TPM JAN 2013

THE BEST JOB IN THE WORLDwww.thepractisingmidwife.com Volume 16 no 1 • January 2013ProfessionalissuesSupportive supervisionThe politics of volunteeringExploring the fitness to practise hearingNEW! Immigrant women and maternity careNEW! Sexual health after childbirth

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Contents4 EDITORIAL 30 NEW! Altered sexual health after childbirth: part 15 COMMENT Maternal spheres: what are we doing Deirdre O’Malley and Valerie Smith consider the with men? Tina Miller potential risk factors associated with changes in sexual health after childbirth6 NEWS 33 From serenity to halcyon birth centre Kathryn12 Parting the clouds: a vision of supervision of Gutteridge describes how a midwifery led care midwifery Dr Jen Leamon and Jilly Ireland explain model optimising birth has made a great what supportive supervision can achieve difference to the people of west Birmingham16 Volunteering in the maternity services: for whose 37 MIDWIFERY BASICS The social context of infant benefit? Jennifer Hall reports on an inconsistent, feeding In the fourth article of the series, Joyce though valuable role Marshall explores the social context of infant19 REVIEWS feeding in the UK20 NEW! Immigrant women’s perceptions of their 41 RESEARCH UNWRAPPED Midwifery today in Australia Mary Nolan looks at the perceived maternity care: a review of the literature part 1 differences between maternity care and Joanne Fisher and Sharron Hinchliff consider antenatal education in Australia and the UK immigrant women’s maternity care23 Drama in the classroom: fitness to practise Karen 43 AROUND THE CONFERENCES RCM Legal birth Bates describes a creative approach to teaching conference Jenny Fraser reports students about fitness to practise hearings 44 DIARY26 Obesity in pregnancy. Part 2: management In the 44 PROFESSIONAL DEVELOPMENT second of two parts, Frankie Phillips considers the 46 LAST WORD 15 minutes of television time Geraldine management of obesity in pregnancy Butcher laments negativity in programmes on birthEditorial advisory board Jennifer Hall PhD, MSc RN RM © 2013 Medical Education Solutions Ltd. All rights reserved. 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The professionalsAs we begin 2013, looking forward with anticipation and some trepidation, we reflect on the Helen Baston and Julie Wray,professional issues we face in the delivery of high quality maternity services. Joint Editors Working in the NHS involves collaborating with a range of professionals and, increasingly, Cover picture:volunteers. Jenny Hall provides a valuable synopsis of the many different ways that volunteers JOHN COLE/SCIENCE PHOTOcontribute to the care of women and babies, highlighting the importance of clear role LIBRARYboundaries and ensuring that our expectations are appropriate and that volunteers are Photographed at Conquest Hospital,carefully prepared for their role. East Sussex, England.As professionals we are constantly reminded that we practise in an arena that is tightlyregulated. Our professional guidelines and standards are there to help us work in a clientfocused and evidence based way. But we also know that there are serious consequences bothprofessionally and personally if we do not work within the regulatory framework; Karen Batesdescribes an innovative way of preparing student midwives for the implications of suchdigression. Jen Leamon and Jilly Ireland describe how they promote supervision in midwiferyto protect midwives and women and promote normal birth. Kathryn Gutteridge talks us through the journey of user engagement, design andconsultation which paved the way for the development of the Serenity birth centre inBirmingham. She outlines how, in her role as consultant midwife for normality, she was ableto facilitate the implementation of government and local vision to provide a safe birthingenvironment for low risk women. As usual, we also have a range of important clinical papers for you, including: the issuesrelating to regaining optimum sexual health after childbirth; the management of obesity inpregnancy; and an evidence based insight into the context of breastfeeding.The team at TPM would like to wish you all a fulfilling and peaceful new year.CONTACT: 020 8313 9617 SUBSCRIPTIONS: 01752 [email protected]: 66 Siward Road, Bromley BR2 9JZ All subscription enquiries or back issue orders should be addressed to: TPM Subscriptions Department, Proact Marketing, 12 Mary Seacole Road,Joint Editors The Millfields, Plymouth PL1 3JY. Tel: 01752 312140; fax: 01752 313162;Helen Baston PhD, RN, BA (Hons), RM, ADM, MMedSci, PGDipEd email: [email protected] Midwife: Public Health/ Supervisor of Midwives, SheffieldTeaching Hospitals NHS Foundation Trust [email protected] Personal subscription rates (5% direct debit discount in brackets): UK £60Julie Wray PhD, ONC, RN, RM, ADM, MSc, PGCE (HE) (£57); First year of qualification £50 (£47.50); Student (10% direct debitSenior Lecturer, School of Nursing, Midwifery and Social Work, discount) £36 (£32.40); Europe/Eire £70; rest of world £95 (surface) orUniversity of Salford [email protected] £120 (airmail). Institutional/library rates: UK £134; Europe/Eire (airmail) £160; rest of world (air mail) £190. Payment can be made by chequeManaging Editor: Laura Yeates [email protected] payable to ‘The Practising Midwife’ or by credit/debit card: Mastercard,(editorial/author submissions) Visa, American Express and Switch. TPM is published 11 times a year.News Editor: Francesca Robinson [email protected], Copyright: © Medical Education Solutions Ltd, 2013. All rights reserved. No01962 862972 part of ‘The Practising Midwife’ may be reproduced in any material form (including photocopying or storing in any medium by electronic meansAdvertising Manager: Margaret Floate and whether or not transiently or incidentally to some other use of [email protected], 01483 824094 publication) without the written permission of the copyright holder except in accordance with the provisions of the Copyright, Designs andPublisher: Ian Heslop [email protected] Patents Act 1988, or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1P Facebook is a registered 0LP. Applications for the copyright holder’s written permission to trademark of Facebook, Inc. reproduce any part of this publication should be addressed to the publishers. Printed in Great Britain by Williams Press, Maidenhead ISSN 1461-3123 Disclaimer: The sentiments expressed by the contributors and advertisers in The Practising Midwife do not necessarily reflect the views of either the Editors or the Editorial Advisory Board.Subscribe today – 01752 312140

THE PRACTISING MIDWIFE • January 2013 5 Comment Tina Miller Professor of sociology at Oxford Brookes UniversityMaternal spheres: what arewe doing with men?Societal changes have, in recent years, shifted expectations in experiences, but rather to think through – and invite debate –relation to men’s emotional involvement in fathering and the about the ways in which men could be more effectivelyfamily. These include changes in practices of gender, and new included and supported in current practices and provision.policies which signal expectations of changes, such aspaternity leave. Men are now more visible figures in what Men and parenthoodwere once almost exclusively maternal spheres. From Men now participate in various activities, antenatally and inantenatal preparations and presence at the birth, to hands on labour, but once these are accomplished, fathers become lesscaring afterwards, the emotionally involved father is a visible as a focus of service provision. Research has shownrecognisable figure in modern ideas of parenthood. that during the antenatal period men are often looking for ways to demonstrate their involvement, whilst also feelingThe joy of birth and the pain of helplessness detached from the pregnancy (Draper 2003; Miller 2010).But given these changes, how well prepared are men for their They can feel reassured that their partner is being preparedjourneys into fatherhood – and should they be there at all? I and will pass on information as necessary, whilst also hopingpose these questions following my research on men and first that the birth will be ‘natural’ (relatively pain free) andtime fatherhood (Miller 2010). The research found that a ‘instinctive’ when the time comes. But a space in which menmajority of the men felt like ‘onlookers’ (rather than involved) feel comfortable and able to share concerns/fears about theat the birth, were distressed by being unable to comfort or birth and impending fatherhood often is not available inrelieve the pain their partners experienced, felt upset that mixed antenatal classes. At the birth too there is a need totheir self determined role of ‘managing’ the birth plan was think about how men are incorporated/supported in thenot accomplished and were emotionally exhausted by what process (or not) and the unexpectedly forceful procedureswere often more brutal births than had been anticipated. involved in births requiring intervention can leave menThere was wonderment, too, at the birth and most would not feeling bewildered. And yet postnatally men are not generallyhave wanted to miss being there, but their experiences of included in debriefing or postnatal visits and are expected tofeeling helpless left them with unanswered questions and just get on with early fathering. Societal ideals do not easilyfeelings of having failed in some way. facilitate open discussions amongst men about their birth experiences and so difficult experiences and feelings ofA new style of fathering vulnerability/failure can remain unspoken and unresolved.So I am curious about how current service delivery andmaternity practices envisage men as paternal actors and It seems timely then to think again about the ways inwhat this entails in terms of antenatal preparation and which men are incorporated into maternal realms. What doespostnatal inclusion. I appreciate that resources are limited, the current organisation of maternity services signal to mennot all fathers-to-be are present and that women may not about their involvement, what it should be and when andwant partner involvement. But increasingly men seek to where it should occur - and apparently end? TPMundertake fathering in ways that are more involved than inprevious generations. Postnatal depression amongst fathers Referenceshas also recently become a matter of concern, which suggeststhat early fatherhood can be experienced as distressing, with Draper J (2003). 'Blurring, moving and broken boundaries: men’s encountersissues unresolved. My concern here is not to medicalise men’s with the pregnant body'. Soc of health and illness, 25(7): 743–767. Miller T (2010). Making sense of fatherhood: gender, caring and work, Cambridge: Cambridge University Press.

6 • January 2013 NewsUK babies are being breastfedMORE MOTHERS ARE BREASTFEEDING for stopping breastfeeding within the women are receiving. However muchat the time of their baby's birth and first week were: baby would not remains to be done, particularly inmore of them are continuing to suck/rejected the breast, mother terms of increasing exclusivebreastfeed for longer, new figures experiencing painful breasts and breastfeeding rates at six months andfrom the Health and social care mother felt the milk supply was prevalence amongst women frominformation centre (HSCIC) show. insufficient. deprived areas.” But experts have voiced concern The use of follow on formula had She added that their new standardsthat there is no change in the increased after six months, from 53 and changes to their accreditationpercentage of mothers still per cent to 69 per cent. The report process will reflect the changes in thebreastfeeding exclusively at six considers this may reflect active health services and in the UK, to helpmonths. marketing of follow on formula in support health professionals to recent years. further build on the promising survey The Infant Feeding Survey 2010 results.shows that 81 per cent of mothers For the first time the survey records(four in five) in the UK in 2010 initially whether mothers gave birth in a Baby Louise Silverton, the Royal Collegebreastfed at birth, rising from 76 per Friendly accredited hospital. Although of Midwives’ director for midwifery,cent in 2005. the practices associated with Baby said: “We warmly welcome the report Friendly accreditation were linked to and its findings that mothers are At three months, the number of increased breastfeeding rates, the breastfeeding longer. However, theremothers breastfeeding exclusively survey showed that breastfeeding is still room for improvement inwas 17 per cent (up from 13 per cent rates in accredited units in England breastfeeding among groups within 2005) and at four months, it was 12 and Wales were lower than in non traditionally lower breastfeedingper cent (up from 7 per cent in 2005). accredited units, while Scotland rates and those who tend to showed no significant difference and breastfeed for shorter durations. However exclusive breastfeeding Northern Ireland showed a higherrates at six months, as recommended likelihood of breastfeeding. This “Furthermore, there needs to be aby the World Health Organization, reflects the fact that historically, sea change inremained low at around 1 per cent of hospitals with low breastfeeding rates public attitudesmothers. in disadvantaged areas of the UK have towards been more likely to seek Baby Friendly breastfeeding Rates of “any breastfeeding” also accreditation than those in more in publicshowed a significant rise. At six affluent areas such as London and the places andweeks, the number of women South East. more needsbreastfeeding at all was 48 per cent in to be2005 and 55 per cent in 2010, while at The result is that Baby Friendlysix months they were 25 per cent in accredited hospitals tend to have2005 and 34 per cent in 2010. lower breastfeeding rates overall due to serving populations that tend not The survey also found that mothers to breastfeed. However, the adoptionare introducing solids later, with a of Baby Friendly practices has beensignificant fall in the number shown in numerous studies tointroducing solids by four months improve breastfeeding rates withinfrom 51 per cent in 2005 to 30 per those hospitals.cent in 2010. Sue Ashmore, programme director Breastfeeding was most common of the Baby Friendly Initiative, said:among mothers who were aged 30 or “The survey shows many positiveover, from minority ethnic groups, left results that reflect the changes ineducation aged over 18, in managerial practice and standards of care thatand professional occupations andliving in the least deprived areas. The three most common reasons

News January 2013 • 7for longer One in four births is now done to increase the visibility of a caesarean but teenage breastfeeding and its acceptability in public. We are concerned that births have fallen due to staff shortages women may not be getting the postnatal CAESAREAN SECTIONS now account for stable. Questions must be asked as to support they need from midwives a quarter of all births, the latest what the driver is behind this increase whilst they establish breastfeeding maternity statistics from the Health in elective surgery.” in the early days after birth, due to and social care information centre a lack of time and resources for (HSCIC) show. She also expressed concern about the midwives to spend with women.” increase in instrumental births. “An The rise in caesareans to 25 per cent increase in caesarean rates and Heather Trickey, research during 2011-12 from 24.2 per cent the instrumental births often reflects a manager (infant feeding) for NCT, previous year is mainly due to a rise in decrease in involvement with the charity for parents, said: “More older mothers. midwives,” she said. mothers are deciding to breastfeed. It is vital that these Just over one in three mothers aged The data show that the age profile of mothers get the support they need 35 and over had a caesarean (35.3 per pregnant women is rising. The number so that more are able to continue cent) in 2011-12 compared to one in of women aged 40 to 49 having babies for as long as they want to. four women aged 25 to 34 (24.7 per rose by more than 15 per cent and cent) and just under one in six of women aged 30 to 34 accounted for the “NCT welcomes the fact that women aged under 25 (16.6 per cent). greatest percentage of births in more mothers are able to 2011/12. breastfeed for longer, which could The instrumental birth rate has also be due to improvements in increased to 13 per cent, with a rise in However there is some good news on women’s ability to access skilled the forceps assisted birth rate to 6.5 per teenage pregnancies - births to mothers help, through more peer cent, thus continuing the trend of aged 13 to 19 have fallen by 10,000, supporters, drop ins, free antenatal increasing instrumental rates for birth. just over a fifth (22 per cent), in five courses for parents and UNICEF years. Baby Friendly training. The Royal College of Midwives’ director of midwifery, Louise Silverton, England’s baby boom has resulted in “However, we are concerned said the figures were worrying. “It a 6 per cent rise in hospital births in the that a high proportion of mothers means that one in four women giving last five years. stop before they planned to in the birth is having a caesarean, which is a early days and weeks. This major surgical procedure. There has… Ms Silverton said that the baby boom suggests that many women are been a rise in the number of elective and the increasing social complexity of still not getting all the help they caesareans, while the number of the care needs of mothers were need during this critical adjustment emergency caesareans has remained impacting on the workload of already period. Mothers who plan to overstretched midwives. breastfeed need access to skilled, knowledgeable, non judgemental, Midwives needed to assess breastfeeding one to one support.” advice at Healthtalkonline I The Infant feeding survey 2010 ACADEMICS WHO RUN Healthtalkonline, think about the site or the advice given. is at: www.ic.nhs.uk/ statistics- the website of the DIPEx charity, which The findings will be used to assess the and-data-collections/ publishes people’s experiences of health impact of the website. All responses will health-and-lifestyles-related- related conditions, is appealing for be anonymous. There is a short surveys/infant-feeding-survey/ midwives to assess their breastfeeding questionnaire that midwives, women infant-feeding-survey-2010 pages. The award winning web pages and their families can complete at: have been produced jointly by the charity www.surveymonkey.com/s/DMHLMRZ. and Bournemouth University. The pages The breastfeeding pages are at are widely accessed, but the charity is www.healthtalkonline.org/Pregnancy_ keen to know what users of the website children/Breastfeeding.

8 • January 2013 NewsHundreds of stillbirths could beprevented, investigation findsHUNDREDS OF BABIES are dying • No clear guidance is given to specific plans. The Royal Bournemouthneedlessly every year because the NHS women on how to look for signs and Christchurch Hospitals NHShas a chaotic approach to preventing that their baby is moving less Foundation Trust said it “does not havestillbirth, an investigation by The Times than normal, and hospitals are any in place and is not required to donewspaper has found. unsure what to do when worried so.” women present themselves One in every 200 babies is stillborn Janet Scott, of the Stillbirth andand almost a quarter of these deaths • The exact number of deaths since neonatal death society (SANDS), said:could be avoided, experts say. 2009 is unknown because of “There’s confusion as to what action to bureaucratic delay and confusion take to reduce deaths, which results at The investigation revealed that: that have left data unusable best in inconsistent care and at worst in an attitude that they are doing enough. • Few hospitals have any plans to • Patchy and complacent But it’s not enough, because 4,000 cut the rates of stillbirth, which investigation of deaths means babies a year are dying.” are among the highest in the that doctors often wrongly developed world assume that stillbirths could not Health Minister, Dan Poulter, said: “In have been prevented. my time working on maternity wards I • The NHS relies on tape measures never experienced a greater tragedy to screen most low risk women in The Times asked all 144 English than the death of a baby. Whilst the final third of pregnancy hospital trusts that run maternity units maternity care is constantly improving, what plans they had in place to cut our National Health Service needs to do • Guidelines on measuring unborn their stillbirth rates. Of the 98 units that a lot more to reduce the number of babies, for example with replied, only six said that they had any stillbirths.” customised charts, are routinely ignored despite estimates that they could save 800 lives a yearNew maternity and children’s servicesopen at the Royal Oldham HospitalA £44M NEW MATERNITY UNIT, outstanding result in a recent UNICEF “Despite the challenges of the recentchildren's unit and neonatal intensive breastfeeding support audit. redesign of inpatient maternitycare unit has opened at the Royal services and the merging of OldhamOldham Hospital. Dr Val Finigan, consultant midwife and Rochdale midwifery teams, we for the infant feeding team at Pennine have jointly succeeded in sustaining Approximately 5,300 babies are Acute Hospitals NHS Trust, said:expected to be born a year at the UNICEF standards forthe new maternity unit in the breastfeeding, demonstrating thepurpose built four storey quality of services provided by thebuilding, which also includes a trust.midwife led birth centre. “The pass rates achieved are an The facility includes 14 outstanding example of thelabour rooms all with ensuites midwives’ ability to work togetherand a postnatal ward with 29 to ensure local women receive thebeds. best standards of care in relation to feeding and caring for their Midwives at the trust babies.”recently achieved an

News January 2013 • 9More babies survive premature birthbut rise is predicted in number ofchildren with lifelong health problemsMORE BABIES ARE SURVIVING after the decade the number of admissions to Although the study revealed someextremely premature birth before 26 neonatal intensive care units of these evidence of improvement in theweeks, but the number with major babies increased by 44 per cent. By proportion of babies who survivedconditions on leaving hospital remains 2006, survival shortly after birth without disability there was no changelargely unchanged, an analysis of the increased by 13 per cent to 53 per cent in the rate of severe impairment, say thedata for England has revealed (Costeloe but the proportion of survivors leaving authors.et al 2012). hospital with major health problems was unchanged. However, they stress that these A second study (Moore et al 2012) findings should be interpreted withshows some improvement in the These results suggest that the total caution, and say \"only assessment of thenumber of extremely pre term children number of children in the community 2006 cohort at school age will clarifywho survived without disability at three with lifelong health problems as a result whether there have been importantyears of age but no change in the rate of of extremely pre term birth will rise and changes in the high prevalence ofserious health and developmental represents an important increase in impaired cognitive and behaviouralproblems over the same 10 year period. workload for health, educational and outcomes.\" social services, conclude the researchers. References: Costeloe K, Hennessy E, Haider S et Taken together, these two studies(known as the EPICure studies), suggest The second study compared the al (2012). ‘Short term outcomes after extremelittle progress has been made in neurological and developmentalreducing serious long term problems in outcomes of extremely premature preterm birth in England: comparison of twoextremely premature babies, despite the babies at age three years between 1995introduction of a range of measures and 2006. The proportion of survivors birth cohorts in 1995 and 2006: the EPICuredesigned to improve clinical outcomes. with severe disability at three years was unchanged but an estimated 11 per studies’. Brit med jour, 345: e7976. The first study compared survival and cent more babies born between 22 andoutcomes of babies born between 22 25 weeks survived without disability. Moore T, Hennessy E, Myles J et al (2012).and 25 weeks in 1995 and 2006. Over ‘Neurological and developmental outcome in extremely preterm children born in England in 1995 and 2006: the EPICure studies’. Brit med jour, 345: e7961.Crown prosecution service to crackdown on female genital mutilationTHE CROWN PROSECUTION service Keir Starmer, director of public complaint to the prosecutor taking a(CPS) has announced plans to crack prosecutions, has now published an charging decision – needs to know whatdown on the crime of female genital action plan in a bid to tackle the to do to improve detection rates,mutilation (FGM). problem. \"It's critical that everything strengthen investigations and, on the possible is done to ensure we bring the part of the Crown Prosecution Service, There has been growing concern that people who commit these offences to start getting these offenders intothe practice continues to take place in against young girls and women to court,\" he said.the UK and that young girls are taken justice and this action plan is a majorabroad by their families to undergo it. step in the right direction Louise Silverton, director of midwifery for the Royal College of FGM has been a criminal offence for \"Everyone who can play a part in Midwives, said: “It concerns me that sonearly 30 years but there has never stopping female genital mutilation – many UK midwives are seeing cases ofbeen a prosecution. from the doctor with a suspicion that FGM. We need to have good mechanisms an offence has been committed and the in place for midwives to report and take In the UK, it is estimated that up to police officer investigating the initial appropriate actions about FGM.”24,000 girls under the age of 15 are atrisk of FGM.

10 • January 2013 NewsMidwife led birth centre opensat the Bradford Royal InfirmaryMidwife Ann-Marie Orr and Emma A £1.2M MIDWIFE LED birth centre has opened at the Bradford Royal Infirmary asWoolner with baby Kayden part of a £3.6 million investment in maternity and neonatal facilities. The seven bedded unit has two birthing pools and a relaxing environment where women can give birth in specially designed home-from-home rooms. IPod docking stations are attached to the walls of every room and birthing aids include birth stools, mats and balls. The adjacent 13 bed consultant led labour ward has been refurbished and a new bereavement room created. In addition Bradford Hospitals NHS Foundation Trust has spent £400,000 recruiting 37 new maternity staff and £2m has been earmarked for an expansion of the neonatal unit. Midwives worked closely with the trust’s estates department and the Bradford and Airedale maternity services liaison committee to ensure that the design and décor were correct. Consultant midwife, Alison Brown, said the opening of the birth centre was a “very exciting development for women across the city. “We want women to feel as if it's their space and we want them to be very comfortable in it. This is also a momentous day for staff as it has been five years in the planning,” she said.BFI launches new standards Welcomes and farewells at the Iolanthe Midwifery TrustTHE BABY FRIENDLY INITIATIVE has unveiled a new set of standards for maternity,neonatal, health visiting/public health and children's centres/early years settings. DR JULIE WRAY, senior lecturer at the University of Salford and joint editor of The The standards incorporate previous standards as specified in the Ten steps to Practising Midwife has joined the trusteesuccessful breastfeeding and Seven point plan for sustaining breastfeeding in the group of the Iolanthe Midwifery Trust, acommunity, but update and expand them to fully reflect the evidence base on charity which promotes and improves thedelivering the best outcomes for mothers and babies in the UK. care of mothers, babies and families through awarding grants and fellowships I The document can be downloaded at: www.unicef.org.uk/BabyFriendly/ in support of midwifery education,Health-Professionals/New-Baby-Friendly-Standards practice and research.G Baby friendly award for De Montfort University She is joined on the trustee group byDE MONTFORT UNIVERSITY (DMU), Leicester, has received the internationally Sheena Byrom, freelance midwiferyrecognised Baby Friendly Initiative (BFI) award for the high levels of education in advisor, consultant, speaker and authorbreastfeeding provided to students on its midwifery courses. and Phoebe Pallotti, clinical midwife at the Jessop midwifery led unit, PhD student DMU’s midwifery courses are two of only 13 university courses which have and student ambassador for learning andbeen successfully accredited as ‘baby friendly'. teaching at the University of Sheffield. The BFI award for universities was introduced in 2008 to ensure high levels of The new recruits will replace two longeducation in breastfeeding are incorporated in midwifery and health visitor standing trustees: Jean Davies and Dr Lukecourses. Zander, who have decided to draw their roles to a close after 13 and 12 years Rowena Doughty, senior lecturer in midwifery, said: \"We decided to work with respectively, and Professor Ruth Deery whothe BFI to ensure a high standard of training in breastfeeding for all student has signalled her intention to step downmidwives graduating. By ensuring that our students are fully trained in how to early in 2013.help a mother breastfeed her child, more women will be able to breastfeed theirbabies for longer.”



12 • Supervision of midwifery January 2013 • THE PRACTISING MIDWIFEParting the clouds: a visionof supervision of midwiferyAs supervisors of midwives,Dr Jen SUMMARY This paper describes a response to the evidence thatLeamon and Jillian Ireland midwives often have a limited view of the roles and responsibilitiesdescribe two approaches to of the supervisor of midwives (SoM) and SoM team. Using a creativepromoting transparency and a approach (word clouds) and midwife/SoM stories, the importance ofdeeper understanding of what relationships which are supportive of midwives, women andsupportive midwifery supervision normality is highlighted. Emotional intelligence and interprofessionalcan do for midwives and mothers communication are also shown to be key aspects of the role. Supervision has an important role to play in supporting midwives' development, promoting normality and generally protecting midwives and the public. Reflection using creative media can contribute to this. Keywords Emotional intelligence, guardianship, reflection, relationship, creative Authors Dr Jen Leamon, supervisor of midwives in Salisbury and leader of the preparation of supervisors of midwives at Bournemouth University and Jillian Ireland, supervisor of midwives in Poole and BournemouthIntroduction There is a need for reflective professional education of preOne of the challenges faced by greater understanding and post registration midwives tosupervisors of midwives (SoMs) is of the statutory communicate an experience, vision orcommunicating the role, its framework by both model of care, for example via art,responsibilities and the principles midwives and SoMs poetry or craft work (Hall and Mitchellunderlying SoM practice to non SoM 2008; Leamon 2012; Bedford and Laucolleagues. Several studies described in word cloud; the second uses stories 2012) .a recent systematic review found that shared by midwives and SoMs.the participating midwives displayed a In recent years word clouds haverange of perceptions on this issue Word cloud become familiar in newspapers, blogs(Henshaw et al 2011) and the review We agreed to use a visual image to and in education (McNaught and Lamsuggested that there is a need for share priniciples of SoM practice. 2010); the Royal College of Midwives’greater understanding of the statutory Creative approaches have a place in the (RCM) midwife word cloud presented asframework by both midwives and SoMs. way we articulate the art and science of a sticker and poster is shown on their our midwifery roles and in the website. In this paper the authors, both SoMs,share two effective methods which We chose the word cloud as it canthey have found for communicating the assimilate a lot of information by usingSoM’s role and how this can support a computer programme to place themidwives and women in achieving safe words into a 'cloud'. The process ofand positive birth experiences. The first creating a word cloud is to identify textapproach describes the creation of a and upload it to the online resource. The more frequently a word is used in a

THE PRACTISING MIDWIFE • January 2013 Supervision of midwifery • 13document, the bigger it will appear in Preparing for Lucy’s role as being focused on annual reviews Mthe word cloud. On entering the whole birth with the support and adverse incident investigation. Toof the Nursing and Midwifery Council of her SoM had ensured redress this we have selected two(NMC) (2006) publication 'Standards for her effectiveness stories which show collaborativethe preparation and practice of beyond the planned working and positive relationshipssupervisors of midwives', into the situation between mothers, midwives and SoMs.Tagxedo tool, the word cloud in Figure 1was produced. practice, these being between women, The stories highlight a number of midwives and SoMs (NMC 2010). We words and phrases associated with SoMFigure 1 Word Cloud 1 identified words from the literature practice: being an advocate of women Whilst this made an interesting word linked to the principles and practice of and midwives; enabler of choice; midwifery supervision and explored showing emotional intelligence; andcloud, the emphasis was on preparation them using a visual thesaurus. These using and promoting reflection andto become a SoM rather than its role words along with key words, phrases guardianship in everyday practice. Theand principles. By inputting the and actions from the NMC publication actions associated with these describecompetencies alone, the word cloud in (2006), were entered into one of the the interrelatedness of the head, handsFigure 2 resulted. tools and, after some playful and heart of the individual SOM or manipulation of colour, layout and text team. In sharing these stories we haveFigure 2 Word Cloud 2 style, the poster entitled 'What can your altered names to ensure anonymity Figure 2 showed us words which, SoM offer you?' was produced (shown (NMC 2008). in Figure 3).whilst identifying aspects of the SoM *Lucy and Mandy: being preparedactivity, do not illustrate the Figure 3 Poster showing the positive Several years ago as part of thesignificance of relationships in good role of supervisors of midwives preparation for the SoM programme at Two stories Bournemouth University, I (JL) heard a Henshaw et al's (2011) review identifies story from one of the participants midwives' understanding of the SoM about a local strategy of advocating for a woman and midwife. Lucy was expecting her second child and the baby was in breech presentation at around 36 weeks. The risks of different options and actions were discussed, involving the community midwife, a SoM and consultant obstetrician. Lucy decided, having taken everything on board, including reading the ‘Hannah trial’ (Hannah et al 2000), that she would like to progress with a home birth. What followed was a story of balance in the advocacy of Lucy and her desire for a home birth with the support of a well prepared midwife, Mandy, who had some experience of breech birth, supported by a SoM. Mandy went on call, supported to review her knowledge and practice skills by simulation. The second midwife on call had experience of breech birth. The SoM’s creation of the plan for Lucy was communicated to the obstetricians for their information. Mandy was called to Lucy’s house in the early hours of the morning around

14 • Supervision of midwifery January 2013 • THE PRACTISING MIDWIFEterm, to find her in established labour Local Supervising Authority (LSA) Referencesand progressing towards the birth. All guidance (Drazek 2008). The resultingwas well with the mother and with the plan, completed before the baby was Bedford H and Lau A (2012). ‘Enhancingbaby who came into the world head born, echoed aspects of the creativity in midwifery education: developingfirst. Lucy had reported having documentation from the agency. A a personal philosophy of care’. Paperexperienced some big movements significant aspect of enacting the plan presented at the RCM conference, Brighton.several days beforehand. was communication with relevant parties including the community Drazek M (2008). Guidance for Supervisors of Within the week Mandy was called midwife in the commissioning parents' Midwives. www.northwest.nhs.uk/LSA/. Lastout to another planned home birth. home town and social services in the accessed 5th October 2012.This baby was born soon after Mandy areas of the birth mother andhad identified it to be in the breech commissioning parents. Toni and Jayne Hall J and Mitchell M (2008). ‘Exploring studentposition on pushing. She reflected that discussed this process with colleagues midwives’ creative expression of the meaningpreparing for Lucy’s birth with the and since then a trust policy has been of birth’. Thinking skills and creativity, 3(1): 1-14.support of her SoM had ensured her developed and the topic is included ineffectiveness beyond the planned mandatory update education. Hannah ME, Hannah WJ, Hewson SA et alsituation. (2000). ‘Planned caesarean section versus Concluding words planned vaginal birth for breech presentationToni, Darcy and commissioning parents: We hope we have given insight into the at term: a randomised multicentre trial’. Thebeing responsive role and underlying principles of SoM Lancet, 356(9239): 1375-1383.This story is a creative amalgam of real practice through the word clouds andevents taken from different situations. stories we have created and drawn from Henshaw AM, Clarke D and Long A (2011).Toni took over the care of a woman practice. The SoM role is important in ‘Midwives’ and supervisors of midwives'expecting her third child on the labour supporting midwives, promoting perceptions of the statutory supervision ofward; information provided at shift normality and protecting the public. If midwifery within the United Kingdom: ahandover suggested all was low risk you want more information regarding systematic review’. Midwifery, 11(11): 4.and going well. As Toni spent time with supervision of midwifery please look atDarcy she discovered that she was the NMC documents in the references Leamon J (2012). ‘I am here: reflective learningacting as a surrogate mother. In her list and at the new Midwives’ Rules and a poem about a midwife, mother and anotes, there were documents from the when published early this year. To find baby’. Essentially MIDIRS, 3(2): 46-49.agency being used to set up and out more about local midwiferysupport the surrogacy relationship, but supervision in your own area, please McNaught C and Lam P (2010). ‘Using a Wordlethere was no documented plan from consider sharing and discussing the as a supplementary research tool’. Thethe trust to support Toni in her care of poster (Figure 3): 'What can your SoM qualitative report, 15(3): 630-643.Darcy, the baby and the commissioning offer you?' TPMparents. At this time there was no NMC (2006). Standards for the preparation andpolicy on surrogacy in place in the trust. Dr Jen Leamon is supervisor of midwives practice of supervisors of midwives, London: in Salisbury and leader of the preparation NMC. Toni could see that Darcy and the of supervisors of midwives atcommissioning parents were well Bournemouth University and Jillian NMC (2008). The code: standards of conduct,prepared and had access to support Ireland is supervisor of midwives in Poole performance and ethics for nurses andfrom the agency, community midwife and Bournemouth midwives, London: NMC.and health visitor who would beinvolved with the commissioning NMC (2010). Supervision, support and safety:parents. At this time Darcy’s labour was analysis of the 2008-09 LSA reports to theprogressing well. Given the lack of trust NMC, London: NMC.policy, Toni spoke to the on call SoM,Jayne. Jayne came in to ensure an Further resourcesappropriate, safe and sensitive plan wascreated in relation to the needs of the Royal College of Midwives (RCM): www.rcm.org.birth mother and the baby. To do thisshe accessed both the RCM's position Visual thesauruses: www.visualthesaurus.com; www.wordsift.com.statement on surrogacy (currentlyunavailable but in RCM archives) and Word cloud tools: www.wordle.net; www.tagxedo.com; www.wordsift.com.



16 • Volunteering January 2013 • THE PRACTISING MIDWIFEVolunteering in thematernity services:for whose benefit?Having canvassed the views of SUMMARY In recent years volunteers have become part of thevolunteers and employers,Jennifer maternity services to support midwives in the UK. FutureHall reports on an inconsistent, midwifery students are being expected to have gained suchthough valuable role experience when applying for courses. They are providing significant support for women in relation to breastfeeding and in other supportive roles. However this article aims to explore what volunteers are doing, questions whether the recent shortage of midwives is leading to volunteers being asked to take on tasks that are beyond their unpaid status and asks who is really benefiting from this role. Keywords Midwifery, volunteers, student midwives, NHS Author Jennifer Hall, Senior Lecturer in Midwifery at the University of the West of EnglandIntroduction During the interview History of volunteering in maternityI have been in education for a number process now the Volunteering in the NHS per se is not aof years now. Ten years ago, when majority of aspiring new thing. Many hospitals wereasking whether an interviewee had students are founded through the funding andexperienced life in the maternity ‘volunteering’ for a support of volunteers who became aservices, the cry was always ‘No: no-one period of time ‘league of friends’. The Womenswill let me.’ Getting into maternity Voluntary service, (now WRVS) foundedservices as an outsider was always I am grateful for the mass of responses I in 1938 to help those civilians in needimpossible. But something has received and the following is based on during World War 2, has evolved tochanged. During the interview process these. It is clear that some debate is provide social services, mainly to thenow the majority of aspiring students required around this development. elderly, with support in GP practices asare ‘volunteering’ for a period of time. well as patient support in hospitals andIn listening to some of the stories of provision of cafés and shops. Volunteerstheir activities I thought it was time to have also been present in main hospitalinvestigate the ‘volunteering’ services with library and hairdressingphenomenon. I sent out a few emails provision. However hospital basedand also contacted our friends on maternity services have been less keenStudentMidwife.Net to ask about to include those from outside the service.volunteers’ and employers’ experiences. In 1956 Prunella Briance established

THE PRACTISING MIDWIFE • January 2013 Volunteering • 17the early group interested in natural Breastfeeding support Some had needed tochildbirth that was to become the The main area where volunteering has volunteer first withinNatural Childbirth Trust, then the developed is within the area of another area of theNational Childbirth Trust and now NCT breastfeeding support. Research hospital before a place(2012). These volunteers provided birth evidence identified that peer support came available inpreparation classes and parenting and group support improved both maternity areassupport in the community, although initiation rates and duration of feedingthere was a reluctance to encourage (Fairbank et al 2000). In this area, Maternity Support Workers (MSWs),their presence within hospitals. therefore, volunteer support has who are taking on more skills that wereCertainly in the 1980s I remember some become an acceptable and valued traditionally the midwife’s role; andantagonism from colleagues towards resource within the last 10 years. now volunteers appear to be taking onlocal NCT teaching and birth supporters some of the jobs of MSWs. A report bywho were not family members. Over However this need for support has the Institute for Volunteering Researchtime this relationship has changed and been fuelled by the current shortage of (Teasdale 2008) showed that differentit has become commonplace for women midwives and a realisation that it has age groups of volunteers had differentto attend antenatal education by other become more of a challenge to provide motivations for doing so: older groupsthan midwives and for birth supporters acceptable levels of care to women. had more altruistic motivations whileto be welcomed. Maternity services have opened the younger volunteers had career based doors to increasing the numbers of motives, either for improving English or as work experience. Evidence from theTable 1 What are volunteers doing? Ward areas study demonstrated ex service users’Birth Areas Breastfeeding support mental health improved throughDoula Answering doors volunteering. Other evidence shows the positive impact on the participantStocking up treatment areas (Paylor 2011; Casiday et al 2008).Making tea for women and staff Answering phone Places for volunteersAnswering calls from women in labour Talking to women Overall those who responded to me didMeeting and accompanying women into Answering women’s call bells not indicate any difficulty in finding arooms Stocking up cupboards volunteer place, but this may beEnsuring water is available because it was not a question I asked. Some had needed to volunteer firstTransferring blood vials to the blood chute Making beds within another area of the hospital before a place was available in maternityMaking up folders Taking parents to visit babies in NNU areas. Others did indicate an issue ofCommunity Clearing the kitchen/emptying rubbish challenges due to competition amongst those wanting to be student midwivesBreastfeeding counselling Filling water jugs with waiting lists for places mentioned. A particular challenge was raised by anWorking with maternity charities Bathing babies aspiring male student midwife whoHelping with antenatal classes Distributing food indicated that for him it had beenAntenatal Transporting to and from the pharmacy impossible to obtain a volunteer place, Caring for a baby who is to be adopted (for despite sending numerous emails. HeProviding tours of the maternity unit a shift) was clearly frustrated that, in theHelping with ultrasound and Administrative dutiesamniocentesis Taking women to showersOtherResearch support workers MAssisting with a paediatrician’s newbornclinic: escorting women and babies withtheir notes

18 • Volunteering January 2013 • THE PRACTISING MIDWIFEcompetitive world of student midwives, A particular challenge what volunteers are allowed to do washe was feeling disadvantaged as a male raised by one who stated that some staffat being unable to secure an opportunity was raised by an welcomed help to make a bed or bath afor experience, which appears to be baby but for others volunteers weren'texpected now prior to interview. It would aspiring male student allowed to do anything practical.be interesting to know if other aspiringmale midwives have similar problems. midwife who indicated Though boundaries may be thought to be in place, and many volunteersTraining that for him it had been complained that they felt they could doIn many trusts management of more ‘hands on’, it is evident that somevolunteers is carried out by a specific impossible to obtain a are able to overstep these boundariesvolunteer coordinator, though others depending on the midwife’s beliefs. Iare managed within the context of the volunteer place suspect, too, that in the busy birth areasservices management. Volunteers are where uniform is often replaced byexpected to have completed a CRB volunteers were expected to meet ‘scrubs’, midwives may not recognisecheck. Those who contacted me found women and their partners at the door volunteers as such and expect them tothat training for the post varies according of the unit. One volunteer told me how fulfil the role of a MSW. In suchto the trust. They listed issues such as out of her depth she has felt at having ‘busyness’, conscientious volunteersconfidentiality, back care and safe to deal with angry and stressed parents. may also feel they can ‘do more’ to helphandling, hand washing, child the midwives and women.protection, fire safety and infection In the past, hospital tours were alsocontrol. Others were less complimentary carried out by midwives, often those Cost cuttingabout training for the roles they were from the community bringing their Some may consider this is not aexpected to carry out, especially if this antenatal groups in together, again as a problem, but it could be argued thatwas by another volunteer. In order to be way of providing reassurance. Some of volunteers are being used in manyeffective in the role, it is clear that the volunteer tour guides expressed cases to replace MSWs as they are freevolunteers require appropriate guidance frustration at not being able to answer and willing to do the role. In Teasdale’sand support, especially in an area as the questions of those who were being (2008) report some volunteers felt theycomplex as maternity services. It would shown round, especially around were being used as ‘cheap labour’ whichseem appropriate that midwives should provision of relief of pain, and needing was echoed by some staff. In additionbecome involved in being aware of the to find a ‘passing midwife’ to answer caution needs to be applied to ensuretraining of volunteers to ensure that some of the questions. They expressed that the safety of mothers and babiesvolunteers know what is expected of concern at those on the tour hearing remains paramount and the care theythem and are able to carry out the tasks. the noises coming out of some of the receive is by skilled, qualified staff, who rooms and the need to handle this are in turn protected by contracts andVolunteers doing midwives’ jobs sensitively. This must be less than terms of service. This is about ensuringThose who contacted me came from all satisfactory for those touring as well as that there is a quality, regulated serviceareas of the maternity services though the volunteers. and ethical principles of confidentialitymostly based in the hospital setting. and non maleficence are adhered to.Table 1 gives a list of the tasks these Role boundaries Volunteers should also be protectedvolunteers are carrying out. It is The list also includes caring for babies from situations for which they are notinteresting to see this list as there are a on postnatal wards or taking parents to educated and that their goodwill is notnumber of things here that midwives visit their baby in an intensive care abused for the sake of cost cutting.were previously expected to do as part situation and needing to deal withof their role. For example I can remember parents’ stress. Other volunteers told Who is benefiting?how important it was for a midwife (or me they had been present with The question remains how much isstudent) to answer the telephone to midwives examining women, which volunteering benefiting the service inwomen in labour to ensure they had had made them feel uncomfortable; cost saving on salaries for boththeir queries answered straight away by they had witnessed births, watched maternity and administrative staff anda person qualified to answer; this would caesarean sections or had been given how much is it benefiting the volunteer,reduce stress and anxiety and make the the opportunity to watch an giving them confidence and a sense ofwoman feel welcomed to the unit. Some amniocentesis. The discrepancy between well being as well as opening the door to career opportunities? Many of the

THE PRACTISING MIDWIFE • January 2013 Volunteering • 19Those who still want to worked and what pressures midwives Jennifer Hall is Senior Lecturer in Midwiferybe midwives are are really under. Those who still want to at the University of the West of Englandcertainly entering the be midwives are certainly entering theprofession having seen profession having seen the reality from Referencesthe reality from first first hand, which may have a positivehand, which may have a effect on attrition rates. Ultimately, Casiday R, Kinsman E, Fisher C et al (2008).positive effect on though, the key question lies in what Volunteering and health: what impact does itattrition rates effect this is having on the care of really have? London: Volunteering England. women and their families in therespondents reported how much fragmentation of care or on providing Fairbank L, O'Meara S, Renfrew MJ et al (2000). ‘Aconfidence they were gaining in peer support for women where it is systematic review to evaluate thespeaking to women and large groups, lacking through the reduction of the effectiveness of interventions to promote theas well as seeing how the service numbers of midwives? Research needs initiation of breastfeeding’. Health Tech to be carried out into how these roles Assess, 4(25): 1-171. are affecting care and who this is really benefiting, as well as monitoring the NCT (2012). Our history, London: NCT. expanding role of volunteers to ensure Paylor J (2011). Volunteering and health: protection for all concerned. TPM evidence of impact and implications for policy and practice, London: Institute for Volunteering Research (IVR). Teasdale S (2008). In good health. Assessing the impact of volunteering in the NHS, London: IVR and NAVSM.Reviews Also on page 29 101 Amazing things process that impacts over many generations – depending on about pregnancy the person being conceived’ and then gives Florence Nightingale as an example. Does the author intend to imply Afron Monro that people who have less notable lives than Nightingale do not impact on future generations? Presumably everyone 2012, Carroll and Brown Ltd, 128pp, £9.99, influences generations to come simply by virtue of their pbk ISBN 978 1 907952 11 1 existence? The book’s 101 facts are organised The information given may be accurate, but is rarely useful. into sections which cover We are told that babies are exceptionally adaptable to conception, life in utero, labour different environments, but not what the implications of and birth and finish with the this might be for the mother. While the book’s language is newborn and the postnatal mum. generally accessible (when not simplistic), sometimes surprisingly complex vocabulary appears, such as the It is hard to know who exactly the reference to ‘intersex genitalia’ on page 15.intended readership is, and its purpose is certainly unclear. Icannot tell whether it was written simply as a coffee table Occasionally, the writing seems to lack sense. For example,publication, whether it hopes to inspire pregnant women or when talking about pregnancy, we are told that ‘althoughwhether it intends to offer advice on how to have a safe there is a division between a mum’s body and that of herexperience of pregnancy, birth and early parenthood. baby, they are both entirely within the mum’s body’ (p28).Some of the ‘facts’ appear to be directed at women who This is a book that has lost its way, whatever angle it isaren’t living in the 21st century (do readers really need considered from, and I could not recommend anyone to buy it.informing that ‘some (people) take drugs for years orundergo operations to both increase or decrease fertility’?) Mary NolanOccasionally, the book has simply not thought through Professor of perinatal education at University of Worcesterwhat it is saying. For example, talking about the start ofpregnancy, it claims: ‘Those shared minutes can also start a

20 • Immigrant women’s perceptions of their maternity care January 2013 • THE PRACTISING MIDWIFEImmigrant women’s perceptionsof their maternity care: a reviewof the literature part 1In the first article of a two SUMMARY Every year since 2004, the Office for National Statistics (ONS) haspart article,Joanne Fisher recorded increasing levels of immigration with nearly 600,000 immigrantsand Sharron Hinchliff entering the UK in 2011 (ONS 2012). More than 50 per cent of theseconsider immigrant immigrants were women. With this increasing immigration to the UK, a reviewwomen’s perceptions of of the literature was conducted to understand the experiences that immigranttheir maternity care women have when encountering the maternity services in the UK. Twelve quantitative and qualitative studies were included in the review, each approach contributing uniquely to our understanding of the subject area. Five themes were identified when the articles in the review were analysed. They were: communication, impediments to accessing healthcare, relationships with healthcare providers, cultural standpoint and social circumstances. The first two of those themes will be considered in this article. Keywords Immigrant women, perceptions, maternity services, review Authors Joanne Fisher, midwife and nurse working in the family nurse partnership and Sharron Hinchliff, lecturer in nursing and midwifery at the University of SheffieldIntroduction Even working immigrant the past nine years the birth rate hasIn 2008, the House of Lords Select professionals who used gone up and now stands at its highestCommittee (HLSC) conceded that the English daily had level for nearly 30 years (ONS 2011). Inmaternity services are particularly difficulties when it came 2010 ONS recorded that 25.1 per centaffected by immigration, as the to conversations about of all live births were born to immigrantmajority of immigrant women are of health mothers, although in some Londonreproductive age (HLSC 2008). They boroughs this rose to nearly 70 per cent.acknowledge that the true impact ofimmigration on maternity services is Methodnot known as no data are collected on Whilst the original aim was to performimmigrants accessing health services; the literature review solely using UKin particular, entitlement to NHS care papers, it became apparent that thereas European economic area (EEA) was limited empirical research from thecitizens. However, it is known that for UK. Therefore the review was widened

THE PRACTISING MIDWIFE • January 2013 Immigrant women’s perceptions of their maternity care • 21to include countries that provided Even when materials may not be there. Mpopulation inclusive maternity care, were available,the When translating, it can be difficultwere English speaking (or had women were frequentlypublished their studies in English), had not directed to them due to achieve the correct language ora comparable socio economic profile to insufficient dialect, some words or concepts canand offered some similarities with their awareness of their literally get lost in translation as therematernity structure. They were all in the existence among health are no corresponding words in the othertop 20 countries by percentage of the professionals language. The idiosyncrasies ofworld’s immigrants living there. Both language mean that healthquantitative and qualitative approaches by Petticrew and Roberts (2007). A professionals may never attain an idealwere included. narrative analysis of the papers was conversation, even with someone that carried out and five themes identified is fluent in English. Chu (2005) found Using defined search terms the (variations in the maternity services that even working immigrantonline databases of Applied Social experience of the immigrant groups professionals who used English dailyScience Index and Abstract (ASSIA), studied were evident within these had difficulties when it came toBritish Nursing Index (BNI), the themes). The diversity of findings could conversations about health.Cumulative Index to Nursing and Allied be associated with the substantialHealth Literature (CINAHL), ISI web of cultural differences that separate the Bender et al (2001) discussed theknowledge, MEDLINE and PsycINFO immigrant groups. problems associated with healthwere searched to identify relevant professionals speaking a specialisedliterature in the field of immigrant Findings language that they term ‘Medicalese’.health. Theme 1: Communication This may be overcome if they use an Briscoe and Lavender (2009) identified interpreter who is used to working in Twelve research studies were that there is often an assumption by the healthcare setting. However, someretrieved. Eight employed a qualitative individuals that communication has women in the study by Herrel et alapproach, two used triangulation to achieved a level of comprehension (2004) picked up on inadequateinclude both a quantitative and between its participants that simply translation, asserting that theyqualitative approach and the two understood the medical terminologyremaining were quantitative. better than the interpreters. The quality of the eight qualitative Nabb (2006) found that it was thepapers and the two papers using both healthcare workers in her research thatapproaches was appraised using the had concerns that the translation wasCritical appraisal skills programme not always correct and that they were(CASP) appraisal tool. The two worried that informed consent mayremaining quantitative studies were have been affected.appraised using a framework adapted Lack of English ability was a main

22 • Immigrant women’s perceptions of their maternity care January 2013 • THE PRACTISING MIDWIFEfocus of the findings from I Next time Hill N, Hunt E and Hyrkas K (2012).Carolan and Cassar (2010) and The next paper will conclude with the ‘Somali immigrant women’s beliefsTebid et al (2011). They remaining themes identified by the regarding pregnancy and birth in theobserved that varying levels of literature review including relationships United States’. Jour of transcult nurs,fluency in English produced with healthcare providers, cultural 23(1): 72-81.obstacles in pregnancy care. standpoint and social circumstances. HLSC (2008). First report of sessionThe immigrant women all felt 2007-2008: the economic impact ofthat they lacked knowledge TPM immigration, London: The stationeryabout available services and office.pregnancy in general. They Joanne Fisher is a midwife and nurse Lin ML, Shieh C and Wang H (2008).wanted information but it working in the family nurse partnership ‘Comparison between pregnantwas often unavailable in and Sharron Hinchliff is lecturer in nursing Southeast Asian immigrant anddiffering formats and and midwifery at the University of Taiwanese women in terms oflanguages due to a lack of Sheffield pregnancy knowledge, attitude towardresources. Even when materials were pregnancy, medical services experiences andavailable, the women were frequently Resources prenatal care behaviours’. Jour of nurs res,not directed to them due to insufficient CASP: http://www.casp-uk.net/ 16(2): 97-108.awareness of their existence among Nabb J (2006). ‘Pregnant asylum-seekers:health professionals. References perceptions of maternity service provision’.Theme 2: Impediments to accessing Evidence based midwifery, December:health care Bender DE, Harbour C, Thorp J et al (2001). ‘Tell www.rcm.org.uk/ebm/ebm-2006/dec-Physical access to health care can be me what you mean by ‘si’: perceptions of 2006/pregnant-asylum-seekers-perception.restricted by the lack of patients’ own quality of prenatal care among immigrant ONS (2011). Frequently asked questions: birthstransport and clients may not be able to Latina women’. Qual health res, 21(11): 780-794. and fertility 2010,outlay the funds for public transport to www.ons.gov.uk/ons/search/index.html?newaccess their appointments even if their Briscoe L and Lavender T (2009). ‘Exploring query=births+to+immigrants. Accessed 24thtravel expenses are later reimbursed. maternity care for asylum seekers and September 2012.Whether public transport is adequate is refugees’. Brit jour of midw, 17(1): 17-23. ONS (2012). Migration statistics quarterly report,also subjective and dependent on the London: ONS.locale of the healthcare setting. Carolan M and Cassar L (2010). ‘Antenatal care Petticrew M and Roberts H (2007). Systematic perceptions of pregnant African women reviews in the social sciences. A practical guide, Competing obligations, such as attending maternity services in Melbourne, Oxford: Blackwell Publishing.family care or having a small support Australia’. Midwifery, 26(2): 189-201. Reitmanova S and Gustafson DL (2008). ‘Theynetwork to help with childcare, were can’t understand it: maternity health andidentified by Lin et al (2008) and Chu C (2005). ‘Postnatal experience and health care needs of immigrant Muslim women inReitmanova and Gustafson (2008). needs of Chinese migrant women in St. John’s Newfoundland’. Mat and child Brisbane, Australia’. Ethnicity and health, health jour, 12(1): 101-111. Hill et al (2012) and Shafiel et al 10(1): 33-56. Shafiel T, Small R and McLachlan H (2011).(2011) found length of waiting times ‘Women’s views and experiences ofwas an issue. There was a sense of Herrel N, Olevitch L, DuBois DK et al (2004). maternity care: a study of immigrant Afghanfrustration for the participants who felt ‘Somali refugee women speak out about women in Melbourne, Australia’. Midwifery,that whilst it was deemed acceptable their needs for care during pregnancy and 28(1): 198-203.for health professionals to run late for delivery’. Jour of midw & wom health, 49(4): Sword W, Watt S and Kruger P (2006). Access toappointments, the same rules were not 345-349. care experiences of immigrant and Canadianextended to them. born women. Jour of obs gyn and neo nurs, 35(6): 717-727. Sword et al (2006) found that Tebid R, DuPlessis D, Beukes S et al (2011).immigrant women had no statistically ‘Implications for nurse managers arisingsignificant difference in ability to get from immigrant women’s experiences ofaccess to services for a physical, midwifery care in a hospital’. Jour of nursemotional, mental health problem or man, 19: 967-975.breastfeeding concerns. However, withother issues surrounding social support,immigrant women reported beingunaware of the services they could access.

THE PRACTISING MIDWIFE • January 2013 Fitness to practise • 23Drama in the classroom:fitness to practiseKaren Bates describes SUMMARY The fitness to practise hearing was brought to students at thea creative approach to University of East Anglia. The day was a mock up, as close to real events asteaching students possible, with interim orders and substantive hearings. It enabled students toabout fitness to engage with aspects of practice in a different way from the traditional ‘chalkpractise hearings and talk’ methods. The cases chosen reflected all disciplines. Electronic voting systems were used to determine what the students felt outcomes should have been, and then they had an opportunity to hear what outcome the panel decided upon. Evaluative data were obtained following the event to see what impact this approach had on students’ learning and their appreciation of the importance of professional practice. The comments we received were overwhelmingly positive and as a result we shall be repeating the day for students, supervisors of midwives and post registration nurses and midwives. Keywords Fitness to practise, education, student midwives, supervisors of midwives, professional hearings, NMC Author Karen Bates, midwifery lecturer at the University of East AngliaIntroduction A good level of midwives and nurses have never beenAs a midwifery educationalist and a understanding about so great in terms of professionalpanellist on the Nursing and Midwifery what it means to be on a accountability. During 2011-2012,Council (NMC) Fitness to practise (FP) professional register referrals increased to over 4,000: nearlypanel, it was my belief that observing a should be an essential 3000 more referrals than were made inFP hearing would be the most effective element of any 2004 (NMC 2012). A good level ofway of providing depth and programme of study understanding about what it means tounderstanding of the professional preparing a student for be on a professional register should beframework underpinning professional professional registration an essential element of any programmepractice. I wanted midwifery students of study preparing a student forfrom the University of East Anglia (UEA) professional registration. Mto observe a NMC FP hearing and theprocesses the panel goes through I know from my own professionalbefore coming to a reasoned development as a supervisor ofjudgement about a registrant’s fitness midwives that attending a hearing hadto practise. an impact on me; it made me think about my own professional practice Our students are qualifying at a time and what it really means to bewhen the demands on registered accountable, at the same time

24 • Fitness to practise January 2013 • THE PRACTISING MIDWIFEStudents were asked to vote using the electronic voting systemsrecognising the requirement for all of A panel may impose an this approach to learning in midwiferyus to raise and escalate concerns, where interim order on the or nursing education programmes.we have them, about someone else’s registrant’s practice,practice (NMC 2010). which will suspend their Interim orders registration or make The morning was spent introducing the Now I am a panellist in the FP them subject to students to ‘interim orders’. In order toprocess, I have come to realise that it is conditions of practice ensure an appropriate level of publicnot all about punishment; there is also protection is in place whilst the NMCa sense of wanting to support So, the FP hearing was brought to the investigate fully the allegations againstregistrants to stay in practice, at the students instead. a registrant, a panel may impose ansame time as affording the required interim order on the registrant’slevel of protection to the public. I The day was a mock up of a FP practice, which will suspend theirwanted the students to understand hearing, something along the lines of a registration or make them subject tothat if a registrant is able to ‘moot’ hearing. The concept of ‘moot’ conditions of practice - but it can onlydemonstrate insight into any failings in hearings is embedded in law degree do that if it is satisfied that an order istheir practice and show that they have programmes and these provide an either necessary to protect members oflearnt from the experience, becoming opportunity for law students to the public, or otherwise in the public orbetter practitioners as a result, the FP participate in and observe a mock court the registrant’s interests.panel will also be fair and measured in case. The concept was developed intheir response; not all registrants who economic education by Lon Carlson and The maximum length of time for ancome up in front of the FP panel are Skaggs (2000). Role play and drama interim order (without a high courtstruck off the register. have also been successfully used in extension) is 18 months. The interim social work education (Villadsen 2012), order is reviewed six months after it is To make attendance at a FP panel a but very little has been written about first imposed and then every threecompulsory part of the students’ months thereafter, until the case hasprogramme of study would have been resolved at a substantive hearing.involved financing the field trip and, as Registrants are invited to attend for thewith most things, there were budget initial hearing and any review whereconstraints. Whilst students were there is likely to be a variation to theadvised about the value of attending order imposed. The registrant may bringsuch an event, the evidence was that witnesses and can be represented.students were not doing so.

THE PRACTISING MIDWIFE • January 2013 Fitness to practise • 25However, at this stage the panel is not students were invited to the fitness to the end of the day, shown in Table 3.convened to hear the substantive facts practise drama and the proportions are At the beginning of the day, only 16of the case or to try the evidence; it is shown in Table 1. The cases reflected allthere to make a risk assessment of the disciplines and, within nursing, each per cent felt that they had a very goodlikelihood of the registrant repeating branch of nursing was represented. understanding of the professionalthe alleged behaviour, and make an framework, whereas this had risen toassessment of risk of harm to the public The cases were based on allegations 72 per cent by the end of the activity.if the alleged behaviour was repeated. from published cases on the NMC site, but in recognition of this being a Qualitative comments from theSubstantive hearings learning situation the cases were students provided further evidence thatOnce the NMC has undertaken the contrived, to a certain extent, to this had been a very successful way todetailed investigation involving lawyers increase the capacity for learning and approach this area of professionaland gathering statements, the case will reflection on different aspects of practice. Here are just a few of thebe heard at a substantive hearing by professional behaviour. The cases were comments we received:the Conduct and competence therefore fictional, with anonymity forcommittee or at a Health committee the registrants being scrutinised. “It has reiterated to me the(HC). The hearing decision and reasons importance of competent nursingfor the decisions are published on the All those one would expect to see at a practice, good record keeping andNMC website, except those hearings FP hearing were portrayed by midwifery accountability. A worthwhile day.”heard by the HC or where application is and nursing lecturers and the day wasmade to hear submissions and evidence run with the formality of a NMC “I liked the fact that it wasin private. The default position is that hearing. interactive.”not only should the NMC be there toregulate practice, but that they should Students participated in the drama “Kept me engaged throughoutbe seen to do so. by using the electronic voting handsets the day.” to say what they felt outcomes should A registrant’s fitness to practise can be. They were then able to measure “Really enjoyed it.”be impaired because of misconduct, what they thought against the “I am glad I have attendedlack of competence, health, criminal outcome determined by the panel. today!”conviction or caution or the determination This day was undoubtedly a success.of another regulatory body. Evaluation It brought to life concepts which students Evaluative data showed us that evaluate as being dry; they find it hard A substantive hearing will be called overwhelmingly this approach had a to grasp exactly what ‘professionalto decide whether the registrant’s significant impact on students’ learning accountability’ will mean to themfitness to practise is impaired, and if so, and their appreciation of the because they are not qualified yet.whether any sanction should be importance of professional practice. It was a day that will be repeated forimposed. the students and will also be developed Students were asked at the beginning into a study day for post registrationThe fitness to practise drama of the day to rate their understanding midwives, supervisors of midwives andAll senior nursing and midwifery of the professional framework and their nurses. TPM responses are shown in Table 2. Table 2 Students’ initial understanding Karen Bates is a midwifery lecturer at the of the professional framework We then asked the same question at University of East Anglia 82% Table 3 Students’ understanding after References 16% 2% the fitness to practise drama Carlson JL and Skaggs NT (2000). ‘Learning by 72% 26% 2% trial and error: a case for moot courts’. Jour of econ ed, 31(2): 145-155.I have a very good understanding NMC (2010). Supervision, support and safety: I have a fair understanding analysis of the 2008-09 LSA reports to the I don’t really understand NMC, London: NMC. what it means I have a very good NMC (2012). Annual report - fitness to practise, understanding London: NMC. I have a fair Villadsen A, Allain L, Bell L et al (2012). ‘The use understanding of role play and drama in interprofessional I don’t really understand education: an evaluation of a workshop with what it means students of social work, midwifery, early years and medicine’. Soc work ed, 31(1): 75-89.

26 • Obesity in pregnancy January 2013 • THE PRACTISING MIDWIFEObesity in pregnancyPart 2: managementIn the second of two parts, SUMMARY Obesity is placing a huge burden on healthcare resourcesFrankie Phillips considers and the wellbeing of individuals. The first article in this two part seriesthe management of (October 2012) reviewed the prevalence of obesity in pregnancy andobesity in pregnancy the increased risks for pregnant women to their own and their babies’ health. Management of obesity during pregnancy also places a large burden on midwifery resources. A renewed focus is needed on achieving a healthy weight for pregnancy to ensure optimal outcomes and reduce risks. Keywords Obesity, weight, healthy eating, diet Author Dr Frankie Phillips, independent registered dietitianIntroduction Midwives are in an pregnancy. Guidance from NICE (2010)A healthy weight before pregnancy is ideal position to help encourages taking action at the earlieststrongly recommended, but many women achieve a opportunity (such as the first midwifewomen are already obese when they healthy weight and a appointment) to discuss the woman’sbecome pregnant. Obesity is a serious safer pregnancy eating habits and how physically activethreat to women of childbearing age she is. Clearly, a first step is identifyingand midwives are in an ideal position to whether a woman is actually obese,help women achieve a healthy weight and so measuring weight and height atand a safer pregnancy (National the first contact, being sensitive to anyInstitute of Health and Clinical concerns she may have regarding herExcellence (NICE) 2010). weight, is crucial. From this, the body mass index (BMI) can easily beManagement of obese mothers Midwives are in an ideal position to calculated. The BMI should be discussed MIdeally, obese women should be given advise women on appropriate weight with the woman with any riskssupport to lose weight before they management during the antenatal explained, and a diet and physicalbecome pregnant and NICE (2010) period and beyond, as women are activity plan agreed. Simple dietarystrongly emphasises this strategy known to be motivated to make goals might include to eat breakfast,because being obese before pregnancy changes that will optimise their carry healthy snacks and consume atis considered a greater risk than excess pregnancy outcome and their baby’s least five portions of a variety of fruitweight gained during pregnancy. wellbeing (Jackson et al 2011). and vegetables each day. A summary ofHowever, there is a clear need for key NICE (2010) guidelines on weightinterventions to minimise risk for those There are currently no evidence management in pregnancy is shown inwomen already pregnant and obese. based guidelines in the UK on Figure 1. recommended weight gain during

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28 • Obesity in pregnancy January 2013 • THE PRACTISING MIDWIFEFigure 1 Guidelines on weight management in pregnancy Obese mothers should be given practicalA healthy weight should be achieved before a woman becomes pregnant advice andMeasure height and weight and calculate BMI at the first contact and record in the encouragement to losehand held notes weight before and after pregnancy, includingAdvise that moderate activity during pregnancy will benefit her and her unborn child access to specialist help if they need itGive specific advice on safe physical activities of moderate intensity of around 30minutes per day; avoid being sedentaryDispel any myths about what and how much to eat during pregnancy; there is noneed to ‘eat for two’Explain that a BMI >30 poses a risk to the woman and her unborn childDo not weigh women repeatedly during pregnancy, only weigh again if there are in pregnancy, without resorting toissues of clinical management or if nutrition is a concern drastic dieting.Offer women with BMI of 30 or more a referral to a dietitian for assessment and Another study in Liverpool (Abayomipersonalised advice et al 2009) suggested that to meet a target of offering an initial and a followSuggest reputable sources of information and advice about diet and activity, such as up appointment to all obese (and‘The pregnancy book’ (Department of Health (DH) 2009) significantly underweight) pregnant women in one centre would need a 300Encourage women to lose weight after pregnancy per cent increase in staffing and related resources. Research also suggests that Source: NICE 2010 appropriate diet and exercise during the postnatal period may help women to Emphasis is placed on the fact that strong evidence to support the case for lose their postnatal weight (Amorim etdieting during pregnancy is not diet related weight management in al 2007).recommended. However, several studies pregnancy, using healthy eatinghave explored the effects of a healthy approaches (Thangaratinam et al 2012). This is echoed in NICE guidanceeating approach, as opposed to The review found that dietary and which also recommends that obesedangerous ‘crash dieting’, to good effect lifestyle interventions in pregnancy are mothers should be given practical(Abayomi et al 2009). effective in reducing gestational weight advice and encouragement to lose gain without any adverse outcome risk. weight before and after pregnancy,Evidence on weight management Diet based interventions focused on a including access to specialist help ifduring pregnancy healthy diet including wholegrains, they need it. Clearly there are greatAn epidemiological study from the US fruit, vegetables and beans, providing implications on already stretched(Kiel et al 2007) suggested that obese adequate protein. Dietary approaches resources to commit to such a plan.women who gain less than seven kg significantly reduced the risk of preduring pregnancy have good outcomes eclampsia, gestational diabetes and pre Conclusionand may fare even better in terms of term birth, and reduced gestational The rising prevalence of obesity in thepre eclampsia, caesarean birth and weight gain by four kilogrammes. No population of pregnant women couldexcessive birth weight (although rates effect was observed on caesarean rates lead to increased risk of miscarriage,of small for gestational age were or induction of labour and there was no stillbirth and infant mortality. Achievinghigher) than those gaining weight evidence that those interventions an optimal weight before pregnancyaccording to the IOM guidelines; evaluated were associated with any and gaining appropriate amounts offurthermore, low weight gain has a adverse maternal or fetal outcomes. weight during pregnancy isweaker association with spontaneous There is clearly a need for ongoing recommended to ensure a safe, healthypre term birth in obese women than in debate, but it would appear that a birth and for the future health of thethose with a lower BMI (Dietz et al 2006). prudent healthy eating dietary mother and child. For obese women, approach can reduce risks associated A recent review of studies on diet and with obesity and excessive weight gainweight gain during pregnancy has given

THE PRACTISING MIDWIFE • January 2013 Obesity in pregnancy • 29pregnancy is a window of opportunity For obese women, pregnancy and on the risk of pretermto start to change towards healthier pregnancy is a window delivery’. Epidemiology, 17(2): 170-177.eating and an improved lifestyle, the of opportunity to start Jackson RA, Stotland NE, Caughey AB et albenefits of which extend to the whole to change towards (2011). ‘Improving diet and exercise infamily, as well as healthier future healthier eating and an pregnancy with Video Doctor counseling: apregnancies. TPM improved lifestyle randomized trial’. Patient educ couns, 83(2): 203-209.Dr Frankie Phillips is an independent Cochrane Collaboration. Kiel D, Dodson EA, Artal R et al (2007).registered dietitian DH (2009). The pregnancy book, London: Crown. ‘Gestational weight gain and pregnancy Dietz PM, Callaghan WM, Cogswell ME et al outcomes in obese women: how much isReferences enough?’ Obs gyn, 110(4): 752-758. (2006). ‘Combined effects of pre-pregnancy NICE (2010). Weight management before, duringAbayomi JC, Watkinson H, Boothby J et al body mass index and weight gain during and after pregnancy. Clinical Guideline 27, (2009). ‘Identification of ‘hot spots’ of London: NICE. obesity and being underweight in early Thangaratinam S, Rogozinska E, Jolly K et al pregnancy in Liverpool’. Jour hum nutr diet, (2012). ‘Effects of interventions in pregnancy 22(3): 246-254. on maternal weight and obstetric outcomes: meta-analysis of randomised evidence’. BritAmorim AR, Linne YM and Lourenco PMC (2007). med jour, 344 doi: 10.1136/bmj.e2088. Diet or exercise or both for weight reduction in women after childbirth, London: TheReviews Also on page 19 Baillière’s midwives’ The book is a great reference guide that could fit in your dictionary (12th edition) pocket, although more comfortably in you work bag. It is easy to read, especially when you need to know or refresh Denise Tiran your memory on a subject in a hurry. The dictionary will be particularly helpful for midwifery and nursing students 2012, Elsevier, 292pp, £9.99, pbk, during clinical placement. However as a reference point, it ISBN 978 0 70204 48 47 should be available in all ward environments. I would like to thoroughly The writing is small which could present problems in poor recommend the midwifery lighting, making glasses a must, if worn. However this has dictionary/reference book as a must obviously been balanced well with the compactness and for every professional involved at nature of the dictionary and is a much easier size than a whichever level in midwifery. The large book to carry around.book does ‘what is says on the tin’ so to speak. As adictionary every subject related to midwifery and obstetrics Overall the dictionary is of good quality and an excellentis covered with a short description as you would expect A-Z; standard - it is money well spent, especially as it is updatedif further information is required this would need to be on a four yearly cycle, so you know that you have somethingsought by further reading. up to date. There will be no disappointment with this dictionary which certainly helps towards educating yourselfThe appendices at the end of the book are particularly and colleagues.useful, with emergency scenarios discussed and themnemonic given, although one must be mindful that Joanne Gowermnemonics can change, and these must be used in Deputy screening coordinator at Doncaster and Bassetlawconjunction with hospital guidelines and policies and NHS Foundations Hospitals Trustevidence based practice.

30 • Post childbirth sexual health January 2013 • THE PRACTISING MIDWIFEAltered sexual healthafter childbirth: part 1In the first of a two part article Deirdre SUMMARY In recent years, sexual health after childbirth hasO’Malley and Valerie Smith consider the emerged as an area of concern for women and healthcarepotential risk factors associated with professionals. In the first of this two part series whichchanges in sexual health after childbirth considers sexual health after childbirth, the potential risk factors associated with altered postpartum sexual health are explored. The role of healthcare professionals in providing evidence based, individualised and timely information to women on the potential for altered sexual health after childbirth is also discussed. Keywords Sexual health, postpartum, body image, breastfeeding, dyspareunia Authors Deirdre O’Malley, clinical tutor in midwifery and Valerie Smith, midwifery research fellow, both at Trinity College, DublinIntroduction Sexual health declined vaginal dryness and sexual satisfactionThe World Health Organization (WHO) from the first trimester (Barrett et al 2000; Klein et al 2009).(2006) defines sexual health as a to the third trimester Sexual health after childbirth, in thecomplex biological and sociological and was not recovered context of this paper, is considered toconcept that requires a positive and by six months be associated with a composite ofresponsible approach to sexuality and postpartum factors including resumption of sexualsexual relationships. Sexual health and intercourse, frequency of sexualits potentially altered state following focus on pain during sexual intercourse intercourse, desire, arousal, ability tochildbirth have received little attention (dyspareunia) (Buhling et al 2006) or a achieve orgasm, vaginal dryness,in the past; but recent literature provides variety of outcome measures, such as dyspareunia and satisfaction withevidence of emerging attention to this sexual desire, sexual arousal, orgasm, sexual relationships.important aspect of postpartum care(Thompson et al 2002; Pastore et al 2007). Potential risk factors Pre-existing or pregnancy onset altered Attempting to define what sexual healthcontributes to optimum sexual health There is a limited understanding as toafter childbirth is challenging. Some what constitutes normal female sexualauthors focus on the timing of health and this makes it difficult whenresumption of sexual intercourse considering previous sexual health(Radestad et al 2008) while others

THE PRACTISING MIDWIFE • January 2013 Post childbirth sexual health • 31 Breastfeeding women have reported experiencing vaginal dryness, dyspareunia, increased nipple sensitivity,leaking milk and decreased arousalproblems as potential risk factors for frequency of sexual intercourse, (2008) also noted that women’s Maltered postpartum sexual health. reduced scores for achieving orgasm satisfaction with their body imageHowever, there is some evidence to and increased scores for dyspareunia. deteriorated by six months post birth.suggest that pre-pregnancy, pre- They suggest a relationship betweenexisting sexual health problems do Body image altered sexual health and low scoresincrease the potential for altered sexual Childbirth and adaptation to a for body image.health after childbirth. Barrett et al mothering role, including physical(2000), for example, reported that changes such as weight gain, breast Breastfeedingwomen who experienced dyspareunia changes, abdominal striae, varicose The physiological and hormonalprior to pregnancy were four times veins and a lack of sleep can all affect a changes associated with breastfeedingmore likely to experience dyspareunia woman’s perception of her body image have been considered as potential risksix months after birth. In a series of post birth and this has the potential to factors for altered sexual health afterinterviews with 26 women at 16 weeks negatively affect sexual health after childbirth. Breastfeeding women havegestation, during the third trimester of childbirth. Pastore et al (2007) reported experiencing vaginal dryness,pregnancy and at six months post reported that maternal body image dyspareunia, increased nipplepartum, Trutnovsky et al (2006) also was a concern for 50-55 per cent of sensitivity, leaking milk and decreasedreported increased altered sexual women four months and twelve arousal (Connolly et al 2005).health after childbirth in women who months postpartum and that altered Postpartum oestrogen levels, forhad reported sexual health problems body image played a significant role in example, are low in breastfeedingduring pregnancy. In this study women women’s sexual perception of mothers, resulting in reduced vaginalreported a decrease in the perceived themselves. In a series of focus group lubrication and atrophy of the vaginalimportance of sexuality, sexual interviews aimed at determining how epithelium. These in turn can lead tointercourse and contentment with some women experience their sexual reduced physical arousal and painfulsexual life six months post birth. Pauls life after giving birth, Olsson et al sexual intercourse.et al (2008) surveyed 107 women on (2005) reported that womenthe effects of pregnancy on sexual experienced dissatisfaction with their A lack of interest in sexual activity athealth. They reported that sexual perceived altered body image two months after birth has also beenhealth declined from the first trimester following pregnancy and this associated with breastfeeding, andto the third trimester and was not negatively impacted on their dyspareunia is reported to persist forrecovered by six months postpartum. perception of their sexual self and up to six months postpartum in someWomen identified changes in the their sexual relationship. Pauls et al breastfeeding mothers (Barrett et al 2000). Olsson et al (2005) concur with these findings, with breastfeeding mothers reporting a lack of sexual desire after childbirth and a lowered sense of importance attached to their breasts in relation to their sexual life.

32 • Post childbirth sexual health January 2013 • THE PRACTISING MIDWIFEDiscussion Timely and appropriate research fellow, both at Trinity College,Pre-pregnancy sexual health problems advice on the use of Dublinare difficult to quantify with limited lubricants, oestrogeninformation on this topic, as the pessaries and open Referencesmajority of studies focus on sexual communication withhealth after childbirth where women their partner can help Barrett G, Pendry E, Peacock J et al (2000).are recruited either during pregnancy or breastfeeding women ‘Women's sexual health after childbirth’. Britduring the postpartum period. One feel reassured jour of obs and gyn, 107(2): 186-195.study, however, has demonstrated astrong association between pre- and prolong breastfeeding duration, it Buhling KJ, Schmidt S, Robinson JN et al (2006).pregnancy dyspareunia and is essential that breastfeeding women ‘Rate of dyspareunia after delivery indyspareunia at three and six months are informed of the associated primiparae according to mode of delivery’. Eurpostpartum (Barrett et al 2000). physiological changes that might affect jour of obs and gyn and rep biol, 124(1): 42-46.Trutnovsky et al (2006) also provide their sexual health functioning. Timelysome evidence of women experiencing and appropriate advice on the use of Connolly A, Thorp J and Pahel L (2005). ‘Effectsdecreased libido, decreased arousal and lubricants, oestrogen pessaries and of pregnancy and childbirth on postpartumreduced frequency of sexual intercourse open communication with their partner sexual function: a longitudinal prospectiveas pregnancy progresses. It is can help breastfeeding women feel study’. Int urogyn jour and pelvic floorimportant, therefore, for healthcare reassured about their sexual health and dysfunct, 16(4): 263-267.professionals to consider discussions, relationship with their partner (Converyincluding changes in sexual health and Spatz 2009; Barrett et al 2000). Giving Convery KM and Spatz DL (2009). ‘Sexuality andpatterns, during the antenatal period women information about the potential breastfeeding: what do you know?’ MCN - Amand at antenatal education classes. for sexual health changes following jour of mat child nurs, 34(4): 218-223.Addressing sexual health functioning in childbirth will enable them to managethis way will potentially facilitate open, transitory changes, recognise persistent Klein K, Worda C, Leipold H et al (2009). ‘Doeshonest communication between problems and encourage open the mode of delivery influence sexualhealthcare professionals, women and communication between them and function after childbirth?’ Jour of wom health,their partners. It will introduce the their partners. 18(8): 1227-1231.concept of sexual health after childbirthand assist women in seeking Conclusion Olsson A, Lundqvist M, Faxelid E et al (2005).appropriate and timely help should they A number of risk factors associated ‘Women's thoughts about sexual life afterrequire it. with altered sexual health after childbirth: focus group discussions with childbirth have been identified in this women after childbirth’. Scand jour of caring The perception of altered body image paper. Midwives and maternity services sci, 19(4): 381-387.has emerged as a considerable problem healthcare providers are encouraged tofor some women following childbirth. adopt a pivotal role in discussing these Pastore L, Owens A and Raymond C (2007).Women have indicated that they are factors with women to ensure optimum ‘Postpartum sexuality concerns among first-dissatisfied with their altered body postpartum health. In the second part time parents from one US academic hospital’.image and struggle to accept their of this article, the possible causes for Jour of sex med, 4(1): 115-123.body’s changes (Olsson et al 2005). altered sexual health after childbirthWomen need reassurances from are explored. TPM Pauls RN, Occhino JA and Dryfhout VL (2008).healthcare professionals that physical ‘Effects of pregnancy on female sexualbodily changes and psychological Deirdre O’Malley is clinical tutor in function and body image: a prospectiveadaptations following childbirth are a midwifery and Valerie Smith is midwifery study’. Jour of sex med, 5(8): 1915-1922.normal part of the pregnancy andchildbirth process. Women who are Radestad I, Olsson A, Nissen E et al (2008). ‘Tearsexperiencing significant problems in the vagina, perineum, sphincter ani andshould be offered counselling, in rectum and first sexual intercourse afterconjunction with their partner where childbirth: a nationwide follow-up’. Birth,appropriate, with an experienced 35(2): 98-106.healthcare professional. Thompson JF, Roberts CL, Currie M et al (2002). With a national and international ‘Prevalence and persistence of healthdrive to increase breastfeeding rates problems after childbirth: associations with parity and method of birth’. Birth, 29(2): 83-94. Trutnovsky G, Haas J, Lang U et al (2006). ‘Women's perception of sexuality during pregnancy and after birth’. Aust NZ j obs gyn, 46(4): 282-287. WHO (2006). Defining sexual health: report of a technical consultation on sexual health, Geneva: WHO.

THE PRACTISING MIDWIFE • January 2013 Midwifery led care in Birmingham • 33From serenity tohalcyon birth centreKathryn Gutteridge SUMMARY This article follows the journey of Sandwell and West Birminghamdescribes how a midwifery Hospitals NHS Trust quest for improving normal birth outcomes for a complexled care model optimising and diverse population. The opportunities that led to commissioning a co-birth has made a great located and freestanding birth centre are explored and how the design wasdifference to the people of influenced by less clinical beliefs about birth. Through the story of both birthwest Birmingham centre developments, Kathryn Gutteridge shows the changes that have been seen in both clinical outcomes and families’ comments. From a failing maternity service to a beacon of light where midwifery care and a belief that ‘your birth in our home’ really matters. Keywords Midwifery led care, leadership, transforming, environment, families Author Kathryn Gutteridge, consultant midwife at Sandwell and West Birmingham hospitals NHS TrustIntroduction I was delighted when we whereas City Hospital based in MThis article is part one of two that look had the opportunity to Birmingham delivered services forat the development of midwife led develop a co-located 4,000 women and families.services at a busy central Birmingham birth centre within the Demographically the women differ inmaternity unit. The unit serves a current establishment their ethnicity and health profiles:deprived population known to have arange of social and health challenges. scrutiny from the Health Care Sandwell: particularly staticThe first part of the article follows the Commission. The Trust had two population, traditionally employedprimary development of the midwife maternity units on separate hospital residents in heavy industry andled pathway including the building of sites despite the merger of the mining. Community profiles showSerenity Birth Centre and a brief hospitals to form Sandwell and West that the population is mainly mixedoverview of key outcomes. The second Birmingham Hospitals NHS Trust. between white Caucasian and Asianand concluding article will discuss the Sandwell maternity unit was based in immigrants; however latterly therenew free standing Halcyon Birth Centre the Black Country and delivered has been an influx of East Europeanand the journey thus far. approximately 2,500 births per annum, residents. Health needs have been identified as associated with I was appointed as consultant obesity, alcohol abuse, depressivemidwife for normality at Birmingham disorders and teenage pregnancies.hospitals NHS Trust in 2007; maternityservices at that time were undergoing

34 • Midwifery led care in Birmingham January 2013 • THE PRACTISING MIDWIFE City: a dynamic maternity Matters (Department of Health A teaching programme population with a high number of (DH) 2007). was designed to bring migrant, asylum and refugee everyone together women. The indigenous population • Provide a clinically safe service before the opening date is living in poor housing and is with a reduction in medical looking at both clinical largely economically deprived with a intervention for low risk births. and operational issues predominant culture of gang and street crime. The health needs of • Support national and local visions when describing how important these these women are described as for Maternity Services. factors are. complex requiring multi- professional input to deal with • Reduce the length of stay in Looking for serenity infectious diseases, illnesses hospital for low risk births. Another example I suggested the associated with deprivation, such as designers look at was the development nutrition deficiencies and anaemia, • Provide a service that attracts and of hospice services and the care of and enduring health problems. retains high quality staff, patients at the worst times in their especially midwives. lives, where valuing and including the Within the last six years several family is a priority; very often hospicesreviews were commissioned looking at • Support an improvement in the are designed to be places of calm andclinical outcomes, team culture, quality of care for high risk births tranquillity where care is focusedeffectiveness of midwifery supervision as a result of providing a separate around the needs of the family. Thisand a high level review conducted by focus and resource for low risk was to be excellent advice, as everyoneobstetric and midwifery colleges to births. understood the type of facility we weredetermine the operational efficiency of trying to achieve.both maternity units. The decision was A series of user engagements wastaken over a two year period to held with comments fed into the The name for the Birth Centre wasreconfigure onto one site, namely City project board and used to measure the chosen by a prospective father on a userMaternity. project against. These themes were: event and in our public vote; the name clean, safe environment; families to be was so important in developing anProject included in the experience; and dignity identity and selling the message. SoAs consultant midwife and clinical lead to be considered at all times. Thefor low risk care I was delighted when comments were predominantly aboutwe had the opportunity to develop a co- environment and staff attitude, solocated birth centre within the current surroundings and attention to privacyestablishment. The main factors that were critical components and known tosecured this were: poor clinical impede progress if not right (Walsh andoutcomes for low risk women, a high Gutteridge 2011). Families invest amidwifery vacancy rate and low morale. great deal of time, effort and moneyFinding support from the Trust board to into preparing for their babies and Ifund the project was essential; but also liken it to wedding day preparationsthe clinical director knew that low riskwomen on the birthing suite Serenity reception areacompromised the care of women withobstetric/medical problems. A project team was formed and thedesign brief developed: • Promote normality of birth in terms of midwifery led care and a non clinical environment for low risk births. • Offer women choice in line with the requirement in Maternity

THE PRACTISING MIDWIFE • January 2013 Midwifery led care in Birmingham • 35Location Age BMI Parity totals Birth Ethnicity number bring everyone together before the median median N= weight (per cent) opening date looking at both clinicalSerenity (Nulliparous) median Asian and operational issues.MLBC 27.2yrs 29.6 M= African/West Indian (multiparous) White/Mixed British The first birth and many moreDelivery 25.7 yrs 32.8 European After an official opening by RCMsuite N = 371 General Secretary Cathy Warwick ontransfers M = 437 3.180 kgs 313 (38.7) the International Day of the Midwife, 159 (19.6) 2009, we opened for visitors’ tours, N = 88 209 (25.8) which included the public and staff. M = 54 127 (15.7) This was really important as we could explain the philosophy of care to 3.680kgs 36 (15.3) families and interested staff. Our first 42 (29.5) baby was born within 30 minutes of 51 (35.9) opening and was duly celebrated by all 13 (9.1) with photographs and flowers for the family. At the reception area is aSerenity Midwife Led Birth Centre manager specifically to ensure visitor’s book with comments sincebecame real with funding of £850,000 midwives are not waiting and watching opening; this has been a well usedallocated and a tight completion date the pools filling. resource for immediate staff feedback.set to May 2009. Staffing the birth centre Initially I had predicted that 500 Serenity has capacity of five ensuite Midwifery recruitment was critical and women would use the facility in its firstrooms, guest sitting room, shared alongside the building work we were year, building to 1,500 within threekitchen, therapy/assessment room and busily developing our recruitment years; however, I am delighted toan office for staff. The entrance is strategy where we could bring the report that in fact there were oversecured and only midwives have access team together in a creative way. 1,000 in the first year – a significantto it, so families are greeted by staff at Midwives and maternity assistants result.our reception area. Each birthing room were appointed, half from the currenthas water birth facilities: there is one establishments, the other funded by Transfer to delivery suitesfixed pool, the others having inflatable the Trust as new investment. A The intrapartum transfer rate of lowpools with a unique rapid fill and empty teaching programme was designed to risk women stands at 14.9 per cent. Thesystem designed by the project baseline was predicted to range between 25-27 per cent and national Birthing room data for transfer from birth centres is M accepted as 20-30 per cent; however national data do not discriminate between co-located or freestanding birth centres (Hodnett 2004). Of those women who transferred to a delivery suite a significant number had a vaginal birth, which gives an overall total of 95.1 per cent for our low risk population, as shown in Table 1. Category one and two caesarean section rates for the transferred women are 0.63 per cent and 2.63 per cent respectively, giving an overall percentage of 3.26. If this number includes instrumental births, it shows that operative births constitute 5.89 per cent of low risk births – the value of this cannot be overestimated in terms of

36 • Midwifery led care in Birmingham January 2013 • THE PRACTISING MIDWIFEwomen’s morbidity and ongoing health Table 2 The number of women using ‘I am so glad that my plannedoutcomes. water pools for their labour and/ place of birth was too busy for me or birth that night; I got to birth in the mostTable 1 Inclusive data outcomes - wonderful way, with midwives whomode of birth Laboured 138 17 per cent could not do enough for me in an only pool environment that was fit for aOverall vaginal 894 = 95.1 per cent 20.04 princess – me!’birth rate 25 = 2.63 per cent Laboured & 162 per cent birth pool ConclusionOverall assisted Overall the service model appears to bebirth rate Laboured, 132 16.3 right with the outcomes reinforcing the birthed, 3rd per cent theory. Within a short period of usOverall caesarean 31 = 3.26 per cent stage pool opening, the local Primary care andsection birth rate Acute trusts took the decision to close Sandwell Maternity and commission a Overall total women 53.34 second free standing facility in giving birth using water per cent Sandwell. This was to be a challenge as the build had to be completed within aThe use of water the LSA annual report 2007-2008. year and all women booked forIt is vital that low risk women have Sandwell accommodated at Cityaccess to water for their labour and Wonderful care Maternity in the meantime.birth, giving maximum support for their Another success was the introduction ofbirth potential (NICE 2007). Water hideaway double beds, tucked into the Next timebirths have been successful as shown in wall and not visible until after the birth The next part of the article will followTable 2; in the previous year there were when both parents have a short rest the development and building ofonly three in total. The use of Pethidine before leaving for home. Postnatal stays Halcyon Birth Centre and its progress soanalgesia during labour has diminished are short, ranging from two-eight hours far. It will include design features andwith a total use of around 5 per cent for with the majority being about six, pitfalls with a brief description of theour low risk population. This alone has reducing inpatient bed stays significantly. staffing model. Some of the clinicalbeen a successful part of moving away outcomes will be briefly demonstratedfrom medical care to a more midwifery Families are now coming back for and there will be feedback commentssupported model of care. their second baby, which is always a from both Serenity and Halcyon Birth mark of a good service. One woman Centres to give some depth and quality. Prior to Serenity Birth Centre opening who was diverted to us from herthe number of waterbirths at the Trust original hospital said: TPMfor year 2008-09 was 5, this is similar to Kathryn Gutteridge is consultant midwife at Sandwell and West Birmingham hospitals NHS TrustSerenity birthing room References DH (2007). Maternity matters: choice, access and continuity of care in a safe service, London: DH. Hodnett ED (2004). ‘Home-like versus conventional institutional settings for birth’. The Cochrane library, 3: 2-4. Chichester, UK: John Wiley and Sons Ltd. NICE (2007). Intrapartum care: care of healthy women and their babies during childbirth. Clinical guideline 55, London: RCOG. Walsh D and Gutteridge KEA (2011). ‘Using the birth environment to increase women's potential in labour’. Midirs, 21(2): 143-147.

THE PRACTISING MIDWIFE • January 2013 The social context of infant feeding • 37 MIDWIFERY BASICSInfant feeding3. The social context of infant feeding ‘Infant feeding’is the 12th series of‘Midwifery basics’targeted at practising midwives.The aim of these articles is to inform and encourage readers to seek further information through a series of activities relating to the topic. In this fourth article Joyce Marshall explores the social context of infant feeding in the UK,including sources of support for women whilst feeding their babies from health professionals,peer supporters and their family and social network.Scenario Introduction MSally has just arrived ‘home’ to her mother’s house Infant feeding is much more than simply nutrition for a babyfrom hospital with her partner Joe. They are staying as it has cultural and social meaning as part of motherhoodwith Sally’s mother for a few weeks before moving into (Marshall et al 2007). The choices women make in relation totheir own house. Sally had wanted to have her baby at infant feeding can be reinforced or constrained by socialhome as she hated hospitals but had to be transferred norms and expectations. Information and reactions fromto hospital during labour. After baby Eva was born, significant people within women’s social networks (includingSally was distraught because she did not have the health professionals) can affect their emotions, attitudesopportunity to breastfeed within the first hour (she and consequently their behaviour. The huge variation inhad read that this was important) but she enjoyed the breastfeeding initiation and continuation rates across‘special moment’ when she finally breastfed. Sally different countries within Europe provides evidence on thebreastfed Eva a couple of times but was then effect of the social and cultural context within which infantstruggling and asked for help from the midwives. A feeding takes place. For example, in the UK only 25 per centrange of different suggestions was offered by midwives of women are still breastfeeding at six months, comparedwho were very willing to help but seemed very busy. with over 70 per cent in Sweden (Cattaneo et al 2010).None of the suggestions seemed to help and Sally hadbeen left feeling confused and upset. Sally is now The social environment in which people live shapesfeeling much more relaxed at home with her mother as knowledge and the meaning given to infant feedingshe is confident her mother can help if needed as she practices and other aspects of motherhood, at a range ofbreastfed all of her children. Sally’s partner Joe is different levels – societal, immediate social networks andsupportive emotionally but has already suggested Sally individual or family influences. A better understanding ofshould give Eva a bottle of formula milk. the family situation and social network within which a mother is feeding her baby can help midwives and other

38 • The social context of infant feeding January 2013 • THE PRACTISING MIDWIFE MIDWIFERY BASICShealth professionals to support her more Women may want help receive the message ‘breast is best’appropriately. Rather than just conveying to find strategies to whether this is from attending‘breast is best’ messages that can be manage negative antenatal education sessions or fromperceived as ‘pressure’ to breastfeed, comments from family reading books or magazines. Midwiveswomen may want help to find and friends or ways to can play a significant role in thestrategies to manage negative comments find supportive promotion of breastfeeding eitherfrom family and friends or ways to find breastfeeding allies when seeing women in antenatal clinicssupportive breastfeeding allies. or when delivering antenatal education advice given in a didactic style, women sessions. Whilst women usually expectSupport for breastfeeding mothers often want a discursive two way health professionals to promoteMothers can receive support from a exchange with practical help where breastfeeding this can sometimes berange of different sources, such as they are shown rather than told, and perceived as ‘pressure’ to breastfeed,health professionals or lay/peer often they want to know why a particularly if significant people in thesupporters and from their family and suggestion might work, in order to mother’s life are either ambivalent orinformal social networks. A recently unsupportive of the mother’s decisionupdated Cochrane review drawing on Activity 1 to breastfeed (Marshall and Godfreydata involving over 56,000 women from Active listening is an important 2012). Recent research has suggested21 countries found that extra support skill to use when supporting that women do not feel the antenatalprovided by either lay supporters, women to breastfeed. Using an information they receive prepares themprofessionals or both helped women to internet search engine enter the well – that the reality is very differentcontinue to breastfeed for longer and words ‘active listening quiz’, choose (Hoddinott et al 2012). Murphy (1999)helped them to exclusively breastfeed one and use it to assess your active discusses the strong moral nature offor longer (Renfrew et al 2012). Face to listening skills. How might this help infant feeding decisions and suggestsface support had more effect than you to support breastfeeding that the statements women maketelephone support. Schmied et al women? Do you always use open during pregnancy are predictive of(2011) carried out a metasynthesis of questions to encourage dialogue whether or not they will initiatequalitative research papers to examine with women? breastfeeding. However, such decisionsthe components of support that are complex and are influenced bywomen felt were important. They make sense of the situation. partners, the way the mother’s ownfound that key components were Infant feeding is a key part of the mother breastfed and can be affectedbuilding rapport and a trusting by seeing others breastfeed or hearingrelationship, and ‘being there’ for each transition to motherhood and thewoman, making them feel relaxed and support women need changes over Activity 2comfortable rather than pressurised by time as they make this transition. It is Consider how women in your areafeeling rushed by busy supporters. therefore useful to consider this of work are introduced toWithin a trusting relationship and given chronologically to explore the impact breastfeeding. Is there thetime, women felt much more able to different factors have at different times opportunity for women to discussask questions. The same review also in the infant feeding journey and the their experiences and beliefs? Aresuggested that many women lack role of the midwife within this. visual experiences of a babyconfidence and appreciate supporters breastfeeding or discussions with awho acknowledge how they are feeling Pregnancy and decisions about breastfeeding woman part of this?and tell them when they are doing fine infant feeding(Schmied et al 2011). During pregnancy women generally stories about their experiences (Hoddinott and Pill 1999). A style of support that is facilitativeand provides women with realistic Breastfeeding in the early daysinformation is appreciated, including Many women feel vulnerable andpractical and personal aspects of uncertain in the early days after birthbreastfeeding – accurate informationwith sufficient detail (Schmied et al2011). Rather than oversimplified

THE PRACTISING MIDWIFE • January 2013 The social context of infant feeding • 39 MIDWIFERY BASICSand breastfeeding is often a major Women often want a Activity 3 Mfactor within this. Women often want discursive two way Consider your last interaction withto know they are ‘doing it right’ or to exchange with practical a breastfeeding woman. Did youhave ways of knowing that things are help where they are use open questions to encouragegoing well such as the baby feeding shown rather than told, the woman to talk about how shewell and being content (Marshall and and often they want to was feeling? Consider the way youGodfrey 2012). In the hospital setting know why a suggestion offer help to breastfeeding women.there is potential for midwives to might work Do you always explain why you aresupport women with both the offering a particular suggestion soemotional and practical aspects of can be concerned, as professional help that she can work it out herselfbreastfeeding. However, time and will not be so easily available. Building next time? Do you involve partnersstructural constraints can mean that confidence at this time is crucial, in these interactions? Read or listenmidwives are unable to build relationships to the mixed feelings women havewith women, so care can become routine, of going home at: www.healthtalkmeaning that contact with breastfeeding online.org/Pregnancy_children/women is disjointed (Dykes 2006). Breastfeeding Women can have mixed feelings particularly with the practical andabout going home from hospital, technical skills of breastfeeding, thoughespecially if they have had difficulties in emotional aspects are equallybreastfeeding. They are often excited to important (Marshall et al 2007).be going home but at the same time the best training for your little champion ®teaches your child to drink from a rimdesigned and made in the UKwww.bickiepegs.co.uk

40 • The social context of infant feeding January 2013 • THE PRACTISING MIDWIFE MIDWIFERY BASICSIt is essential for Reflection on the scenario support and/or family or informal social Sally felt uncomfortable in the hospital support later on. TPMmidwives to try to find setting but once at home she felt much more relaxed. This scenario is based on Joyce Marshall is senior lecturer inout and to understand a situation encountered in clinical midwifery at the University of practice as part of a research study Huddersfieldthe social context within (with all names changed). It demonstrates how support from family Referenceswhich breastfeeding can help women to sustain breastfeeding but can also be rather mixed. Sally Cattaneo A, Burmaz T, Arendt M et al (2010).occurs for each woman explained how her mother helped her 'Protection, promotion and support of to continue to breastfeed at home. breastfeeding in Europe: progress from 2002in her care However, like many women, Sally felt to 2007'. Pub health nutr, 13(6): 751-759. her partner did not know how to help.Continuing to breastfeed She described him as supportive but Dykes F (2006). Breastfeeding in hospital:Later in their breastfeeding experience said that he didn’t really know what to mothers, midwives and the production line,women often become concerned about do. Her partner was an “absolute star” Abingdon: Routledge.whether or not the baby is getting as far as everything else regardingenough milk. Ways that women can looking after the baby was concerned, Hoddinott P, Chalmers M and Pill R (2006). 'One-‘know’ that their baby is getting enough but was lost when it came to to-one or group-based peer support formilk include: the baby appearing supporting breastfeeding; whilst he breastfeeding? Women's perceptions of ahealthy and having wet and dirty was emotionally supportive, he didn’t breastfeeding peer coaching intervention'.nappies; the way their breasts feel know how to breastfeeding or where to Birth, 33(2): 139-146.before and after a feed; their ability to begin supporting somebody inexpress milk; and the baby gaining breastfeeding. He was more keen than Hoddinott P, Craig LCA, Britten J et al (2012). 'Aweight. These can be considered to be Sally to just give the baby a bottle. Sally serial qualitative interview study of infantways of making the invisible visible and also had a good relationship with her feeding experiences: idealism meets realism'.can increase women’s confidence, but a community midwife who she trusted Brit med jour open, 2: e000504range of factors can undermine this. implicitly. How might the community doi:10.1136/bmjopen-2011-000504.People in women’s social networks can midwife have involved Joe? Do youmake comments about babies’ think it might have been helpful for him Hoddinott P and Pill R (1999). 'Qualitative studybehaviour that cause women to to attend antenatal education sessions? of decisions about infant feeding amongquestion their ability to provide Do you think fathers and other family women in East End of London'. Brit med jour,sufficient milk for their baby. Group members always feel comfortable to 318(7175): 30-34.based peer support for breastfeeding attend? What more might be done tomothers, as is provided at many encourage this? Marshall JL and Godfrey M (2012). 'Shiftingchildren’s centres or baby bistros can identities: social and cultural factors thathelp, and is popular with mothers as it Conclusion shape decision-making aroundnormalises breastfeeding in a relaxed It is essential for midwives to try to find breastfeeding'. In: Liamputtong P (ed). Infantsocial environment that helps to out and to understand the social feeding practices: a cross cultural perspective,improve wellbeing (Hoddinott et al 2006). context within which breastfeeding New York: Springer. occurs for each woman in her care. Activity 4 Although it has been known for some Marshall JL, Godfrey M and Renfrew MJ (2007). Where can breastfeeding women time that extra support improves 'Being a ‘good mother’: managing find mother-to-mother support in a breastfeeding outcomes, women still do breastfeeding and merging identities'. Soc sci group setting in your area? If you not always feel well supported. and med, 65(10): 2147-2159. were to facilitate such a group how Midwives have an important role to might you consider alleviating any play in both supporting women with Murphy E (1999). ‘Breast is best: infant feeding anxieties a mother might have technical and emotional aspects of decisions and maternal deviance'. Soc of when attending for the first time? breastfeeding in the early days and health and illness, 21(2): 187-208. helping women to mobilise other forms of support such as group based peer Renfrew MJ, McCormick FM, Wade A et al (2012). 'Support for healthy breastfeeding mothers with healthy term babies'. Cochrane database of systematic reviews, 5: CD001141. DOI: 10.1002/14651858.CD001141.pub4. Schmied V, Beake S, Sheehan A et al (2011). 'Women’s perceptions and experiences of breastfeeding support: a metasynthesis'. Birth, 38(1): 49-60.

THE PRACTISING MIDWIFE • January 2013 Researchunwrapped • 41Midwifery today in AustraliaResearch unwrapped seeks to unpack a research study by We’re very focused onundertaking a step by step evaluative process aimed at continuity of carefacilitating research usage. This issue of Research unwrapped which we see as vitaltakes on an alternative format: Mary Nolan grasps the not only for women’sopportunity to explore some of the key perceived differences wellbeing but also forbetween the provision of midwifery care and antenatal increasing midwives’education in the UK and Australia, in an interview with Dr job satisfactionJane Svensson. Dr. Svensson, who works in Sydney as a midwife researcherinside a clinical setting, discusses knowledge creation, the transfer ofresearch into practice and key priorities for Australian maternity services. Dr. Jane Svensson is clinical midwifery consultant with specialresponsibility for health education at the Royal Hospital for Women inSydney. Her background is in nursing and midwifery with vast experience inchild and family health. Her PhD is in antenatal education. While attending the National Childbirth Educators' (NACE) conference inOctober, I had the chance to ask Jane about the key issues for midwifery inAustralia and to compare and contrast them with those facing us in the UK.Mary Nolan The NACE conference was held in Sydney in October. This was a special event for me because I was one of the architects of NACE's 'Competency standards for childbirth and early parenting educators’, a ground breaking document which describes in detail the professional, legal and ethical responsibilities of practitioners working in the field and the scope and content of their practice. The competency standards enshrine a commitment to high quality parent education delivered by trained and skilled practitioners who aim to play a major part in protecting the physical, emotional, social and spiritual wellbeing of parents and babies. Dr Jane Svensson M

42 • Research unwrapped January 2013 • THE PRACTISING MIDWIFEQuality care can only be MN: Do you use antenatal education MN: How do Australian midwivesdelivered when the to tell women about birth centres and view midwifery in the UK?woman is considered in the choices they can make about placethe context of her of birth? JS: There’s a feeling here that there’sfamily and her a much higher rate of home birth in thecommunity JS: We do. However, antenatal UK and we’re very envious of that! We education is under threat. The number certainly don’t hear much about parent MN: What are the key issues for of antenatal education coordinators in education in the UK – it doesn’t seem tomidwifery in Australia today? hospitals is being reduced and the figure much. hours of those still in post are being cut JS: We’re very focused on continuity back. Parents have to pay for their MN:What’s new in Australianof care which we see as vital not only antenatal education in many hospitals. midwifery?for women’s wellbeing but also for Increasingly, for minority groups such asincreasing midwives’ job satisfaction. single mums, young mums and Chinese JS: Our first cohorts of direct entryWe know that independent midwives and indigenous Australian mums, midwives are just completing theirwho do most of our home births may hospitals are running a branded programmes. This is very exciting andenjoy greater job satisfaction generally programme called ‘Centering Pregnancy’ we’re eager to see what impact theythan hospital based midwives; groups. These are groups for about 10 will have in practice – perhaps they willhowever, independent midwives are women who meet regularly in help boost the number of home birthsthreatened because their professional pregnancy to learn how to care for their and bring down the induction rate!indemnity insurance is going to be babies and develop friendships withwithdrawn in June 2015 . In order not other women. The group leader carries In conclusionto lose their skills from the workforce, out standard antenatal care at the I found it fascinating to see just howmoves are afoot to link them with sessions. similar the issues for midwifery are inhospitals so that they can continue to Australia and the UK. This surelypractise. MN: Your post involves you in a great reflects the globalisation of health and deal of research. What areas of research the ubiquity of the medical model in MN: Are birth centres a strategy for are currently of interest to you? maternity care. Clearly, there is a caseachieving continuity of care? for midwives worldwide to work JS: We’re evaluating the Centering together to achieve a social model of JS: Birth centres are not as common Pregnancy groups to see if they really maternity that recognises that qualityin Australia as in the UK. Probably only are making a difference to the mental care can only be delivered when thea quarter of hospitals have a midwife health of mothers and the overall woman is considered in the context ofled unit attached to them and this wellbeing of their babies. In other her family and her community. It wouldsituation isn’t helped by consultants research we’re also interested in the be very interesting to link midwivespresenting evidence which suggests impact of education for parenting as interested in birth and parentingthat midwife led care may be more opposed to labour and birth. education in the UK with colleagues inexpensive than hospital based care. In Australia, perhaps via social networkingterms of who uses birth centres, it is In the clinical field, we’re focusing on sites, so that they can offer mutualdefinitely educated middle class induction of labour which is very high in support and share information and bestwomen who choose them rather than Australia. The rate in public hospitals is practice points. Anyone interested? TPMless privileged mothers. about 25 per cent and in private hospitals, where a lot of women have Mary Nolan is professor of perinatal their care, it’s reported to be higher. education at the University of Worcester Eighteen months ago, in New South Wales, the Government issued a directive about normal birth and this was part of a drive to bring down the induction rates.

Around the conferences Jenny Fraser reports from RCM legal birth conference 5 July 2012, SOAS, LondonT his fourth joint venture They highlighted the Northwick Park. The head of midwifery between the RCM and Bond need to support women and a supervisor of midwives were Solon was, as usual, a cracking who decline medical interviewed in a ‘chat show’ style. conference. The delegates, treatmentwho grow in number every year (this Mock fitness to practise hearingtime there were 245), were treated to a and highlighting the need to support The afternoon was chaired by Markfirst class day with eminent speakers. women who decline medical treatment, Solon, director of Bond Solon training. and advocating caution to ensure that The hall became a coroner’s court and Professor Cathy Warwick ably chaired midwives are aware of their the audience became the jury. Thethe morning session, commenting on responsibilities. Maternity claims, audience was under no illusion as tothese challenging and difficult times, explained Alison Bartholomew, cause what was expected of a jury.but welcoming midwives who, she said, huge costs to the NHS every year. The ‘actors’ were Denise Linay, RCMare so keen to do the right thing. employment relations advisor, Pat Northwick Park Gould, team manager for RCM EnglandSpeakers There was then an innovative session and Debby Gould, senior midwife. TheyThe speakers included Professor Lesley looking at the lessons learnt from were convincingly cross examined byPage, barrister Barbara Hewson, Carmel real lawyers. It was very thoughtLloyd, assistant director for standards at provoking.the NMC and Alison Bartholomew fromthe NHS litigation authority; they were After all the evidence had been given,by turns encouraging midwives by the coroner summed up and listed thepointing out that most births are safe possible verdicts. From the options available (open; natural causes; accidental death; accidental death aggravated by lack of care; misadventure; or misadventure aggravated by lack of care), the jury overwhelmingly chose ‘misadventure aggravated by lack of care’. Andrew Andrews, medico legal trainer with Bond Solon, revealed that this is the verdict he also would have chosen. The next conference This year’s conference is on the 11th July and, increasingly popular, it is likely once more to be oversubscribed. TPM Jenny Fraser is an independent consultant midwife

44 • Diary January 2013 • THE PRACTISING MIDWIFEJanuary and consultations, labour CTG and ECG Join a world-wide community of women helping7 January Chatham. Info: www. (STAN) study day. women during the most special time of their lives...Breastfeeding peer breastfeedingspecialis London. Contact:support: realising t.com/page2.htm Angela Mason: 0208 Birth ROCKSpotential and avoiding 725 0228 / obsandgypitfalls, Chatham. Info: 8 February @sgul.ac.uk New Year, New Approach!www. Compassionatebreastfeedingspecialist. midwifery. London, 21-23 March Get back to your roots, support mothers duringcom/page2.htm £89 (£69). Info: www. Certified Yogabellies pregnancy and birth and build a successful career yourbirthright.co.uk/ for teacher training. as a YogaBellies Birth ROCKS Mentor.12 January index.asp?PageID=38 Yogabellies for mumInspirational birth. and baby. Manchester. YogaBellies Birth ROCKS is a FEDANT accreditedUnderstanding, 21-23 February Details and contact: antenatal educator course, combining home andinspiring and Certified Yogabellies yogabelliesteachers.co live study.supporting for teacher training. .uk / cheryl@physiological birth. Yogabellies for yogabellies.co.uk Special Offer £100 discount for Midwives on theShepperton, £30 (£25 pregnancy. training price when quoting: ‘PRACMID’unwaged). Info: Manchester. Details Aprilwww.northsurreymidw and contact: 8 April For more information visit our websiteives.co.uk/birthworks yogabelliesteachers.co Mock lactation www.birthrocks.co.uk or .uk / cheryl@ consultant exam and contact Cheryl atFebruary yogabellies.co.uk revision strategies, [email protected] February Chatham. Info: www.Fetal monitoring in March breastfeedingspecialislabour (CTG) study 11 March t.com/page2.htmday. London. Contact: Breastfeeding andAngela Mason: 0208 food, Chatham. Info: 26-27 April725 0228 / obsandgy www.breastfeedingspe Mama [email protected] cialist.com/page2.htm Edinburgh. Info: www.mamaconferenc4 February 19 March e.co.ukBreastfeeding clinics Fetal monitoring inProfessional developmentMSc MATERNAL Whether you’re a children’s nurse, a health visitor, a midwife or a& CHILD HEALTH practitioner working in health and social care, our interprofessional masters course can help you develop in so many ways by:SOCIO-CULTURAL É Enhancing your critical skills and understandingPERSPECTIVES É Familiarising you with the latest international“ This course focuses on global concerns methods and research about maternal and cchhiillddhheeaalltthh.. É Allowing you to choose to concentrate on the It will enable yyoouuttooeexxpplloorreeiissssuueess surrounding the health aannddssoocciiaall areas that interest you most care of women, cchhiillddrreennaannddyyoouunngg And with flexible study arrangements that you people, while considering yyoouurroowwnn can fit around your work, it’s the ideal way to ”unique role in sseerrvviicceeiimmpprroovveemmeenntt.. take that next step towards a great career.www.healthcare.ac.uk For more information contact: Julie Harrison tel: +44 (0)20 8725 2014 or 07768 145 346 email: [email protected] www.healthcare.ac.uk/maternalandchildhealth

Don’t miss an issue Subscribe to and save 5%** DIRECT DEBIT UK ONLY THE BEST JOB IN THE WORLDTHE BEST JOB IN THE WORLD THE BEST JOB IN THE WORLD THE BEST JOB IN THE WORLD THE BEST JOB IN THE WORLD www.thepractisingmidwife.com Volume 15 no 11 • December 2012www.thepractisingmidwife.com Volume 15 no 8 • September 2012 Pwww.thepractisingmidwife.com www.thepractisingmidwife.com Volume 15 no 9 • October 2012 Normal InternationalisrsoufeesssionalAustralian midwifery Volume 16 no 1 • JanuaEducationractisingmidwife.com Nutrition Volume 15 no 10 • November 2012 birth NEW! 12th midwifery basics series on infant feeding Volunteering in Ethiopia The importance of vitamin Dmmeurlgtei ndsccyiptrlaininairnygopbrsotegtrarimc me Pregnancy nausea and vomiting iTnhperpolmacoetionfgsnuopremrvaisl iboinrth Mhoidmweiofepraythayndin Ghana NNEETExSWhWpuel!po!pSpIremooinxlrimguttiiavtcighlesrheosaeuffnaipvttlnoetwhreluvosanismsfttiteoeeoennrprcairhnanigcdldtimbseiarththeeranriitnygcare Obesity and pregnancy Northampton home birth team CNaonenwdfeoZrneelnainlcaeensdin e impact of inconsistency The ‘easy guide’ to normal birthn student learning ALSO: The world’s first womb Home birth without intervention transplants! News, page 7rdeurceagtiisotnraitnioSncomtliadnwdiferyAofmsuidpwerifveis’sepdopsriaticvteiceexperience pPrluosm: tohtienngebwreUaNstIfCeEeFdirnegpo-rpt43 Name Instruction to your bank or building society to pay Direct Debits Please complete parts 1 to 6 to instruct your bank or building society to Job title (if applicable) make payments directly from your account (UK ONLY). Institution (if applicable) 1 Enter full name and postal address of bank or building society Address To: The Manager Postcode Country Name of bank/building society Telephone Email Address Rates Please tick the rate appropriate to you Postcode Save 5% if you pay by Direct Debit (UK personal rate only) – lower rates in brackets 2 Name of account holder Personal rates 3 Bank/building society sort code UK £60 (£57) Newly qualified £50 (£47.50) Student £36 (£32.40 - 10% DD discount) 4 Bank/building society account no Eire/Europe £70 Rest of world (surface) £95 Rest of world (airmail) £120 5 Reference (office use) My course ends Originator’s identification no 2 5 8 7 7 2 Institutional rates 6 Instructions to your bank/building society: Please pay FastPay Ltd re Medical Education Solutions Ltd from the account UK £134 Eire/Europe (airmail) £160 Rest of world (airmail) £190 detailed in the Instruction subject to the safeguards assured by the Direct Debit guarantee. PAYMENT OPTIONS – Three ways to pay! Signature Date 1 Cheque I I enclose a cheque payable to The Practising Midwife for £ Some banks and building societies may not accept Direct Debit instructions 2 By credit card/debit card (circle required option) Please return this form to: TPM Subscriptions, 66 Siward Road, Card number: Bromley BR2 9JZ. Start date: Expiry: 3 digit security code: Issue no (switch only): The Direct Debit guarantee This guarantee is offered by all banks and building societies that take part in the You can also call our credit card hotline 01752 312140 Direct Debit Scheme. The efficiency and security of the Scheme is monitored and protected by your own bank or Please return this form to: TPM Subscriptions, 66 Siward Road, Bromley BR2 9JZ. building society. If the amounts to be paid or the payment dates change, Medical Education Solutions Ltd will notify you 10 working days in advance 3 Direct Debit (UK only) I I would like to pay by Direct Debit and save over 10%. Please complete of your account being debited or otherwise agreed. If an error is made by Medical Education Solutions Ltd or your bank or building society, you are the Direct Debit instruction opposite. guaranteed a full and immediate refund from your branch of the amount paid. You can cancel a direct debit at any time by writing to your bank or building society. Please also send a copy of your letter to us.

46 January 2013 • THE PRACTISING MIDWIFELAST WORD15 minutes of television time Geraldine Butcher laments the tendency of some programmes to negatively dramatise birthC uriosity: Life before explains that this “allows his birth shown on head to be compressed as it is the Discovery wedged through the birth channel on canal”. Birth is “excruciating,January 20th 2012 provides but there is no turning back”.an interesting insight intopregnancy and birth using In speaking about Megan’s4D ultrasound and computer birth, she relates that asgenerated images, but its Megan pushes her baby out,final 15 minutes were a the baby has “nevershocking dramatisation of a experienced anything like thisvery skewed view of birth. violent earthquake surrounding it,” concludingChallenging The vivid use of that Megan’s baby is born starved ofCourtney Cox begins the birth section language emphasising oxygen and looking alarmingly blue,by saying birth is “traumatic and the very worst that which, to me, she didn’t.exhausting for mother and child and could happen is notcan also be deadly”. Feet or bottom first helpful Birth shown as life threateningis a “dangerous position to be in and It is not difficult to see why womenthe umbilical cord is easily trapped, Excruciating watching programmes whichcutting off precious oxygen...Deadly Going on, Courtney Cox says not all negatively dramatise birth could be leftserious pre eclampsia, in which the births are as easy as Sarah’s and that feeling that birth is a battle to be won, aplacenta malfunctions, pumping harmful the “trauma for the mother and child life threatening venture that is besthormones into the mother’s blood stream, can be great”. Contractions are called avoided, a task they will never be ableher blood pressure rockets to dangerous ‘spasms’ and the cervix has to reach to complete and which will damageheights can quickly turn deadly”. There 10cm before the baby can ‘squeeze’ their baby as well as themselves.can be no denying that both breech through: “a tight, agonising fit forpresentation and pre eclampsia can be baby’s head” in which the cervix As a midwife who regularly speaks tochallenging, but the vivid use of “clamps him in a vice like grip.” women who have a fear of childbirth, Ilanguage emphasising the very worst can see the effects and the difficulty inthat could happen is not helpful. When explaining the miracle of trying to change the woman’s moulding in facilitating birth, Cox perspective when it has been damaged Describing the birth of Sarah’s baby, in this way. The programme is availablewhere labour was induced at 37 weeks on DVD and excerpts are on Youtube,because of pre eclampsia, Cox states extending its impact beyond satellitethat during pushing, the baby’s head is television. TPM“forced painfully through the cervix”but that the baby “defies every danger Geraldine Butcher is consultant midwifeof early birth”. at NHS Ayrshire and Arran



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 OOUURRKKNNOOWWLLEEDDGGEE, THIS IS THE FIRST REPORTING OF SUCH FINDINGS OOFFAANNY 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 pprregnancy as this iissaaccrriittiiccal 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. Also provides the recommended 400mcg folic acid and 10mcg vitamin D 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. Originally developed with Conception Breast-feeding ‘Plus Dual Pack Original Prof. A. H. Beckett† OBE, PhD, DSc (1920-2010) Professor Emeritus, University of London 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.ADPRGTRADEP12-12-12E 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 † Professor Beckett is not cited in the capacity of a health professional, but as a product inventor and former Chairman of Vitabiotics. ††Based on a survey of 1000 midwives. For more information on this research, please visit www.pregnacare.com/mostrecommended www.pregnacare.com