ARM Study Day 2018: Conference Review by Ruth Weston

The 2018 ARM study day in Wigan was described by Dr Lesley Choucri as “Midwifery Nourishment” and I couldn’t agree with her more. This was a wonderful day of learning, sharing and refilling our cups ready to go back to our own regions “Stronger Together”.

“Stronger Together” was one of Kathryn Gutteridge’s themes, which came out of her desire to remind us all that we need to stand together during these challenging times. She pointed out that all midwives are midwives, whether they work for the NHS, private companies or as independent midwives. For the good of the profession – and every midwife – we MUST support each other. There is so much horrific bullying, and areas of practice which are lacking in compassion. Can each person make a change by reflecting on their own practice?

Of course, Better Births was an essential part of the ARM study day, and Claire Mathews , deputy Head of Midwifery for NHS England, outlined its implementation with a focus on Continuity of Carer. Because this was a midwifery audience, Claire focused on the understandable worries that some midwives have of how continuity will work for them, especially as some midwives have experience of continuity services where they were given entirely unreasonable caseloads. With a short-term target of around 20% of women to have continuity, Claire recommended that initially trusts worked on encouraging those midwives who were interested in offering continuity to jump in and have a go, lighting the way for others to follow.

I was particularly struck by Jo Dagustun’s talk on her research into women’s experiences of birth which was an uncomfortable listen for the audience of midwives. Jo explained her PhD research which included women’s experiences of  the maternity system.

The key messages I heard in this excellent, many-layered reflection were:

  • That for women the key antenatal teacher/education was their experience of the maternity system itself.  What women are told in antenatal classes and by professionals about what they can choose, the care they can ask for or receive is over written by actual experience.
  • That women’s experiences of the maternity system, including birth, is of a ‘hostile’ environment; spaces and interactions that do not feel friendly towards the health and wellbeing of mother and baby. Women therefore made decisions on what they saw as the best way of protecting the physical and mental well-being of themselves and their child. Far from this resulting in choices for midwifery led care it often resulted in women choosing a medical birth. It also resulted in women providing partial information or telling professionals what they think is expected rather than the truth.
  • Finally, the women interviewed did not see midwives as a distinct profession with in maternity. Indeed they were not clear what midwives are. Processed through a fragmentary system and seeing multiple professionals, midwives did not stand out. In this context women did not want continuity so much as kindness from the professionals they were with.

This final point provoked a lot of reflection. It is shockingly sad that kindness is not standard in the maternity system. It is also disturbing to realise that midwifery does not stand out to most women in the maternity system. Is this how far the profession has faded? Just another health care professional doing their job? It also has some real consequences for continuity, for instance, who would want continuity from a midwife who did not show kindness?

Finally, Jo, with admirable tact and honesty, presented an example of an interaction between a service user and professionals on social media. What came through to me were professionals who thought they were being kind and helpful but from the service user’s perspective were not. Also, she showed health professionals who wanted the service user to see it from their point of view but did not themselves ‘stand in the shoes of the woman’ – surely a mark of the with-woman profession of midwifery. We need to reflect on how much the maternity system has broken the midwifery tradition of being with-woman and made the midwife a just another health care professional.

In better news, a big shout out needs to happen to Airedale Hospital Trust who have been a shining light on the issue of Independent Midwives and their ability to offer intrapartum care, as Airedale is providing them with indemnity to ensure that they can continue to practice. In return the Trust has these amazing and skilled midwives sharing their experience and knowledge, leading to improved services to women and happier staff. Airedale join several other Trusts across the country who are supporting Independent Midwives in a similar way, as is outlined in the recent IMUK blog.

Aquabirths Hi-Lo Keeling Birth ChairMargaret Jowitt’s Hi-Lo system was on display alongside the Aquabirths stand (see photos to the left for two ways that the Hi-Lo can be used). Also known as the Osborne Kneeling Chair, this wonderful piece of kit is a must for every obstetric room. It is a simple, strong and easily cleaned frame with cushioned supports which women can kneel, lean or sit on. The Hi-Lo is designed to ensure that midwives can easily access women for observations, and the small footprint means that it will fit into most obstetric rooms with ease. A video explaining how the Hi-Lo works is hereSoftbirths Mini birth couch

Aquabirths also had their Softbirths mini birthing couch on display which midwives Deborah Hughes and Deborah Neiger had fun modelling as you can see!  A smaller version of the full birth couch, the mini couch fits into smaller spaces to provide comfort and support to women in different upright birthing positions.

ARM Coordinator, Katherine Hales, rounded off the day with an update on ARM’s campaign for an independent midwifery regulator. The NMC is not fit for purpose as has been discussed on this blog multiple times. ARM now believes that it is essential that midwifery is separated from nursing, and has regulation which focuses on the needs of midwives, which the NMC simply does not do. The focus now is on the midwifery code and midwifery panel being managed by midwives under the umbrella regulation of the Health and Care Professionals Council which oversee many other similar sized groups, such as physiotherapists. This regulator seems to work better to support the professionals it oversees than the NMC does.

All in all, an exceptional day – many thanks to ARM for all their hard work!

#WiganARM18

 

 

 

Vaginal Seeding after a Caesarean Birth: Safe? Effective? What does the EVIDENCE say?

caesarean birth Vaginal Seeding after a caesarean birth – what’s it all about?

The news this week has been all about vaginas – specifically the idea of “seeding” a newborn’s gut with a swab from the vagina after a caesarean birth.

Vaginal Seeding after a caesarean birth was first widely covered in the film “Microbirth” which covered the work by Maria Dominguez-Bello and her colleagues, looking at whether the differences in gut bacteria between vaginally and caesarean born babies was due to the fact that caesarean born babies do not absorb gut flora from their mother’s vagina. Because these differences are linked to long term health problems, the research is attempting to find whether the swabs help to change the gut bacteria in a positive way.

The results of the pilot study were very positive, with the gut bacteria of 100% of the “seeded” caesarean-born babies being very similar to those of the vaginally born babies, in contrast to the caesarean-born babies who were not seeded where 100% of them had a different microbiome. The authors state that they don’t yet know whether this would impact the baby’s health over time, nor whether the results would replicate with a wider study group, and more work needs to be done.

Concerns have been raised about the risk of infection from vaginal seeding, and the original paper which triggered the media storm recommends not doing vaginal seeding following a birth which was planned as a caesarean specifically in order to reduce the risk of infection from, say, HIV or herpes.  Surely this is self evident? There is also a question of whether pathogens such as Group B Strep (GBS) may put babies at risk – but as many as 1/3 of women carry GBS at the time of a vaginal birth, and there is no reason to think that this would be more readily passed on through seeding than a vaginal birth although this would be important to look at in future studies.

It has also been suggested that amniotic fluid may “wash” the vagina and change the flora experienced by babies passing through during birth compared with seeding the baby after a caesarean birth. The authors of the pilot found that there was no difference in a woman’s vaginal flora before and after birth, so this does not seem to be the case, and most babies do not simply flow down on a wave of fluid!

Perhaps one consideration is that babies are often born with their eyes and mouths closed, and so when considering vaginal swabbing, it would be useful to know whether the swab should be put into the baby’s mouth or eyes, or simply wiped over them. Timing of when is best to use the swab needs to be better understood, and the pilot study says that parents should be aware that skin to skin and breastfeeding are well understood to be extremely important to a baby’s gut health and long term health.

The pilot was very small, with only 18 babies in the study, and the authors are clear that more research is needed. This is contrary to much of the misleading media coverage which has stated that there is no evidence for vaginal seeding after a caesarean birth. There is, it’s just a very small sample study and is not sufficient to change recommendations.

If only medicine was always this diligent.

Guest post by Emma Ashworth