Southampton University. It issues with the registration, you can reduce your risk of thetook “a bad day at work” to convince her to take the plunge for the same issues by registering your interest through the WA Healthbene t of the family. International Workforce Supply Bureau rather than going it alone or via recruitment agencies.Together again, and with their seven-year-old daughter, the Bathsarrived in Perth on New Year’s Eve. “It was really comfortable For further information about nursing and midwiferystraightaway. ‘Freo’ (local lingo for the port city of Fremantle) looked opportunities in WA, go to www.wago.co.uk and followfamiliar, not unlike Portsmouth,” she said. the Migration – Opportunities for Health Professionals links, contact the Department of Health’s London o ce on“You drive on the same side of the road, the signs are similar – it’s 0207 395 0575 or email your CV directly to [email protected] easy to get the hang of it from the outset.” Their children havesettled in well at school, starting the academic year after the summerschool holidays.

Danielle Clack Antenatal GBS screening: an Australian perspectiveconsiders the challengesof facilitating informed SUMMARY: Women in Australia are offered a variety of options for screening andchoice regarding GBS treatment of group B streptococcus (GBS), depending on which health service they arescreening in Australia engaged with, including a risk-based approach or universal screening. The difficulty for midwives when addressing the evidence supporting these differing policies is that there is no unified national policy on GBS screening in Australia. Furthermore, the Australian population is a discerning one, questioning the implications of procedures and exploring all options. This paper discusses the varying evidence and limitations that midwives need to be aware of in order to inform women, empower their decision-making and provide holistic woman-centred care. Keywords Midwife, group B streptococcus, screening, antenatal, choice Author Danielle Clack, registered nurse and midwife at Gosford District Hospital and BUMP (Birth Utilising Midwifery Practice) research assistant at University of Technology Sydney Woman-centred W oman-centred midwifery care to decline interventions. The challenge of midwifery care embraces informed decision- presenting balanced, evidence-based embraces informed making, where women are information in order for women to decision-making, empowered to choose the health care that is autonomously decide their plan of care where women are right for them. This can be challenging for regarding GBS screening is a topical andempowered to choose midwives when evidence is limited, and women sometimes controversial task for midwives inthe health care that is interpret the term ‘risk’ differently from the Australian health care setting who do not right for them clinicians. In the case of group B streptococcus have a unified, national evidence-based (GBS), screening policies vary widely between guideline. organisations, the wealth of research is inconclusive, and women are increasingly How risky is ‘at risk’? interested in and exploring their care options. Working as a registered midwife in an Discussing GBS infection in the antenatal Australian public hospital means meeting period is essential as it is recognised as the women who wish to explore options outside of leading cause of morbidity and mortality in recommended guidelines, including their right newborns in the UK, Australia and USA (Sheehy et al 2013). In the UK, clinicians use a risk-26 The Practising Midwife | October 2015

Antenatal GBS screening: an Australian perspectiveSTEVE GSCHMEISSNER/SCIENCE PHOTO LIBRARY factor approach in identifying women whose Group B streptococci (GBS) are the leading cause of neonatal meningitis in the UK, accounting newborns are at risk of GBS sepsis, as does The for 42-48 per cent of positive cases Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) (Chan process, including incorrect specimen collection/ IAP because of a negative antenatal screen et al 2014; Daniels et al 2010). This guideline anatomical site, incorrect gestational age, when an intrapartum screen proved positive has been disputed in a recent Australian study inconsistent laboratory processing, and (Gavino and Wang 2007). Conversely, some that found the key risk factors of: indigenous discrepancies between who performed the women and neonates would have been exposed status; parity; maternal fever; twin birth; and swab (Verani et al 2014). Gavino and Wang to antibiotics unnecessarily due to a positive previous GBS status, were not significant in (2007) conducted a pilot study comparing a antenatal screen that was negative intrapartum. determining or predicting GBS infection, and culture-based screen at the CDC’s recommended Only the woman herself should decide if this that identifying women based on these ‘risk 35-37 week gestation, with two swabs taken discordancy is a tolerable risk or not. factors’ alone fails to identify those truly at during labour; one for culture and one for risk (Ireland et al 2014). polymerase chain reaction (PCR). This study Prevalence of antibiotics highlighted the transient nature of GBS where Screening there was an 18 per cent discrepancy rate The possibility of false-positive results leading between antenatal and intrapartum results, The Center for Disease Control and Prevention demonstrating how the current universal to unnecessary antibiotic exposure is a (CDC) made a recommendation in 1996 (CDC screening strategy at 35-37 weeks gestation 1996), with updates in 2002 and 2010, that all leaves some women and neonates open to growing concern for Australians. Clifford et al women be offered a vaginal and perianal swab infection, as they would not have been offered at 35-37 weeks gestation to screen for GBS (2012) discuss the use of and exposure to colonisation, and those with positive results be The possibility of false- offered intrapartum intravenous antibiotic positive results leading antibiotics which have the potential to cause prophylaxis (IAP), in order to reduce the risk of neonatal GBS sepsis (Verani et al 2010). Clifford to unnecessary allergic and anaphylactic reactions, the et al (2012) cite a large American cohort study antibiotic exposure is a of over 600,000 live births, concluding that the development of antibiotic resistance, universal screening approach was at least 50 growing concern for per cent more effective than risk-based Australians interruption to intestinal microbiology, the assessment. When related to the Australian population, this suggests that 15-25 per cent potential for altered gene expression, altered more women would receive antibiotics in labour using the universal screening strategy immunological and metabolic programming, as than the risk-based strategy. Women throughout Australia may be offered either of well as poor economy in unnecessary these options depending on their care provider. medication delivery and hospital stay. The Inconsistency release of the new documentary, Microbirth, in The decision to use universal screening means accepting its limitations. Verani et al (2014) September 2014 is a timely catalyst for further reviewed the medical records of the mothers of neonates diagnosed with early onset GBS exploration into the potential side effects disease and found that 44 per cent of the sample had errors in the antenatal screening antibiotics may have on the microbiology of birth (One World Birth (OWB) 2014). The ramifications of these potential biological consequences are yet to be proven conclusively, and evidence to support the microbiome-hypothesis has yet to be >> The Practising Midwife | October 2015 27

Antenatal GBS screening: an Australian perspectivepublished. However, Australian women are prevent one case of early-onset GBS infection Technology Sydneylooking to their care providers for advice on (Angstetra et al 2007). There is strong argumentthese subjects, challenging midwives further for delaying screening to as late in pregnancy Referenceson this already difficult topic. as possible in order to maximise accuracy, though intrapartum PCR testing is not Angstetra D, Fergusen D and Giles W (2007). ‘InstitutionSaving currently available to women in Australia. of universal screening for group B streptococcus (GBS) from a risk management protocol results in reductionOne standout piece of Australian research, Presenting the evidence for GBS screening of early-onset GBS disease in a tertiary obstetric unit’.conducted at Westmead Hospital, analysed the is a challenge for midwives in Australia who Aus NZ Jour Obs Gyn, 47(1): 378-382.advantages and disadvantages of using real- work within varying organisations’ differing CDC (1996). ‘Prevention of perinatal group Btime PCR testing to identify GBS carriage in guidelines. There is a delicate balance between streptococcal disease: a public health perspective’.women who present with prelabour rupture of promoting hospital protocol while supporting Morbid Mortal Weekly Rep, 45(RR-7): 1-24.membranes (PROM), and has now implemented and empowering women to choose the care Chan W, Chua S, Gidding H et al (2014). ‘Rapidits impressive results (Chan et al 2014). that is right for their situation. As women have identification of group B streptococcus carriage byWestmead Hospital continues to utilise a risk- differing opinions when it comes to interpreting PCR to assist in the management of women withbased screening strategy to identify those at the definition and context of ‘risk’, prioritising prelabour rupture of membranes in term pregnancy’.risk of GBS sepsis, and now additionally offers the potential of antibiotic exposure, the Aus NZ Jour Obs Gyn, 54: 138-145.induction of labour with intrapartum IAP to significance of medical intervention, the impact Clifford V, Garland S and Grimwood K (2012). ‘Preventionthose who present with PROM and a positive of hospital stay and relevance of GBS as a of neonatal group B streptococcus disease in the 21stPCR screen, rather than routine induction for natural vaginal flora organism, this discussion century’. Jour Paedia Child Health, 48: 808-815.all PROM presentations (Chan et al 2014). With is challenging midwives in all parts of Australia. Daniels J, Gray J, Pattison H et al (2010). ‘Intrapartuma 4.4 per cent discordancy rate, Westmead We must continue to stay up to date with tests for group B streptococcus: accuracy andHospital has minimised the unnecessary use of current research in order to provide women acceptability of screening’. Int Jour Obs Gyn, 1: 257-265.induction of labour and intravenous with informed choice on this topic. tpm Gavino M and Wang E (2007). ‘A comparison of a newantibiotics, as well as possible related side- rapid real-time polymerase chain reaction system toeffects, while reducing the risk of neonatal Danielle Clack is a midwife at Gosford District traditional culture in determining group BGBS infection (Chan et al 2014). This new Hospital and a BUMP (Birth Using Midwifery streptococcus colonization’. Am Jour Obs Gyn, 197(4):approach is saving the public health system Practice) research assistant at University of 388e1-4.approximately AUD$328,208 in reduced Ireland S, Larkins S and Kandasamy Y (2014). ‘Group Bworkload, reduction in medication One Australian study streptococcal infection in the first 90 days of life inadministration, decrease in inpatient admission, states it would take North Queensland’. Aus NZ Jour Obs Gyn, 54: 146-151.improved neonatal outcomes, and shorter OWB (2014). Microbirth, feature length documentary.maternal hospital stays by 162 days per annum, 5,704 antenatal UK: OWB.which is not offset by an increase in day screens in order to Sheehy A, Davis D and Homer C (2013). ‘Assistingassessment unit admission (Chan et al 2014). prevent one case of women to make informed choices about screening forThis translates to women as choice, flexibility, early-onset GBS group B streptococcus in pregnancy: a critical reviewless intervention, and empowerment. of the evidence’. Women Birth, 26(1): 152-157. infection Verani J, McGee L and Schrag S (2010). Prevention ofThe challenges perinatal group B streptococcal disease: revised guidelines from CDC. Morbid Mortal Weekly Rep,It is clear that the detection of GBS in 59(RR10): 1-32.antenatal and intrapartum women is an Verani J, Spina N, Lynfield R et al (2014). ‘Early-onsetimperfect process, without 100 per cent group B streptococcal disease in the United States’.reliability. In fact, one Australian study states it Obs Gyn, 123(4): 828-837.would take 5,704 antenatal screens in order to28 The Practising Midwife | October 2015

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Deborah Sharp and Why women stop breastfeedingFrancesca Entwistle in the early daysmake use of audit to SUMMARY: Increasing breastfeeding prevalence rates has been identified as key tounderstand why mothers improving health and well being outcomes for mothers and babies (Dyson et al 2008;who start to breastfeed are Unicef 2013; Renfrew et al 2012a; Renfrew et al 2012b).not continuing exclusively Within one maternity unit in England, in 2014, 80 per cent of women initiatedto day 10 postnatally breastfeeding at birth, but by day 10, only 45 per cent were breastfeeding exclusively, identifying a drop off rate of 35 per cent. As part of achieving the Unicef UK Baby Friendly standards, retrospective audit was undertaken to investigate why women were not continuing to exclusively breastfeed. Findings from the study identified that when a baby received a supplement of formula milk before 72 hours of age, the mother was less likely to be exclusively breastfeeding at 10 days. This was statistically significant (Sharp 2014). An innovation was implemented for some mothers to receive additional one-to- one feeding support in hospital and the community, as a result of which supplementation rates decreased. Keywords Breastfeeding, Unicef UK Baby Friendly Initiative (BFI), supplementation Authors Deborah Sharp, infant feeding co-ordinator at Bedford Hospital NHS Trust and Francesca Entwistle, professional advisor at Unicef BFI and supervisor for Deborah’s masters in midwifery and women’s health degree Increased Introduction suggest that the early emotional interactionsbreastfeeding rates are between a baby and its parents are It is suggested that the greatest benefits of fundamental to brain development and associated with a breastfeeding occur when a baby is breastfed subsequent success, life chances and the ability reduction in costs to exclusively for their first six months with to form strong loving relationships (Gerhardt breastfeeding remaining an important part of 2004; Sunderland 2007; Royal College of the NHS, due to the child’s diet up to the age of two. A recent Midwives (RCM) 2012). reduced incidence of report commissioned by Unicef UK, confirmed specific diseases and that increased breastfeeding rates are Improving breastfeeding rates has now beenadmission to hospital associated with a reduction in costs to the NHS, identified as a key indicator in improving public due to reduced incidence of specific diseases health and local authorities are required to and admission to hospital (Renfrew et al prioritise breastfeeding support to increase 2012a). Breastfeeding provides an ideal breastfeeding initiation and prevalence opportunity for the development of emotional (Department of Health (DH) 2012). It has, attachment between mother and baby and however, been recognised that these there is an increasing amount of evidence to improvements are not significantly made or30 The Practising Midwife | October 2015

Increasing breastfeeding prevalence ratessustained without implementation of the Baby Figure 1 Grading of supplements using BFI criteria Staff suggestionFriendly Initiative (BFI) standards (Dyson et al 2%2006; National Institute of Health and Care Clinically indicated withExcellence (NICE) 2013). optimum care given Maternal request 5% without fullyBreastfeeding prevalence Clinically indicated care informed choiceWhilst there have been significant could have been improved 28%improvements in breastfeeding initiation ratesin the UK (from 62 per cent in 1990, 76 per 13% Fully informedcent in 2005 to 81 per cent in 2010), only small maternal choicenumbers of women continue to breastfeed Reason not documentedexclusively. In 2010, only 17 per cent of all 26% 26%mothers were still exclusively breastfeeding atthree months, 12 per cent at four months and the neonatal unit, who had initiated that are known to be significant and, as such,1 per cent at six months (McAndrew et al breastfeeding but were not exclusively this is a limitation (Becker et al 2011; Dyson et2012). At the point of handover of care from breastfeeding at day 10. Identification of the al 2006; Renfrew et al 2012b; McAndrew et althe midwifery service to the health visiting target group revealed that 80 women met 2012).teams, typically day 10, the exclusive these criteria during this month and thatbreastfeeding rate within this maternity unit sampling 68 would give a 95 per cent Analysis of findingswas 45 per cent identifying a drop off rate of confidence level; the final sample size was 74.35 per cent and reflecting the national picture. The BFI Ten steps to successful breastfeeding A review of the raw data indicated that there were used as a baseline to develop the 10 audit The aim of the study was to use audit to criteria. was too much to statistically analyse all of theinvestigate the reasons why women within thetrust did not continue to exclusively breastfeed This study was not able to capture the data, given the limitations of the study. Atheir infants at day 10. Results of the study important individual, complex, socio, culturalaimed to assist in the preparation for Stage 3 influences on women’s infant feeding choices decision was made to concentrate theof the Unicef UK BFI assessment, and to helpwomen breastfeed for longer. All of the babies statistical analysis on the issue of received a formulaDeveloping the audit tool supplement before day supplementation with formula before 72 10 with 68 per cent ofA comprehensive literature search was these having the first hours. All of the babies received a formulaperformed to critically evaluate the research formula supplementsurrounding exclusive breastfeeding duration, supplement before day 10 with 68 per cent (50to inform the study and audit design. Ethics before 72 hourscommittee approval was sought and was of the 74) of these having the first formulaconfirmed as not being required. Aretrospective, anonymised audit of 74 clinical supplement before 72 hours. Statisticalpostnatal notes, was undertaken in September2013 to examine why women stopped significance was tested using the chi squareexclusively breastfeeding earlier thanrecommended. The study focused on women test. This confirmed that the sample size waswho had had a live baby at >37 weeksgestation, >2.5 kgs weight and not admitted to large enough to produce correct results from the responses, with a 95 per cent confidence level. The chi square test results gave a P value of 0.011, concluding that a statistically significant factor affecting the cessation of exclusive breastfeeding before day 10 was the introduction of formula supplements before 72 hours. In addition 51 per cent of the sample received the first supplement whilst in hospital. Reasons for giving supplements were graded using the Unicef UK, BFI criteria (See Figure 1). Only two indications for formula >> The Practising Midwife | October 2015 31

Increasing breastfeeding prevalence ratesNumber of babies Figure 2 Age at discharge from hospital and age when first supplement was given In order to get home quicker, rather than 30 wait for the baby to Age when supplement want to breastfeed, the mother may see the 25 was first given Age at discharge easiest, quickest from hospital solution to get home is to give a supplement of 20 formula 15 the mother may see the introduction of 10 formula supplements at this time as the solution to their concerns about breastfeeding 5 and the well being of their baby (Becker et al 2011). The introduction of supplements often 0 results in the baby appearing more settled which, in turn, may reinforce the belief about 0-6 7-12 13-18 19-24 25-72 72-96 96-120 the inadequacy of their breast milk to satisfy their baby ( Becker et al 2011; Dyson et al Age (Hours) 2006).supplementation of a breastfed baby are The formula supplementation rate of the In addition, women now go home in theconsidered to be acceptable: these are when sample group was 51 per cent whilst in early postnatal stay period (six-72hours), andclinically indicated, with optimum care given, hospital and this was significantly higher than women are often ‘advised’ that beforeor fully informed maternal choice. the national average (31 per cent). Renfrew et discharge from hospital, the baby should be al (2012b), reviewing the findings of the ‘feeding well’. Although not proven from the The audit demonstrated that only 5 per National Infant Feeding Survey, suggest that audit results, it has been considered that incent of supplements given were clinically supplementation in hospital trusts continues order to get home quicker, rather than wait forindicated and only 26 per cent of mothers had to be common practice (McAndrew et al 2012). the baby to want to breastfeed, the mothermade a fully informed choice about the may see the easiest, quickest solution to getintroduction of a supplement. When mothers breastfeed responsively, home is to give a supplement of formula. This breastfeeding behaviour suggests that infants could explain the peaks in supplementationWhy formula supplements are given feed at least eight times in 24 hours after 48 during this period, as illustrated in Figure 2. hours of age, which is often in clusters andAs part of the BFI accreditation process, includes during the night (Morbacher 2010; Improving midwifery careinternal auditing of staff and mothers’ Unicef 2008). It is suggested that this patternknowledge was conducted at the same time as is radically different from the culturally The findings of this audit and of the internalthe study, but did not form part of the study desirable pattern expected of many mothersand formal results. It is worth noting that who would like to get their baby ‘into an earlythese audits identified that staff often routine’ (Unicef 2008). Mothers may confusestruggled to support women who had chosen this frequent feeding with milk insufficiencyto breastfeed, particularly regarding the topic and concerns about the baby’s well being.of supplementation. Conflicting messages and Combined with the early physiological changeslack of information meant that mothers did in the breasts, the demands of the baby tonot always understand why they needed to breastfeed frequently and lack of confidence,avoid giving supplements to their baby.32 The Practising Midwife | October 2015

Increasing breastfeeding prevalence ratesUnicef UK / Mead One-to-one support improves outcomes References audit results conducted as part of the BFI limitations of this study. The introduction of Becker G, Remmington S and Remmington T (2011). accreditation process, identified areas of supplements as a key factor affecting cessation ‘Early additional food and fluids for healthy breastfed midwifery care that could be improved to help of exclusive breastfeeding is supported by the full-term infants (review)’. The Cochrane Library, 12. mothers to continue to breastfeed their baby larger body of evidence that needed to be DH (2012). Improving outcomes and supporting exclusively. Tools and strategies were addressed. transparency: Part 1 A public health outcomes developed to assist maternity staff through framework for England, 2013- 2016, London: DH. education and enhanced communication skills If women are to be supported to breastfeed Dyson L, McCormick FM and Renfrew MJ (2008). to develop their own practice. It was for longer, there is a need to examine how to ‘Interventions for promoting the initiation of anticipated that they would then be able to provide targeted, predictable, face-to-face breastfeeding (review)’, The Cochrane Library, 4. help and support women with their choice to support to those who are likely to give Dyson L, Renfrew MJ, McCormick F et al (2006). breastfeed and to avoid introducing supplements within the first 72 hours (Renfrew Promotion of breastfeeding initiation and duration: supplements. As a result of the audit an et al 2012b). In January 2015 the Trust was evidence into practice briefing, London: NICE. innovation was implemented: mothers who awarded BFI Accreditation. tpm Gerhardt S (2004). Why love matters: how affection were having breastfeeding difficulty were shapes a baby’s brain, London: Routledge Press. identified and given additional one-to-one Deborah Sharp, infant feeding co-ordinator at McAndrew F, Thompson J, Fellows L et al (2012). Infant feeding support whilst in hospital and further Bedford Hospital NHS Trust and Francesca feeding survey 2010, London: Health and Social Care targeted support in the community. The Entwistle, professional advisor at Unicef BFI and Information Centre. supplementation rates of breastfed babies supervisor for Deborah’s masters in midwifery Morbacher N (2010). Breastfeeding answers made whilst in hospital were monitored every month and women’s health degree simple, Amarillo: Hale Publishing. following the completion of the study for an NICE (2013). Postnatal care. NICE quality standard 37, eight-month period. As a result of the As a result of London: NICE. introduction of the above strategies, the the introduction of Renfrew MJ, Pokhrel S, Quigley M et al (2012a). Preventing supplementation rate of breastfed babies in the strategies, the disease and saving resources: the potential contribution of hospital decreased from 51 per cent to 18 per supplementation rate increasing breastfeeding rates in the UK, London: Unicef. cent with all of these being categorised as of breastfed babies in Renfrew MJ, McCormick FM, Wade A et al (2012b). medically indicated or fully informed maternal hospital decreased ‘Support for healthy breastfeeding mothers with choice. healthy term babies (review)’. The Cochrane Library, 5. RCM (2012). Maternal emotional wellbeing and infant Conclusion development: a good practice guide for midwives, London: RCM. The Influences affecting a woman’s feeding Sharp D (2014). A clinical audit examining the factors choices are very complex and an in-depth affecting cessation of exclusive breastfeeding at day exploration of these factors was beyond the 10 of Trust A, unpublished masters dissertation from the University of Hertfordshire. Sunderland M (2007). What every parent needs to know: the incredible effects of love, nurture and play on your child’s development, London: Dorling Kindersley. Unicef UK (2008). Three-day course in breast feeding management, participant handbook, London: Unicef. Unicef UK (2013). The evidence and rationale for the UNICEF UK Baby Friendly Initiative standards, London: Unicef. The Practising Midwife | October 2015 33

Midwife Anna Kent Providing hope: midwifery teaching in Bangladeshtravelled to Hope Hospitalin Bangladesh, where she SUMMARY: Bangladesh is recognised as a resource-poor country that has made somehad a short placement very positive steps to reducing maternal mortality over the last decade. However theteaching clinical skills to death rate of women directly caused by pregnancy and childbirth still remains muchstudent midwives higher than countries such as the UK, often due to lack of access to good quality and affordable basic health care. In this article, Anna Kent writes of her experiences teaching obstetric emergency clinical skills to Bangladesh’s first ever student midwives. The students were recruited from rural villages to complete a three-year fully funded Midwifery Diploma Programme at one of seven education centres across the country. The goal of the programme is for the students to eventually return and practise as midwives in their home communities, enabling greater access for women to good quality basic health care, directly reducing maternal mortality across Bangladesh. Keywords Maternal mortality, Bangladesh, postpartum haemorrhage, health inequality, midwifery Author Anna Kent, a midwife and nurse from Nottingham who specialises in HIV. She has previously worked for Médecins Sans Frontieres (MSF) in South Sudan, Haiti and Bangladesh I smiled back at the T he white-washed clinic looked very short voluntary teaching placement at Hopestudent midwives with exotic, set against a background of Hospital, a venture of the non-government my translator beside jungle and palm trees, with pregnant organisation HOPE foundation for women and me, remembered the women arriving on the backs of brightly children, in Cox’s Bazar region of Bangladesh. painted rickshaws. I was a little daunted on my vital importance of first morning: I stood at the front of the class, Bangladesh as a country has made some education and 30 expectant faces looking up at me with the positive improvements to maternal health over enthusiastically heat already over 25oC. I smiled back at the the last few years, reducing maternal mortality student midwives with my translator beside me, by nearly half between the years 2000-2013 started my lecture remembered the vital importance of education, (World Health Organization (WHO) 2014). It is and enthusiastically started my lecture. estimated that Bangladesh has 170 maternal deaths per 100,000 live births (WHO 2014), but This was my experience of commencing a when compared to the UK statistic of eight34 The Practising Midwife | October 2015

Midwifery teaching in BangladeshTeaching neonatal resus Teaching active third stage and postpartum haemorrhagematernal deaths per 100,000 live births by a postpartum haemorrhage (PPH), a access to a caesarean section if labour(Manktelow et al 2015), there is still progress catastrophic bleed after childbirth (United becomes obstructed. It is completelyto be made. Nations Children’s Fund (Unicef) 2008). A PPH unacceptable that so many women in our is almost completely preventable if women world still have to endure the pain and fearLacking have a trained midwife, good quality from childbirth associated with not having a medications that are used in a timely way and trained midwife; for many this becomes aMidwifery has only recently been recognised as death sentence. This is why educatinga profession in its own right in Bangladesh and The students are midwives on the clinical management andproblems are compounded by a reported recruited from isolated prevention of PPH is so very important,national shortage of nurses and midwives. especially in countries that have a highThere are now government hospitals that villages in the maternal death rate.provide maternity care, but the quality of surrounding area,services can be variable, and access difficult where women often The hope of HOPEwhen some women have to travel long have no access at alldistances. The devastating reality is that many to a trained midwife There is optimism that things can change.families live below the poverty line, so they Hope Hospital has received support fromcannot afford maternity care to save the life of several organisations including Bangladeshthe pregnant woman and her baby. Rural Advancement Committee (BRAC) University and funding from the DepartmentUnacceptable for International Development (DFID) to extend services beyond the existing 40-bedEvery day across the world, over 1,000 women surgical hospital. They now have an educationdie in childbirth and most of these deaths are centre that enlists 30 student midwives perin resource-poor countries (WHO 2015). year, which is the programme wherein I have >>Around half of all maternal deaths are caused The Practising Midwife | October 2015 35

Midwifery teaching in BangladeshStudent midwivesbeen very privileged to teach clinical skills. The and she died trying to get to a hospital. The A promising futurestudents are recruited from isolated villages in loss of a mother or baby is devastating, nothe surrounding area, where women often matter where in the world someone is from, Until the day when all women in Bangladeshhave no access at all to a trained midwife. The but for Riazul, it also made her determined to have access to antenatal/postnatal care and aphilosophy of the Diploma in Midwifery at study to be a midwife. safe birth with a trained midwife, the maternalHope Hospital is for the midwives eventually to and child mortality rates will remainreturn to their rural home communities and The students know the road ahead is unacceptably high. However, as the first cohortprovide essential midwifery care, with the challenging: women in Bangladesh face the of student midwives graduate this year fromability to refer complicated births to a same pregnancy complications that we see in Hope Hospital, there is indeed hope that thingsconsultant unit when needed. With six other the UK, but can have additional complex can change for the better. tpmsimilar institutes following the same morbidities such as malnutrition orprogramme across the country, there is also a tuberculosis. I was deeply humbled by Riazul Anna Kent is a midwife and nurse fromplan for a 75-bed HOPE maternity and and her fellow students’ resolve to improve the Nottingham who specialises in HIV. She hasobstetric fistula centre on site at Hope lives of women in their own communities. previously worked for Médecins Sans FrontieresHospital. (MSF) in South Sudan, Haiti and BangladeshInsight I was deeply humbled References by Riazul and herIn between the classes, I was very fortunate to fellow students’ Manktelow BM, Smith LK, Evans TA et al (2015).spend time with Riazul, a third year student Perinatal mortality surveillance report January-midwife who told me about her home life in resolve to improve the December 2013, Leicester: University of Leicester.the villages. No one in her family had lives of women in their Unicef (2008). Maternal and newborn health, Newpreviously received education and it was a York: Unicef.great honour for her to be able to study own communities WHO (2014). Maternal mortality in 1990–2013,towards her diploma. Riazul had seen her aunt Geneva: WHO.give birth at home with only family members WHO (2015). Global health observatory data. Womenas support, but sadly when her aunt had had a and health, Geneva: WHO.PPH there was no way to stop the bleeding36 The Practising Midwife | October 2015

In the second of a two- Women’s lived experiences of domestic violence duringpart article, Kathleen pregnancy (2)Baird considers the role SUMMARY: This paper is a follow up paper to a study which explored women'sthat midwives can play in experiences of domestic violence before, during and after pregnancy. Findings from this study suggested that women would like midwives to be able to recognise the signs ofrecognising and domestic violence and to be able to offer them an appropriate response and support. Midwives are well placed to recognise the signs of domestic violence and provideresponding appropriately appropriate support. This paper addresses some of the challenges and dilemmas for midwives when identifying and supporting women who have experienced domesticto a positive disclosure violence and provides some key messages for midwifery practice. Keywords Domestic violence, domestic abuse, pregnancy, midwives, education Author Kathleen Baird, director of midwifery and nursing education in Women's and Newborn and Children's Services at Menzies Health Institute of Queensland, Griffith University, Australia One of the most Background Professional and communitydisturbing features of domestic violence is As identified in part 1 of this article (Baird responsesthat, for some women, 2015), domestic violence and abuse against women is a global public health issue (World Women who experience domestic violence tend a pregnancy is no Health Organization (WHO) and London School protection against it of Hygiene and Tropical Medicine (LSHTM) to access health services frequently, as theystarting or escalating 2010). Pregnancy is often perceived to be a positive time in a woman’s life, but one of the seek help for their injuries; and in response if it is already most disturbing features of domestic violence is occurring that, for some women, a pregnancy is no many professional health organisations have protection against it starting or escalating if it is already occurring in a relationship (Kendall- issued clinical guidelines on how to identify Tackett 2007). and respond appropriately (WHO 2013). Whilst the evidence suggests that the use of brief questioning by healthcare professionals can lead to higher disclosure rates, there continues to be a reluctance among some NHS professionals, including midwives, to ask >> The Practising Midwife | October 2015 37

Domestic violence during pregnancywomen about domestic violence (Baird 2011). The unique relationship positively discloses about domestic violence. IfAs a result, in many areas within the NHS, that midwives develop a midwife suspects that domestic violence maypolicy development and community be happening, there are several importantimplementation have been slow (Garcia- with women allows steps they should follow:Moreno et al 2014). communication Asking about domestic violenceRole of the midwife regarding domestic Identification of women who are or have been violence to occur subjected to domestic violence is essential forThe maternity care system can provide women appropriate support and referral (Garcia-with a safe environment in which to disclose for health professionals if the duty to report Moreno et al 2014). It is important forabout domestic violence. It is well documented causes conflict with their own ethical unease midwives to ask women confidently andthat women feel they can trust healthcare about maintaining confidentiality and the without predetermined judgement.professionals with a disclosure about violence increased risk that a disclosure may cause for Questioning should always take place in a safeand abuse. For some women it may simply be the woman and her family. and private environment, without the presencethat they wish to talk to someone about the of a partner or a child who could repeat theongoing violence, find out what options are Of course the reluctance of midwives to conversation to another person. If the questionavailable to them and discover how to access enquire about domestic violence can also be is asked through an interpreter, thatsupport organisations outside of health. attributed to a lack of confidence and interpreter should be a professional, andTherefore, it is important that midwives are knowledge. Midwives may be unclear about neither known to the family nor a familyable to provide advice, support and help. their role in addressing domestic violence and member. Midwives should have a low threshold find it difficult to listen to or understand a for asking women, if they are suspicious of Midwives have frequent contact with woman’s disclosure (Baird 2011). Evidence physical injuries or observe psychologicalwomen during pregnancy and therefore the suggests that the implementation of policies symptoms, including depression.maternity services are ideally placed as a and education programmes can come upuniversal point of contact for all childbearing against both individual and organisational It is important that midwives acknowledgewomen. The unique relationship that midwives barriers (Garcia-Moreno et al 2014). For that some women may choose not be honest indevelop with women allows communication instance, just because a hospital introduces a their first response; a woman may decide toregarding domestic violence to occur. However, policy dictating that all women should be withhold the information until she has formedit is vital that midwives receive specialist routinely asked about domestic violence, does a relationship with the midwife. Women ofteneducation to be able to approach routine not necessarily guarantee that that will feel stigmatised and may fear that they won’tenquiry in a sensitive and non-judgemental happen or that they will receive suitable be believed or will have their children removedway and to be able to respond appropriately support. To be able to conduct routine enquiry from them and this may prevent them fromand safely to a positive disclosure. safely, effectively and responsively, midwives disclosing. Some women will also be reluctant require education and ongoing support from to disclose because opening up and telling The more frequently midwives undertake within their organisation. someone about the violence can pose a threatroutine enquiry and hear a disclosure, the to the woman. Indeed, it is when they leave orgreater their understanding and confidence What can midwives do? attempt to leave a violent partner that mostwill be (Baird et al 2011), thereby improving women who will be, are murdered (Women’stheir overall practice. Feder et al (2009), when The primary aim of routine enquiry is to Aid 2009).conducting a systematic review, concluded provide support and help for any woman whothat women find routine enquiry in certain Responding to a positive disclosurehealth settings acceptable, providing that the When midwives receive a positive disclosure,health professional asking the question is they must be aware of the appropriate referralcaring, sensitive and non-judgemental. Phelan pathways, which need to be multi-agency and(2007) intimates that compulsory orconditional reporting can present a dilemma38 The Practising Midwife | October 2015

Domestic violence during pregnancy Midwives may be Key messages for midwives Risk assessment and safety planning unclear about their role An important consideration for midwives in addressing domestic • A supportive response from a midwife following a disclosure is the immediate and could be the catalyst leading to a woman’s long-term safety obligations for both the violence and find it pathway to safety and recovery woman and her children. Midwives must be difficult to listen to or aware of their organisation’s protocol for understand a woman’s • All women disclosing about domestic promoting and safeguarding children and violence should be reassured that their whom to contact if they have concerns about disclosure information will be shared in a safe and the safety and wellbeing of any children. Risk appropriate manner assessments should ensure that the emotionaldeveloped in collaboration with non- needs as well as the physical risks of womengovernment organisations (NGOs), such as • NHS organisations should have robust and children are considered. Women fromlocal women’s support groups. Midwives domestic violence policies and guidelines for different communities may have differentshould also have an awareness of their hospital midwives to adhere to needs because of language difficulties andguidelines and protocols, and the referral isolation. Women should never be encouragedpathway to the Multi-Agency Risk Assessment • NHS organisations should identify a single to leave a violent relationship until a full riskConference (MARAC), which is part of a co- designated person to advise midwives on assessment has been performed and a robustordinated community response to domestic appropriate referral pathways and provide safety plan put in place to protect both her andviolence and abuse. Whatever referral support for midwives who identify immediate her children. It is important that a safety plan ispathways are selected, they should always aim and significant risk (Department of Health tailored to meet each woman’s individual needsto meet the needs of the woman and her (DH) 2010) and developed in partnership with otherchildren. relevant specialised agencies (Sharpen 2009). • NHS organisations should provideDocumentation of domestic violence midwives with support and ongoing Referral and working in collaborationAccurate and contemporaneous record education so they have the tools to ask about It is important that midwives do not feel theykeeping of a domestic violence disclosure is domestic violence in a confident and sensitive have to deal with a woman’s positiveimperative. Recording of a disclosure about manner and to be able to respond safely and disclosure on their own. Working with others isdomestic violence should follow the same effectively crucial and an essential component of beingpractice guidelines as any other aspect of able to support the woman and her children.midwifery practice. It is vital that any • Midwives should be aware of their own Responding effectively to domestic violenceinformation pertaining to a positive disclosure local support agencies, and have knowledge should never be a one-agency response;should not occur in the woman’s handheld of the services they provide. collaborative working is essential, to achievenotes or any notes that the perpetrator may the best and safest outcome for a womanhave access to. The information should be It is imperative that a disclosure is only shared (Baird 2011). Ensure that the woman hasrecorded and stored safely, possibly in hospital with those who need to know, safely and information about her local women’s supportnotes, computer notes (that are not visible to effectively. For many midwives, making the agency and, if the woman is in immediatethe perpetrator) or in the woman’s GP notes. right judgement can often be a difficult danger and it is unsafe for her to go home, call balance. A midwife may decide to share the the police. tpm information, without the woman’s consent, if s/he feels a referral to other relevant agencies Kathleen Baird is director of midwifery and will help protect a woman and her children or prevent a serious crime. It is essential that nursing education in Women's and Newborn and midwives understand the constraints to their confidentiality, and that they are able to Children's Services at Menzies Health Institute of explain clearly to the woman what their choices are and what information they are Queensland, Griffith University, Australia >> legally obliged to share. For information to be shared safely within each clinical area, clear national guidance should be available (HM Government 2008). The Practising Midwife | October 2015 39

Domestic violence during pregnancyReferences It is important that Kendall-Tackett KA (2007). ‘Violence against women midwives do not feel and the perinatal period: the impact of lifetimeBaird K (2011). ‘Working with women and children they have to deal with a violence and abuse on pregnancy, postpartum, and experiencing domestic violence’. Primary Health Care, breastfeeding’. Trauma, Viol Abuse, 8(3): 344- 353. 21(1): 16-21. woman’s positive Phelan MB (2007). ‘Screening for intimate partnerBaird K (2015). ‘Women’s lived experiences of domestic disclosure on their own violence in medical settings’. Trauma, Viol Abuse, 8(2): violence during pregnancy (1)’. The Pract Midw, 18(3): 199-213. 27-31. Garcia-Moreno C, Hegarty K, Lucas d’Oliveira AF et al Sharpen J (2009). Improving safety, reducing harm,Baird K, Salmon D and White P (2011). ‘A five-year (2014). ‘The health-systems responses to violence children, young people and domestic violence, London: follow up study of the Bristol pregnancy domestic against women’. The Lancet, doi: 10.1016/S0140- DH. violence programme to promote routine enquiry’. 6736(14)61837-7. Women’s Aid (2009). The survivor’s handbook – children Midwif, 29: 1003-1010. HM Government (2008). Information sharing: guidance and domestic violence, Bristol: Women’s AidDH (2010). Responding to violence against women and for practitioners and managers, London: Crown. Federation of England. children – the role of the NHS, London: DH. WHO (2013). Responding to intimate partner violenceFeder G, Ramsay J, Dunne D et al (2009). ‘How far does and sexual violence against women: WHO clinical and screening women for domestic (partner) violence in policy guidelines, Geneva: WHO. different health-care settings meet criteria for a WHO and LSHTM (2010). Preventing intimate partner screening programme? Systematic reviews of nine UK and sexual violence against women. Taking action and National Screening Committee criteria’. Health Tech generating evidence, Geneva: WHO. Assess, 13(16): 1-113. LONDON 2016 THURSDAY 4TH FEBRUARY BIRMINGHAM 2016 FRIDAY 1ST JULY MANCHESTER 2016 THURSDAY 27TH SEPTEMBER For further information or details regarding submitting a paper, please visit www.maternityandmidwifery or contact [email protected] The Practising Midwife | October 2015

What about next time? A series of reflections I can be a midwife!In this article, one of our Completing education following day but just wanted to know if there was anything she could use to relieve the itchingoccasional series, Sarah The final year of midwifery education acts as a in the mean time. I suggested paracetamol and aHaddrell reflects on a transition period between student midwife and cool shower/flannel. I recommended going to newly qualified midwife. Skills are honed and the hospital that evening, but she declined. Thenvery positive experience of knowledge deepened in preparation for the class resumed.using her knowledge and accountable practice. Buried under dissertations,intuition to recognise a assessments and placements, students can feel During the rest of the session, I noticed Sallypotentially serious overwhelmed and filled with self doubt. They scratching every few seconds. I also noticed thatcondition in a pregnant may question their ability to be a competent and her ankles were very swollen. After the class, Iwoman and encourage confident registered midwife. During this year, approached her and reiterated that she shouldher to seek help at students begin to work with increasing contact the hospital, as they would probably likehospital. autonomy and start to trust their learning. to take some bloods. I asked if the midwife appointment in the morning was just a routine*In this series names are I felt the need to write a reflection focusing clinic appointment. She explained that it was anchanged to ensure anonymity on the event which sparked an important extra appointment because she had hypertension, moment of enlightenment in my education – an which they wanted to monitor. I urged her to During this year, event that keeps recurring in my mind; now I ring the hospital to check that all was ok. students begin to work want to document it in order make sense of it as an important moment in my education. This What were your feelings? with increasing reflection uses aspects of MacDonald’s reflective autonomy and start to model (2014), which I find accessible and easy to use. When Sally approached me during the break, I felt comfortable talking to her and giving trust their learning What happened? general advice (but hoped that she wouldn’t ask anything too complex as I was aware that I am The event took place when I was observing an only a student and did not have a mentor to NCT antenatal class. One of the pregnant women hand to check my responses!). I was also aware (35+3/40), Sally*, approached the NCT teacher of the NCT teacher, and the fact that I was and myself during the break. She said that she meant to be observing the class, so didn’t want was very itchy and wondered if we could to overstep the boundary with her. When the recommend any creams. When I asked her some teacher didn’t interrupt me, I took that as a sign questions, it transpired that the itchiness was all to continue talking. I was sure that she would over, but her baby was moving normally. I could have stopped me if I was giving incorrect see no obvious rash on her exposed skin. information or advice. I advised that she should be checked over. Watching Sally scratch for the remainder of >> She said she had a midwife appointment the The Practising Midwife | October 2015 41

What about next time?the class, and noticing her swollen ankles, I had What was the outcome for: I could have made the suggestion to call thea gut feeling that I needed to talk to her again, You? I went home, thinking that I had given the hospital in the break. However, I wasn’t awareand to urge her to go to the hospital. When I right advice. of how serious the itching was until I hadheard that she was being monitored for Sally and her baby? Sally called the hospital watched her for rest of the class. Neither hadhypertension, I felt confident that I was giving after the class and was asked to go straight in. there been time to have the conversation thatthe right advice to call the hospital; possible led me to find out about her high blood pressure.raised blood pressure (BP) and itching weren’t The NCT teacher emailed me the next day tonormal, and urgent referral was appropriate. say that Sally had had her baby after induction Would you do the same things again? of labour for pre-eclampsia and congratulated I tried to remember information about me on giving sound advice. She said that I was Yes, because it led to positive outcomes forobstetric cholestasis and pre-eclampsia, and an excellent midwife. And for the first time I mother and baby. I would try and ask more athad a flash of one of my mind maps drawn for didn’t correct her by saying that I am ‘only a the initial contact to get more information andexam preparation - with the end arrow pointing student’. I finally felt competent and confident give the appropriate advice earlier.to potential fatality of mother and/or baby. This to take on the title of midwife. This was anthought frightened me but I was careful not to important moment. What did you learn?let Sally see my concern. I said, “Because of theitching and history of raised BP, the doctors at I felt relieved that I had approached Sally I learnt that the way I communicated and gavethe hospital would probably want to see you. after the class and given appropriate advice. I advice was effective; that my experience isSometimes those things can be a sign of was pleased that I had indicated the importance developing and I was right to listen to mysomething not quite right.” I gave reassurance of going to the hospital enough for her to do it, intuition, to go back to Sally after the class.that it could well be nothing, but that it was without scaring her too much.just worth checking. I also tried to give her the I know more than I think I do! This gave meincentive that the doctors might be able to give Was your knowledge enough? confidence to give referral advice in the future.her something to help with the itching. Yes, it was enough in this scenario, but mostly I feel I need to update myself with the signs,Why did you respond as you did? because Sally didn’t actually ask me too many symptoms and management of obstetric questions about what the doctors would be cholestasis and pre-eclampsia. To do this I willWhen I was talking to Sally, I used knowledge looking for or why. I am not sure how confident go through my midwifery text books and lookfrom university lectures and from working on I would have been if I had had a lot of questions at Trust policies for management.the antenatal ward on placement. I remembered to answer!that pre-eclampsia was often accompanied by I have printed out the lovely email from thesymptoms such as hypertension and changed It was an extra NCT teacher congratulating me, and put it in mybiochemistry, and that it can affect many appointment because portfolio. It was nice to have that recognitionorgans of the body, including the placenta; if she had hypertension, and it marks an important moment for me, as aleft untreated it can lead to maternal seizures which they wanted to student midwife, when I realised I can actuallywhich could result in maternal and fetal death monitor. I urged her to do this: I really can be a midwife! tpm(Fraser and Cooper 2009). ring the hospital to check that all was ok Sarah Haddrell was a student midwife in the UK Similarly, obstetric cholestatsis (also called at the time of writing and is now a midwife inintrahepatic cholestasis of pregnancy) is a rare Perth, Western Australiabut serious condition which can lead to pretermbirth or fetal death (Royal College of Obstetrics Referencesand Gynaecology (RCOG) 2011). Symptoms includeitchiness without a rash, and unusual liver Fraser DM and Cooper MA (eds) (2009). Myles textbookfunction tests. Considering the potential severity for midwives, Oxford: Elsevier Ltd.of these conditions, referral was important. Macdonald S (2014). ‘How to… keep a reflective journal’. Midwives, 1. RCOG (2011). ‘Obstetric cholestasis’. Green-top Guideline 43, London: RCOG.42 The Practising Midwife | October 2015

Midwifery Basics: preceptorshipKerry Taylor, 1. Success at last!Frances Webster-Benwelland Alice Tindall N ational and professional organisations advocate that employers should provide newly qualified midwives with a structured model of preceptorship. This is to increasePreceptorship is the 15th series confidence and competence, consequently strengthening recruitment and retention.of ‘Midwifery basics’ targeted Working alongside a named experienced preceptor further enhances self-belief and ability,at practising midwives. The aim although there is a shortage of evidence of this role being formalised within existing preceptorshipof these articles is to provide models and the need and value of a structured approach can also be questioned.information to raise awarenessof the impact of the work of Introductionmidwives on women’sexperience, and encourage The Nursing and Midwifery Council (NMC) (2006) strongly recommends that, on commencement ofmidwives to seek further employment, all new registrants should have a period of preceptorship. It is widely seen as ainformation through a series of transition phase for newly qualified registrants (Department of Health (DH) 2010a; NMC 2006). Itactivities relating to the topic. can be a complex time with each individual experiencing and coping with this transitionIn this first article of the new differently.series, Kerry Taylor, Frances There are many expectations of what the term ‘preceptorship’ actually means, what it shouldWebster-Benwell and Alice involve (DH 2008; NMC 2006; Bain 1996; Council of Deans Health (CDH) 2009.) However the DHTindall introduce the concept of (2010a) recognised a common theme between all of these definitions and concluded thatmidwifery preceptorship lead preceptorship is ‘a period of structured transition for the newly registered practitioner duringand examine the positive which he or she will be supported by a preceptor to develop their confidence as autonomousimpact of the role professionals, refine skills, values and behaviours and to continue on their journey of life-long learning’ (DH 2010a: 11). A structured, It has been demonstrated that a structured, individualised, protected period of preceptorship is individualised, protected pivotal for consolidated learning and subsequent retention, in an era when increasing numbers of period of preceptorship is junior midwives are leaving the profession (Hughes and Fraser 2011; Whitehead 2014). Newly pivotal for consolidated qualified midwives now look for recognition from their employer that the need for preceptorship learning and subsequent is acknowledged and that it is structured with monitored development, including working with a skilled practitioner to boost their confidence (Avis et al 2013). Furthermore, it would appear that a retention named preceptor facilitates continuity in clinical guidance and that this should underpin an obvious link between midwifery preceptorship and progress through the gateway from Band 5 to 6 (Foster and Ashwin 2014). Historically >> There seem to have been limited examples of organised, supportive practice and named preceptor sign off; this may reflect the fact that the preceptorship model and delivery have been a local decision, in the absence of a national structured and evaluated programme (Davies and Mason The Practising Midwife | October 2015 43

Preceptorship2009). The DH, nonetheless, recommends a been many changes within the NHS. Given the 2011), whilst still formally monitoring progressyear’s foundation as standard (DH 2008), with light of the recent events outlined in and instilling continuity of support (Avis et althe NMC (2006) advising that this should government reports such as Francis (2013), 2013). This also reinforced new midwives’include protected learning time and access to a Keough (2013) and Kirkup (2015), along with exposure to the multidisciplinary team as wellpreceptor with regular meetings. Despite this, the publication of the NHS five year forward as successfully enhancing clinical skills, careit is left to formal preceptors to augment the view (NHS 2014), it seems that now is the prioritisation, ward management andcompetence and confidence of newly qualified pivotal time in which to look at the way newly workplace socialisation (Feltham 2014). Themidwives, concurrent with their provision of qualified midwives are supported to aim was to improve and enhance the newgood care (DH 2010a). successfully complete this transition and midwives’ sense of investment and belonging, ensure that high quality, safe, personal and in line with the LSA’s recommendations (2011)The national picture effective care is provided to all women all of and to embed a structure to guide and support the time. Here we have reported on the them (DH 2010b).The DH (2010a) did identify that they were development and implementation of twoadapting and testing the Scottish Flying start preceptorship programmes in the UK and the Box 1 Reported HEFT midwiferyprogramme within NHS organisations in benefit of these to newly qualified midwives preceptorship experiencesEngland back in 2009, to help standardise and and preceptors.improve preceptorship within the NHS. HEFT midwifery preceptorshipHowever, little more has evolved since then. Midwifery preceptorship at HEFT experienceThis leaves the Edward Jenner programme fromthe leadership academy (NHS LA) (2015) to be In response to the West Midlands’ local Beneficialthe only national programme available for supervising authority (LSA) recommendation No commentnewly qualified practitioners. This is an online that there should be adequate, structuredlearning and development package with the preceptorship support for junior midwives HEFT midwifery preceptorshipaim of increasing the confidence and (Kuypers 2011), a midwife was appointed, in impact on practicecompetence of newly qualified practitioners to November 2012, to lead midwiferyhelp build a more compassionate NHS through preceptorship at Heart of England NHS Significantlythe programme. However, it is is not a formal Foundation Trust (HEFT). The midwifery improvedrequirement and not specifically for midwives. preceptorship lead worked alongside an Extremely experienced midwifery educator within HEFT’s improvedChanges within the NHS faculty of education to develop a package of support to newly qualified midwives across two HEFT midwifery preceptorshipSince the DH (2010a) attempt to create a acute sites within HEFT and to create a signposting to CPDpreceptorship framework and the NMC (2006) comprehensive induction programme. This wascircular on preceptorship guidelines, there have underpinned by working 50 per cent of her Successful time supernumerary, directly supporting the No comment Activity 1 preceptees in clinical practice. The result was the implementation of a midwifery What does the term preceptorship development pathway directly mapped to mean to you? How do you feel it appraisal, to facilitate a smoother process of differs from mentorship and evolution for the newly qualified Band 5 supervision? What do you think midwives to confident Band 6 practitioners. In preceptorship involves? doing so, it avoided the ‘tick list’ approach with no recognition of existing competency, eschewed in other models (Hughes and Fraser44 The Practising Midwife | October 2015

PreceptorshipLessons learnt developed to secure consistent quality and women and families being cared for feel safe equality for all newly qualified midwives, to and that the service they recieve is personalEvaluation of the role was carried out in order ensure that they continued to be confident, and effective, mirroring the trust’s values.to scope the lessons learnt from this initiative competent practitioners. Rotating through all Furthermore, every six months each newlyacross the service. A combination of areas of maternity services every six months, qualified midwife meets with thequestionnaires and online surveys was each newly qualified midwife has the preceptorship support midwife for two hoursemployed to engage with both the preceptees opportunity to develop their knowledge, skills away from clinical practice to reflect on theirand senior midwifery colleagues. The results and experience with the support of two time as midwives, how they may improve theirrevealed that the newly qualified midwives felt allocated preceptors in each area and one-to- own practice and the service. This is a time towell supported and able to expand their one time with the preceptorship support ensure that mandatory education is complete,clinical skills. Application of the pathway also midwife. and an opportunity to book onto future studyhelped improve their self confidence at work, days to address learning needs.engaging them with other learning and With protected study days exclusively fordevelopment opportunities. The senior newly qualified midwives, there are also A small interim survey was conducted usingmidwives surveyed were also wholly positive, opportunities to attend optional a questionnaire with closed and open-endedechoing the feelings of the preceptees, and supplementary teaching sessions to develop questions to determine the value ofvaluing the supernumerary nature of the role. preceptorship within ELHT. All of those Activity 2 surveyed had worked with their preceptor and In total, 92 per cent of all the midwifery the preceptorship support midwife and 100 perpreceptees surveyed said that they found their If you are qualified, have you cent felt that the support offered to them bypreceptorship experience at HEFT beneficial, 62 experienced preceptorship? How do their preceptors was satisfactory, good orper cent stating that the named preceptor had you feel it benefited you? If you excellent. For all of those surveyed, the mostsignificantly improved their first year of didn’t have one, do you feel you important factors in improving theirpractice, and the remaining 38 per cent have missed something that would experience further was to work with theirreporting an extremely improved experience. have helped you? named preceptors more as well as having more time as supernumerary when first rotating to In terms of the potential impact of skills. Each area has skills competencies to be an area.preceptorship upon recruitment and retention, achieved, in alignment with the key skillsa recent Care Quality Commission (CQC) report framework. This enables the newly qualified Band 6 midwives and ward managers also(CQC 2015) revealed that student midwives at midwife to feel more confident and competent recognised the value of support offered by aHEFT said they would apply to HEFT once when they progress to band 6. Furthermore it preceptorship support midwife, in similar ways.qualified as the preceptorship programme is creates the opportunity to collate evidence of It is interesting to note that in the initial 15excellent. their life-long learning and continuous months of the preceptorship midwife being in professional development to meet the post, sickness levels for work-related stressPreceptorship in East Lancashire requirements for PREP and revalidation (NMC were almost nil and staff retention remained 2011; NMC 2014). high for staff local to the area, those leavingDue to the increase in length of the only doing so to work closer to home.preceptorship programme to two years and the The preceptorship support midwife is ablenumber of newly qualified midwives on the to work supernumerary and flexibly and in Key recommendations to trustsprogramme averaging over 50 at any one time, doing so, not only are any needs of newlya preceptorship support midwife was employed qualified midwives met and resolved promptly, Through formalised support, the midwiferyin 2014 whose full-time role was to it also relieves the pressure on other midwives, preceptorship role and programme developedconcentrate solely on the development and who can often be pulled away from tasks to at HEFT and ELHT facilitates the transitionsupport of newly qualified midwives. provide support. This then ensures that the from midwifery student to qualified practitioner, underpinning quality and safety With the aim of increased staff and client in the provision of care (DH 2010a; NMC 2006). >>satisfaction and staff retention, acomprehensive preceptorship programme was The Practising Midwife | October 2015 45

PreceptorshipThis approach promotes the consistent Activity 3 Bain L (1996). ‘Preceptorship: a review of the literature’.standard of compassionate, holistic care Jour Adv Nurs, 24(1): 104-107.expected of NHS employees (Francis 2013). The Looking within your area of clinical CQC (2015). Heart of England NHS Foundation Trustevidence from both trusts has demonstrated practice, how do you feel that the Birmingham Heartlands Hospital Quality Report,that a role such as this can enhance the skills preceptorship for newly qualified London: CQC.and confidence of newly qualified midwives, midwives could be improved? Can CDH (2009). Report from the preceptorship workshopstheir value being felt by other midwifery you identify any skills or areas in retreat, Bristol (unpublished).preceptors and ward managers alike. Within which you feel that newly qualified Davies S and Mason J (2009). ‘Preceptorship for newly-HEFT the success of the midwifery midwives would benefit from having qualified midwives; time for a change?’ Brit Jourpreceptorship lead also demonstrates a trust’s more support? How do you feel this Midwif, (17)12: 804-805.commitment to maintaining positive support may be best provided? DH (2008). A high quality workforce. NHS next stagerecruitment and retention through a service review, London: Crown.which both attracts and supports newly make the transition more easily. DH (2010a). Preceptorship framework for newlyqualified practitioners (CQC 2015). Thus, the Midwives undergo formal education to become registered nurses, midwives and allied healthongoing provision of a named preceptor at mentors and support student midwives professionals, London: DH Publications.trusts nationally, such as those at HEFT and throughout their learning, yet there is no DH (2010b). Midwifery 2020, London: DH Publications.ELHT, would provide a sound basis for programme of education or or support for Feltham C (2014). ‘The value of preceptorship for newlyfacilitating the continuity of support for newly midwives to become preceptors. The Midwifery qualified midwives’. Brit Jour Midwif, 22(6): 427-431.qualified midwives (Foster and Ashwin 2014). basics series will look at how midwives can be Foster J and Ashwin C (2014). ‘Newly qualified supported to be preceptors, what challenges midwives’ experiences of preceptorship: a qualitative Although the structure of preceptorship they may face and how best to overcome study’. MIDIRS Midwif Dig, 24(2): 151-157.differs between trusts, the need for support for these. In addition, future articles will cover Francis R (2013). Report of the Mid Staffordshire NHSnewly qualified midwives remains a common skills sessions on key topics that are essential Foundation Trust public enquiry. Executive summary,theme and necessity. Given the lack of for newly qualified midwives to learn and London: The Stationery Office.structure of exactly what a preceptorship develop, in order to be confident autonomous Hughes A and Fraser DM (2011). ‘‘Sink or swim’: theprogramme should involve and how long it professionals in their life-long journey of experience of newly qualified midwives in England’.should ideally last, it is clear that support is the learning, and ensuring excellence continues Midwif, 27(3): 382-386.key component that newly qualified midwives across maternity services throughout the UK. tpm Keough B (2013). Review into the quality of care andrequire and what they feel they benefit from treatment provided by 14 hospital trusts in England:the most. Kerry Taylor was a preceptorship support overview report, London: NHS. midwife at ELHT and is midwifery lecturer at Kirkup B (2015). The report of the Morecambe Bay It may be a suggestion for other trusts University of Central Lancashire, Frances investigation, London: The Stationery Office.looking to develop the quality of their Webster-Benwell is faculty senior Kuypers B (2011). The local supervising authoritypreceptorship programme, to look at the value educator/midwifery lead and Alice Tindall is midwifery officer’s annual report April 2010–Marchof a preceptorship support midwife, whose role faculty senior educator and midwifery 2011, West Midlands: LSA.is solely the support and development of newly preceptorship lead, both at Heart of England NHS LA (2015). Edward Jenner programme, London: NHS.qualified midwives who are undertaking a NHS Foundation Trust NHS (2014). Five year forward view, London: NHS.period of preceptorship. NMC (2006). Protecting the public through professional References standards, London: NMC.Midwifery basics series NMC (2011). The PREP handbook, London: NMC. Avis M, Mallik M and Fraser DM (2013). ‘Practising NMC (2014). Revalidation evidence report, London: NMCThrough this series on preceptorship, we will under your own pin – a description of the transition Whitehead B (2014). ‘Preceptorship pays off’. Nurs Stand,begin to learn and understand what anxieties experiences of newly qualified midwives’. Jour Nurs 28(25): 72-73.newly qualified midwives experience and how Management, 21(8): 1061-1071.they overcome these, whilst providing top tipsto help newly qualified midwives of the future46 The Practising Midwife | October 2015

Thinking outside the boxSara Wickham Pondering placentophagy Part 1looks at a recentsystematic review and I am by now used to the kind of spin that Internet discussion can put onconsiders the issues birth-related stories, and I’m not usually too surprised when, on readingrelating to placenta the actual research article which has inspired a headline or discussion, Iconsumption find that it doesn’t bear much relationship to the dialogue that has been knitted from it. So when I went searching for the research paper behind the debates which included an article entitled, ‘What to expect when you're expecting to eat your placenta. A new review of the literature finds no evidence that “placentophagy” is good for mothers. It could even be harmful’ (Beck 2015), I’d like to think I was pretty open-minded about what it might contain. I wasn’t really expecting to find any solid evidence of harm or benefit but, I thought, it’s entirely possible that I have missed a significantly sized research study that had been carried out in this area. The systematic reviewA recent systematic review which looked at That wasn’t the case, though. The original article that had inspired thewhether there are any benefits to placentophagy -the consumption of one’s placenta after birth - has debates was a systematic review, led by a psychiatrist. According to a mediaconcluded that there is no evidence of benefit orrisk and that these require further investigation. In story adapted from the researchers’ press release (Medical News Today (MNT)this article, I reflect on this practice and theresponses to the review in the light of my own 2015), the lead author’s interest stemmed from conversations with women whoexperiences. I note the alleged benefits ofplacentophagy but reflect upon how, in my wanted to know if eating their placenta would interfere with antidepressantexperience, this is often carried out alongsideother nutritional interventions and is thus hard to medication. Reduction of depression is one of the key alleged benefits ofevaluate, either observationally or throughresearch. In the second part of this article I will placentophagy, along with (and according to the various websites whichcontinue this reflection and consider what optionswe have when we have no evidence. promote it, rather than solid research evidence) improved hormonal balance, increased breast milk production, faster postpartum recovery, reduction of postnatal bleeding, faster perineal healing and replenishing iron stores. If even half of these alleged benefits were true, this would be the best postpartum tonic ever. The systematic review included 10 articles; only four of which involved humans, the other six being animal studies. The authors emphasised that placentophagy is an activity undertaken by only a minority of women and they summarised their findings thus: “Experimental animal research in support of pain reduction has not been applied in humans. Studies investigating placenta consumption for facilitating uterine contraction, resumption of normal cyclic estrogen cycle, and milk production are inconclusive. The health benefits and risks of >> The Practising Midwife | October 2015 47

Thinking outside the boxplacentophagy require further investigation of start reflecting on my own experiences of eat brilliantly and send their partner acrossthe retained contents of raw, cooked, and encountering placentophagy and pondering town to get really good iron supplements, rawencapsulated placenta and its effects on the the state of the evidence in this area. organic dark chocolate and good orange juicepostpartum woman” (Coyle et al 2015: 1). to mix into their placenta smoothie. So it is Are there benefits? hard to separate those elements out from anyPersonal and public views of the benefits of placenta consumption, especiallyplacenta In the early years of my midwifery career, when observing a small number of women in which were spent mostly in the USA, women practice rather than looking at data gatheredI will put my cards on the table and admit that who wanted to consume their placenta tended via randomised controlled trials.I don’t have strong views about the to sort this out themselves. There were no paidconsumption of placentas. Which is slightly placenta encapsulation services, though there A part of me would like to think there arestrange, as I have strong views on lots of was a bit of trading and sharing of capsule- benefits to placentophagy, because I do like allthings, but not that. I have strong views that making machines, expertise and tips amongst that circle of life stuff and I’m rather partial towomen should be able to engage in women. Those were different days, and the admiring placentas. But another part of meplacentophagy in the comfort of their own infection control disaster scenarios that some can see the point of the sceptics who arguehomes and without being hassled if they want people might imagine when contemplating that placentophagy is probably more of ato, and strong views about the general such ideas just weren’t a part of the mind-set cultural trend than a tradition passed down thefabulousness of the placenta, but as far as in that area at that time. My role was mainly in ages and that the placenta – which isconsuming it is concerned? Meh, not really helping the family to store their placenta marvellous and beautiful and all that otherbothered either way, sorry. I have cared for appropriately, especially if they gave birth in a good stuff – also acts as a barrier and wastewomen who have consumed, printed, buried, birth centre and needed to borrow a shelf in recycling facility for the baby. So because of allencapsulated and slow cooked their babies’ the clinical fridge while they availed of those points I cannot completely dismiss theafterbirths, and I even know of a woman who themselves of the bathing or snoozing facilities concerns merely as inappropriate and fear-took a big bite out of her newly born placenta before going home. based scaremongering. That doesn’t stop mebecause she instinctively felt that was a good from wishing that people could expressthing to do, and all power to her, but I’ve still Having cared for women who ate placenta themselves and their views in less misogynistic,never developed a strong view on the question capsules, or fried their afterbirth into a patriarchal words and actions, though.of whether doing so carries special benefits. casserole, have I observed any benefits of placentophagy? I truly don’t know. I need to In part two, I will continue pondering But even though I’m somewhat ambivalent acknowledge that, on the whole, the women placentophagy and consider what options weon this topic and wearily used to the disdain in who consume their placentas tend already to have when we have no evidence. tpmwhich many people hold women’s bodies and be on the health-conscious, nutritionally well-the reality of birth, I’m still saddened by the informed and well-nourished end of the Sara Wickham is an independent midwiferylevel of vehemence that they use to share that, spectrum; the kind of women who, if they find lecturer and consultantespecially online, and especially when they out they have low iron levels postnatally, willstart wielding power that threatens women’s Referencesrights to do what they like with their own I do like all that circle ofbodies. Ask me privately what I think about life stuff and I’m rather Beck J (2015). What to expect when you're expecting toplacentophagy and you’ll get the equivalent of eat your placenta. Available at: http://tinyurl.com/that aforementioned ‘meh’. Show me a partial to admiring pjpfbt2 Accessed 24th July 2015headline that sparks discussion about it being placentas Coyle CW, Hulse KE, Wisner KL et al (2015).yukky or dangerous or needing intense ‘Placentophagy: therapeutic miracle or myth?’ Archregulation to be imposed upon women, though? Wom Mental Health, DOI: 10.1007/s00737-015-0538-8.Now I’m paying attention, although perhaps MNT (2015). Eating the placenta: trendy but no provennot for the reasons that were intended, and I health benefits and unknown risks. Available at: http://tinyurl.com/okhgsyn Accessed 24th July 201548 The Practising Midwife | October 2015

Electronic fetal heart ratemonitoring training programmeFREE for all NHS staff – register todayWhat is the eFM programme? eFM is a FREE web-based training programme developed by the RCOG and RCM in partnership with HEE e-Learning for Healthcare. This resource has been updated in line with the 2014 NICE guidelines on Intrapartum Care.Who should do the programme?The programme has been designed for obstetriciansand midwives. Its aim is to teach and assess learners inall aspects of intrapartum electronic fetal monitoring. It’s100% online, so it can be accessed from your hospital,your home and anywhere in between.It’s also free at the point of access for anyone with avalid NHS email address.For more information on why you should undertake this training, visit:www.e-lfh.org.uk/programmes/electronic-fetal-monitoring

Last word Fight for rights: a mother’s perspectiveMichelle QuashieW hy did I have to fight for my right was hoping my consultant would support my to step out of my body and abandon this to a physiological birth? Because decisions. journey, but I couldn’t; there was no way out... my first two children were born by I felt emotionally unstable.emergency caesarean! With my second, I Fearfulhaemorrhaged at 37 weeks due to placenta Supportive midwifeprevia and experienced uncontrollable shaking I was met with a no negotiation response andas my body went into shock on the operating my wishes were ridiculed. My ability to birth I needed support and guidance that I could trusttable. These memories haunt me, leaving scars was doubted as I had never experienced labour so I contacted the local supervising authority, anot visible to the human eye. before; I was advised that if I were to go into phone call that proved to be my lifeline. I was labour I would be taken straight for surgery. put in contact with a midwife who wouldLabelled high risk The focus of the conversation centred on the support me and be my advocate. Transferring major catastrophe that would occur if I was to my care at 37 weeks was very stressful, but wasThe high risk label applied to my third pregnancy rupture and I was reminded that this could a small price to pay for feeling supported. Thisresulted in my care being consultant-led. I was result in the loss of my life, rendering my restored my confidence and I began to feeltold I was ‘not allowed’ to have a physiological children motherless. Conversations were risk strong again. I and my midwife believed in mybirth due to the catastrophe it could cause. averse and left me fearful. body; I felt I was ready for birth.Caesarean section was to be my fate. I left this meeting in turmoil. My intuition Amazing body As time passed my anxiety grew stronger and knowledge were battling with my respectand, by 35 weeks, I felt desperate. How could I for the medical profession’s opinion; one that Whilst in labour I was still fighting off medicalend a perfectly healthy pregnancy with major was claiming to have our lives in their interest. intervention in favour of my intuition and theabdominal surgery? I began to search the But why did I feel so scared, trapped and research I had done. Despite this, after threeInternet for information on vaginal birth after incredibly vulnerable? The conversation had left weeks of prodromal labour, 72 hours of leakingcaesarean (VBAC). me doubting my physical capabilities. I wanted membranes and 22 hours of labour, I was holding my beautiful baby. My body had justHope My intuition and done the most amazing thing: I had given birth knowledge were battling vaginally!The more research I did, the more I became with my respect for thehopeful. I spoke to other VBAC women, I read I will never underestimate my strengths andrelevant guidelines and I joined support groups. medical profession’s capabilities again. My body is amazing! ThisEverything I read and heard contradicted the opinion feeling of empowerment has changed me fromclaim that surgery was my safest option, and the inside out. Birth has made me feel strong,supported vaginal birth as viable for me. so strong - and I will never be doubted again. tpm I attended my 36 week consultant meeting Michelle Quashie is mother to three childrenfeeling fully informed about my choices. I and a member of the Maternity Service Liaisonbelieved that there was no medical reason to Committeeprevent me from having a physiological birth. I50 The Practising Midwife | October 2015