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Midwives experience domestic abuse too…so how can they be supported in the workplace?

On Thursday October 4th 2018, The Royal College of Midwives (RCM) launched a report entitled ‘Safe Places? Workplace Support for those Experiencing Domestic Abuse’ at its Annual Conference in Manchester Central.

love shouldn't hurt-printed on back of woman

I was privileged to be asked to perform and write up the analysis for this report. The findings truly moved me. If you know my work at all, you will know that it is heavily focused upon securing the psychological wellbeing of midwives. This is because I do not believe that excellence in maternity care can be delivered to mothers and babies without the provision of effective support for midwives.

Findings here revealed that some midwives trained to recognise domestic abuse and support women, were sometimes not recognising that they themselves are victims of domestic abuse.

“I was allowed to stay overnight on my delivery suite to avoid going home to my abusive partner”

“I was made to feel I was a nuisance, constantly asking me and contacting me, pressurizing me in to coming back to work. I gave in and did but I was soon off again as I still wasn’t well, and I then left midwifery because I didn’t want to be dismissed. I didn’t receive any support that was effective for me”

“I have and was been treated very badly by my place of work, absolutely no support or care and compassion”

“I was given a specific senior midwife who I could go to for support, to discuss things at times when home was particularly bad and to deal with any sickness absence – helpful as one person knew what was going on and I could be truthful, especially about the reasons for sickness absence sometimes”

“All staff should be asked about domestic abuse or violence on a regular basis”

“Police and social services were unhelpful, and no support provided. Neither I nor my children were offered counselling or directed to appropriate services despite asking several times for help. One police officer even commented that due to my ethnicity I could handle the situation myself.”

person holding white printer paper

Based on the findings the RCM has put forward the following evidence-based recommendations. These will enable maternity service managers and NHS Trusts/Boards to support staff experiencing domestic abuse more effectively.

  • All NHS Trusts/Health Boards should develop specific policies to support who are victims of domestic abuse, aligned to existing guidance from the NHS Staff Council developed in 2017.
  • NHS Trusts/Health Boards should provide and publicise confidential domestic abuse support services for affected staff, including access to IDVAs, external counselling and legal services as appropriate.
  • NHS Trusts/Health Boards should ensure that all managers and supervisors are trained on domestic abuse issues, so that they can recognise signs of domestic abuse in their staff and confidently undertake their safeguarding obligations.
  •  NHS Trusts/Health Boards should ensure that staff at all levels are trained on domestic abuse issues and made aware of relevant workplace policies as part of their induction programme and continuous updating and are made aware of support services.

It was a pleasure to work with esteemed colleagues at the RCM to put this report together. Midwives and maternity support workers are a highly valued workforce whom we rely on to provide optimal care for mothers and babies. It is our sincere hope that this report will enable maternity service managers and NHS Trusts/Boards to support staff experiencing domestic abuse more effectively.

“Thank you to all of the midwives and maternity support workers who took part in this survey. The wellbeing of maternity staff is intrinsically linked with the safety and quality of maternity services. Your thoughts, feelings and experiences have helped us to arrive at a deeper understanding of the resources required to support those experiencing domestic abuse.”

woman carrying newborn baby

If you would like to follow the progress of work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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How does patient and public involvement work in research? An example exploring midwives’ workplace wellbeing.

Patient and public involvement or #PPI is defined by INVOLVE (part of, and funded by, the National Institute for Health Research) as: 

“Research being carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them. This includes, for example, working with research funders to prioritise research, offering advice as members of a project steering group, commenting on and developing research materials and undertaking interviews with research participants.”

three person pointing the silver laptop computer

In our latest publication, we explain how patient and public involvement works in maternity service research. Here, we asked childbearing women about their experiences in relation to the workplace wellbeing of midwives. We also asked them how they felt about new research looking to create and test an online intervention designed to support midwives. We did this via a discussion group, where participants were offered refreshments and remuneration for their time. Our aim was to answer the following questions:

  1. What are the perceptions of new mothers in relation to the barriers to receiving high quality maternity care?
  2. What are the perceptions of new mothers in relation to the psychological wellbeing of midwives working in maternity services?
  3. What are the perceptions of new mothers in relation to a research proposal outlining the development and evaluation of an online intervention designed to support midwives in work-related psychological distress?

These PPI activities helped us as researchers to do the following:

  • Better understand this research problem from the perspectives of new mothers
  • Validate the direction of future research plans
  • Explore new areas for data collection based on what really mattered to mothers and their babies
  • Improve upon the design of the proposed online intervention based on what really mattered to mothers and babies.

You can read our full methodology via the linked citation below:

Pezaro, Sally, Gemma Pearce, and Elizabeth Bailey. “Childbearing women’s experiences of midwives’ workplace distress: Patient and public involvement.” British Journal of Midwifery 26.10 (2018): 659-669.

This article was launched in the October edition of the British Journal of Midwifery at the Royal College of Midwives annual conference in 2018 .

white and black Together We Create graffiti wall decor

Put simply, the findings in relation to what participants said were analysed thematically and turned into meaningful insights or ‘PPI coutcomes’. In this sense, we used a co-design approach to inform the direction of new research. How did this work exactly? See figure below.

Figure 1. Overall findings

Initially, we considered that it may have been useful to include midwives in PPI activities, as they were to be the intended recipients of the intervention proposed. However, INVOLVE briefing notes state that:

“When using the term ‘public’ we include patients, potential patients, carers and people who use health and social care services as well as people from organisations that represent people who use services. Whilst all of us are actual, former or indeed potential users of health and social care services, there is an important distinction to be made between the perspectives of the public and the perspectives of people who have a professional role in health and social care services.”

A such, we could not include midwives in these PPI activities due to them having a ‘professional role in health and social care services’. Nevertheless, as midwives were the intended end users and direct beneficiary of the intervention proposed, we argued that they should “not necessarily be excluded from PPI activities simply because they treat patients”. This debate lends itself to further academic discussion and we welcome ideas on this going forward.

two person standing on gray tile paving

Both national and international strategies and frameworks relating to healthcare services tend to focus on putting the care and safety of patients first , yet these findings suggest that to deliver the best care to new mothers effectively, the care of the midwife must equally be prioritised. As such, we now intend to seek further funding to continue this work and secure excellence in maternity care.

If you would like to follow the progress of work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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The pregnant midwife: A personal reflection on having a baby as a midwife

I have always had a passion for matters around pregnancy, birth and babies. For years I have enjoyed being a midwife, clinically in research and in teaching. My passion started at around 4 years old when my brother was born. Mesmerized by a growing belly and the fact that another human was coming in to the world, I read my mother’s antenatal books from cover to cover. Having just experienced the birth of my own baby, I felt compelled to write my own reflections and experiences down….

Please note: For personal reasons I would request that close family members do not read any further.

*Long post alert*

What happens when the midwife has a baby? We are people just like any other having a baby…right?…probably. Did I know too much?…Did that affect my choices? did I have a better choice and/or experience because I had ‘insider knowledge’?… One thing is certain. Having a baby as a midwife was unique for me.

The stick turned blue

Yes, our little Autumn baby was planned….and thankfully, we had no trouble conceiving our little darling, who was due to arrive conveniently after I had  been awarded my PhD. But my period being late and the pregnancy tests showing up negative confused me. This was my first experience of feeling as though ‘I should have known better’! … Of course, though I knew that all I was looking for was a little Human chorionic gonadotropin (hCG), the cheap sticks I had bought clearly were not sensitive enough to detect it…it took a friend to prompt me to spend a bit of extra cash on the test. Of course a fancy pants digital stick did the trick….Silly me. The midwife should have known better (was one of my first thoughts… and a recurrent theme throughout my pregnancy)! The pressure was on!

Of course when the stick did officially ‘turn blue’ my heart jumped into my mouth, knowing that this was an ‘oh sh*t’ moment. No take backsies. Yet, I have no idea why I panicked …it was planned after all! Perhaps it was because..

  1. My parents would know for sure that I was sexually active (ridiculous I know…especially as my husband and I have been together 18 years)!
  2. I really would need to finish my PhD in time
  3. Life was about to change for ever
  4. I think this pregnancy is a good thing (probably)

My unicorn was on her way..

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Choosing my care givers

Unlike many women who my just meet the nearest or most convenient midwife. I had the luxury of knowing a myriad of great midwives who could provide great care for me and my baby. I also had the luxury of knowing how and who to ask directly for what I wanted. I felt spoilt. This felt like a luxury that many women don’t have…but it was also a perfectly reasonable thing to be able to do. I was able to chose a midwife who I knew was ‘on the same page’… and who would care for me continuously throughout…Do all women get this opportunity?

Pregnancy symptoms

For years I have been caring for women with ligament pain, pelvic pain, odd sensations and physical stresses and strains. Being pregnant myself meant that I could finally feel what I had been describing… ‘Ahh…that’s what hey mean by feeling a ‘twang”

One great benefit of being a pregnant midwife is also knowing what symptoms to worry about and what symptoms not to worry about. I imagine that this may have enabled me to experience somewhat less worry than others experiencing such things for the first time….In the beginning anyway!

To tell or not to tell…that is the question

Other than the midwives I knew, there were other care givers throughout my pregnancy who were meeting me for the first time. They all began with the usual spiel about risks/benefits/routine and procedure. The question is (or was).. do I let them go on talking like I know nothing.. or do I let them know that I am a midwife who is used to spouting this spiel myself.

In not telling them, I felt like a fraud.. Like I was making a fool of them… But in telling them of my profession, I felt as though I would be giving up my status as a ‘regular’ maternity service user. My cover would essentially be blown.

A desire for honesty got the better of me. I told all new care givers that I was a midwife. The following happened:

  1. Clinicians dropped any facade of being ‘ultra professional’ – They became more friendly… like we were ‘on the same team’.
  2. I was told frequently ‘Well you know all of this already so I won’t repeat it’

As they did this, I felt a mix of emotions. On the one hand…I felt truly part of the team…a sense of power and autonomy…On the other hand… I felt like I no longer had the safety net of being ‘nurtured’ through my pregnancy. Was I missing out?..I’m not sure. But I was no longer treated as a ‘regular pregnant woman’.

Choosing my own care pathways

In my experience as a midwife, I have seen how some professionals can dismiss the thoughts, feelings and desires of women wanting to make decisions in relation to their own care pathways. For more on this, please see Michelle Quashie @QuashieMichelle 

As such, I sometimes had to fight hard to make sure that the women in my care got what they wanted. I was expecting to have the same fight.

However, I found that once people realised that I was a midwife, they were more willing to trust that my own decisions were informed decisions. They seemed less intent on trying to persuade me one way or another. They seemed to respect and accept my choice more than I had seen some maternity staff respect the choices of other women.

For me this highlighted issues around respecting women’s choice. When do we feel that women can make their own choices without question?…and when do women’s choices cause clinicians concern?….

Whatever the opinion of others… I, as a midwife could seemingly make any choice I wanted with ease…. Is this the same for all? I think not.

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Birth choices

I have actually known what my own birth choice would be for a long time now. My main fear was that my choice would be made unavailable to me. Pre-conceptually I had consulted the obstetric team to discuss my birth choices…Would they be facilitated? because if not…did I really want to get pregnant in the first place?… the answer was ‘Let’s wait and see once you get pregnant’…Damn. I was really looking for a signed deal beforehand.

Once I became pregnant of course, they held all of the cards. I was pregnant…. trapped… The baby had to come out somehow, but I was beholden to them.. as they were the ones who would decide whether or not to facilitate my choice. This also altered the power balance and really made me feel vulnerable… at the mercy of those with the power to say yes or no. It was not a nice place to be.

My midwife, and my consultant midwife were 100% supportive of my decision, but they were not in a position to sign on the dotted line. I wanted a beautiful planned cesarean section. Something which goes against the grain for some.

When it came to meeting the consultant team, I was nervous about what they would ‘allow’. Now… I hate the word ‘allow‘ in maternity services, but this is how it felt. I was asking permission to have this… asking them to facilitate this. They had the power to say no. As a midwife, I believe I knew the right things to say to maximize my chances of them agreeing to my birth choice. I also had all of the up to date guidelines and research to back up my arguments should I need them. I was still nervously holding my breath.

There was some resistance, I had some extra appointments and some hoops to jump through, but with some firm words and some strong midwifery back up, I was able to get my birth choice ‘agreed’ or ‘allowed’.  Though the clinical reasons for my birth choice are too complex to explain here, it felt as though my decision making was not so trusted by other professionals in this case. I also had to repeatedly sit and listen to the list of risks involved, and be repeatedly asked if I had wanted to change my mind. Would this be the case if I had chosen a vaginal birth?

The sense of relief was immense…I could finally start to look forward to the birth and enjoy my pregnancy!

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Though this relief could have come much earlier for me… having the obstetric team on board pre-conceptually would have made my experience so much better!

What I really wanted to do was have my birth choice go unquestioned. I wanted to know all of the facts and then be trusted to make my own decision. Doesn’t every person want this?…

A “good birth” goes beyond having a healthy baby…

But I felt as though I may be denied my choice if it did not conform with what the health professional believed was the ‘right’ decision… This was utterly terrifying. The consequences of my choice being denied would literally mean that I would have less control over what would happen to my body. This was a horrifying thought. I would literally be forced to have a vaginal birth against my will. This is literally how the reality  felt.

For more information around birth rights see: @birthrightsorg

These experiences in relation to birth choices got me thinking about ‘informed’ choice in maternity care…

Everyone is ever so concerned about gaining ‘informed’ consent (and rightly so)… but is it disconcerting that we forever talk about the risks of Cesarean section and rarely the benefits? Equally…do we (as healthcare professionals) inform women of the risks of a vaginal birth? or a hospital birth? Wouldn’t that be ‘true’ informed consent?

As a midwife, I have to admit that my favorite type of birth to be in attendance of is an uninterrupted home birth….they are fab!… but that is my preference as a midwife. My preference as a mother was a cesarean section, and I have to ensure that I remain objective in respect to all women’s choices regardless of these facts.

At the end of the day.. a baby is coming out of you. There are a variety of ways in which this can happen. Should there be a default or ‘preferred’ way? or is this ‘preferred’ way subjective to each and every woman? If so then we must stop talking about the ways in which we might prefer women to give birth…and instead celebrate women’s choice in pursuit of their own subjective ‘positive birth’.

See here about the myths associated with positive birth

In my case, I felt a solidarity with Helen George from Call the Midwife, who was shamed for choosing to have a cesarean section. I also identified with some of the reasons she gave for her very personal choice. Of course there are many other reasons why women may choose a cesarean section. Some have been explored in the following paper:

Why do women request an elective cesarean delivery for non-medical reasons? A systematic review of the qualitative literature

From my perspective…the ‘rights’ and ‘wrongs’ of one’s birth choices are too subjective to ever cast judgment upon.

Challenging poor practice

The care I received from the English maternity services in my area was fantastic….For the most part. Unfortunately I did encounter one incidence of poor practice. Sadly this episode warranted escalation.

As a midwife, I know my duty is to take further action (escalate) mistakes in practice where appropriate. However, as a mother, I was nervous about escalating the poor practice of someone whom I relied on for my care (and to facilitate my birth choices). Would they take revenge? would I loose my place of birth? or would my birth choices be taken from me?…It was a very vulnerable position to be in.

“After all…If you complain to the chef..they may spit in your food.”

Thankfully, with the support of my midwife, I am now working with the General Medical Council (GMC) to ensure that other mothers and babies can be protected from the same actions being repeated.

Aside from this… as a midwife, I feel highly privileged that I was able to spot this poor practice and call it out. Another pregnant woman (non-midwife) may not have spotted this poor practice, and been put at risk unknowingly. This highlights how vulnerable women may be, as they trust us all with their (and their babies) lives. Here the role of the midwife as an advocate becomes even more important for those who cannot always safeguard their own care.

Patient & Public Involvement in research

INVOLVE briefings state that there is an important distinction to be made between the perspectives of the public and the perspectives of people who have a professional role in health and social care services. As midwives are not considered to be patients under this guidance, I have felt unable to participate in Patient and Public Involvement (PPI) activities during my pregnancy. This was difficult, as I would have loved to have participated in PPI whilst pregnant in order to contribute to the improvement of maternity services from a user perspective. This issue is worthy of further discussion… after all, health professionals can be ‘patients’ too right?

Antenatal education

My husband is surely sick of my chums and I always talking pregnancy and birth…and of course passion for the profession can get a little sickly for some. So, I wanted the father of my baby to hear what I already knew from someone other than me. I didn’t want him to rely on me for information…after all, I may come across as a know it all rather than an equal partner in his parenting journey. So we went to NCT classes.

The classes were great and the information was sound….Yet, as a midwife… I could feel myself wanting to ‘approve’ of the information given out to the group.

During the challenges set out for us as a group, I was anxious. What if I got a question wrong? or stuck an anatomy sticker in the wrong place?

oh the shame!

Thankfully, I made no mistakes and my midwifery knowledge held strong. Yet again, I felt compelled to disclose my profession to the group. Not to do so felt dishonest somehow, like I was tricking them into thinking I was new to pregnancy and birth from all perspectives…and not just from a parental one. As such, I was relied upon at times for the lived experience of maternity services. People were also generally glad to have me on their ‘team’ during group challenges.

At the end of the course, I think my husband was glad to learn from someone perhaps more objective than myself. I also think that hearing the facts from another birth educator strengthened my husbands faith in what I had been saying all along…For example.. he now trusts that it is indeed OK to have a glass of wine whilst breastfeeding (Very important)!

And just like any other mum of course… I needed to meet other people sharing the same journey as I was.

And so little ‘Loveday Alice Pezaro’ came into the world. I had the perfect ‘positive’ birth (for me).. The breastfeeding is going wonderfully…and we are now knee deep in baby sensory groups and Costa Coffee chats. This experience from the other side of the fence has provided me with more empathy for women and more passion for womens rights in childbirth. The journey was less scary than I thought it might be. But…………………

What if I can’t breastfeed?

This was another real fear for me…having supported so many other women to breastfeed… what if I couldn’t do it myself? I mean… if the midwife can’t do it…What hope is there? 😮😨😩

These types of fears and anxieties resonate with other midwives who find themselves becoming mothers…In fact, the very pertinent research of my friend and mentor Dr. Sarah Church demonstrates how;

“a reliance on professional knowledge may create opportunities for choice and increased autonomy in some situations, although the need for intervention during childbirth, for example, may challenge the degree of autonomy exercised by midwives and the choices available to them. As knowledgeable experts, midwives demonstrate a very different understanding of risk and safety in relation to their own experiences of childbirth. Professional knowledge may increase their anxieties which may not be addressed appropriately by caregivers due to their professional status. The use of knowledge in this way highlights potential conflict between their position as midwives and their experience as mothers, illustrating that midwives’ ability to exercise agency and autonomy in relation to their pregnancy and childbirth experiences is potentially problematic.”

Final thoughts and reflections

  • Being pregnant as a midwife increased both my anxieties and my autonomy.
  • My professional knowledge impacted significantly upon my own perceptions around risk and safety in maternity
  • As a midwife I knew how to best ‘get’ my birth choices.
  • I felt vulnerable at times, especially in calling out poor practice.
  • I felt as though I was treated differently because of my professional background
  • The pressure to ‘get it right’ was always on.

In conclusion, the whole experience of childbearing was much better than I thought it would ever be. I feared much more than I needed to, and in retrospect, I had a wonderful experience. If only I could have anticipated such good outcomes in advance…the fear of the ‘worst’ happening may have never been an issue. One thing is for sure. My experience of being on the other side of the fence will enrich my midwifery practice forever.

On another note..There are so many wonderful midwives and initiatives out there making births better for women and their babies…There are not enough words to mention all of their wonderful work in this single blog. But I would urge further reading around the following groups:

@birthrightsorg

@MatExpBazaar

@NatMatVoicesorg

@BirthChoiceUK 

@birthpositive 

…and Many more (happy to add to this list if suggestions are given)!

My baby ❤️ ‘Loveday Alice’

Image may contain: 1 person, baby and close-up

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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10 Top tips for caring for women with Hypermobile Ehlers-Danlos Syndrome in pregnancy for International Day of the Midwife #IDM2018 & #EDS awareness month

 or ‘International Day of the Midwife’ falls on May the 5th of every year. The theme for 2018 in three languages is…

  • Midwives leading the way with quality care
  • Sages-femmes, ouvrons la voie avec la qualité des soins
  • Matronas liderando el camino con un cuidado de calidad 

Also… Every May is Ehlers-Danlos Syndrome (EDS) awareness month around the world.

As such….for , and EDS awareness month… I shared 10 top tips for caring for women with hypermobile Ehlers Danlos Syndrome (hEDS) during pregnancy birth and beyond. These tips come from my latest paper, authored in partnership with Dr. Gemma Pearce (@GemmaSPearce) and Dr. Emma Reinhold (@DrEReinhold ), entitled …

Hypermobile Ehlers-Danlos Syndrome during pregnancy, birth and beyond

Here, we present care considerations for midwives and the multidisciplinary team caring for this unique subgroup of childbearing women. However, we hope that women with hEDS will also benefit from this paper, as they make decisions in partnership with their professional health care teams. You can read the press release from this paper here.

I would personally like to thank the board members of the British Journal of Midwifery for making this article FREE for all to read. I would also like to thank the Royal college of Midwives for sharing news of the article here…and the Nursing Times for sharing further news here.

So what can midwives do to maximize the quality of care given to women with hEDS throughout pregnancy birth and beyond?…First of all….Know the facts…

  • There have been no prevalence studies since EDS received a major reclassification in 2017
  • Earlier estimates from 2006 suggest a prevalence rate of 0.75-2% for hyper mobile EDS
  • hEDS is the most common form of EDS
  • Up to 78% of women with hEDS could also have a diagnosis of Postural Orthostatic Tachycardia Syndrome (POTS)
  • POTS predominantly occurs in women of childbearing age
  • EDS is considered to remain largely under diagnosed.

Tips for midwives

  1. Discuss individual needs with women, as no two cases will be the same. Do this early, and always in partnership with the woman and the wider multidisciplinary healthcare team.
  2. Consider early referral to obstetric, physiotherapy and anaesthetic teams in partnership with the woman.
  3. Consider the need for alternate maternal positioning during pregnancy, birth and beyond. To minimise the risk of injury, positioning should be led by the mother.
  4. As wound healing can be problematic, the use of non-tension, non-dissolvable, deep double sutures, left in for at least 14 days is advisable.
  5. Wait longer for local anaesthetics to take effect and consider giving maximum dosage. Always be led by the mother on whether pain relief is sufficient
  6. Always consider the significance of a routine observation in light of existing POTS and/or EDS symptoms
  7. Promote spontaneous pushing rather than directed pushing during birth
  8. Promote effective pain management and the use of therapeutic birthing environments to promote reductions in stress
  9. Consider additional joint support for newborns suspected of having hEDS
  10. Document all joint dislocations and bruising marks on the newborn from birth to avoid misdiagnosis and/or wrongful accusations of mistreatment.

Research into EDS and childbearing is in it’s very early stages. We hope to build on this work to make a difference for all women with hEDS during pregnancy, birth and beyond.

pregnant belly

If you would like to follow the progress of this work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

 

 

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Highlights from the Third Annual #BirthTrauma conference #birthtrauma18

birth trauma study day

Image credit: Scriberia Ltd (@scriberian).

The first week back in January and I am invited by the wonderful becca moore @dr_bjm to share some research thoughts and ideas at the 3rd annual birth trauma study day in London = 

First of all..thank you for arranging and facilitating this day. It really is growing in strength and popularity year on year as this topic gathers momentum. You are a true #maternityleader for making this happen. Thank you also to those who participated in such important debates and discussion…and to those supported me to present my work as a new mum (baby Loveday is now 6 weeks old and as you can see….she was able to join her mum on stage 🙂

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The discussions that followed on Twitter were also pretty awesome and continue to thrive online. I can see may collaborations being born out of this day…what change may come I wonder? – #BirthTrauma19 will be even bigger and better…that’s for sure!

What struck me most about the speakers involved in this conference, is that every one of us was drawing from some kind of personal experience. Our past traumas had been turned into passion…fire and fury to make a change in the world…to make is better for the next person in some way.

“We had turned our wounds into wisdom.” – Me

Thank you to those who engaged in my presentation. I was thrilled to share some of my PhD work and the findings of other research studies to raise awareness of psychological distress in midwifery populations. The beautiful images below capture some of the key messages from my slides.

selfcare

Image credit: Scriberia Ltd (@scriberian).

small things

Image credit: Scriberia Ltd (@scriberian).

64%

Image credit: Scriberia Ltd (@scriberian).

Further statistics around midwives at work can be found here.

Traumatised midwives

Image credit: Scriberia Ltd (@scriberian).

compassion fatigue

Image credit: Scriberia Ltd (@scriberian).

I also really enjoyed the ethical debates around providing online anonymity and confidentiality for midwives in psychological distress who wish to seek help. You can read the wider arguments for this here. Do you have any further thoughts on this? I would love to hear them!

Once again…Thank you so much to everyone for making this event so amazing. The quote that I believe summed up the vibe in the room was this…shared by @millihill .

 

“If we can find ways of harvesting the energy in women’s oceanic grief we shall move mountains.” –Germaine Greer

🎓🌟😀

Overall take home messages…

  • Tailored care is needed for every family
  • A healthy baby is not ALL that matters
  • Good outcomes include good psychological outcomes
  • Kindness and compassion cost nothing yet can really make a difference
  • Appropriate use of language can make or break the birthing experience
  • The power of listening can never be underestimated
  • We must remember that fathers and wider family members may also be affected by trauma in the birth room.
  • A traumatic experience is always subjective. What is traumatic for some, may be unremarkable for others.
  • Mothers can have a positive experience of a clinically complicated birth, or a traumatic experience of a seemingly straightforward birth.
  • Any past trauma can always be re-awoken
  • The best care is delivered by a workforce that is healthy and cared for.

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

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Exploring ‘obstetric violence’ and ‘birth rape’

trauma hiding.jpg

Recently, the wonderful Ibone Olza (Perinatal Psychiatrist and Childbirth Activist from Childbirth is Ours, Spain) contacted me about her work on obstetric violence, birth rape and professional trauma. After reading her papers and watching her present her work, I was compelled to document and reflect upon some of the issues raised, here.

The following points are made within the paper: Fernández, Ibone Olza. “PTSD and obstetric violence.” Midwifery today with international midwife 105 (2013): 48-9.

Birth trauma has been defined as “Actual or threatened injury or death to the mother or her baby” (Beck 2008). Yet such trauma lies in the eye of the beholder, therefore, any trauma experienced by either the mother, newborn or the birth attendant may be due to a subjective experience of stress which does not need to fit any particular criteria necessarily. This means that some traumatic events may be subjective in their nature, and as such, we cannot judge what may or may not cause another person trauma. It is a personal interpretation or perception.

A meta-ethnographic analysis of studies about women’s perceptions and experiences of a traumatic birth reported that women are often traumatized as a result of the actions or inactions of midwifery staff (Elmir et al. 2010). Whatever, such inactions or actions may be…women often use words such as ‘barbaric’, ‘intrusive’, ‘horrific’ and ‘degrading’ to describe their mistreatment (Thomson and Downe 2008).

For Hodges, drugging or cutting a pregnant woman with no medical indication is an act of violence, even when performed by a medical professional in a hospital. Inappropriate medical treatment is also clearly abusive, although few women are aware that this is deliberate mistreatment (Hodges 2009).

The term ‘birth rape’ has been used by women who feel that their bodies have been violated. Kitzinger highlighted that many women who have experienced a traumatic birth display similar symptoms to rape survivors (Kitzinger 2006). The video below explores these issues in greater detail, as we can hear the lovely  Ibone Olza  sharing this work.

 

One of the things I was most encouraged about, was that  Ibone Olza  considers the wellbeing of the midwifery staff in her work. Birth attendants are often also traumatized by these acts, and may feel powerless to intervene. In a recent study by Beck, 26% of obstetric nurses met all the diagnostic criteria for screening positive for PTSD due to exposure to their patients who were traumatized (Beck and Gable 2012). Being present at  abusive deliveries can magnify staffs’ exposure to birth trauma.

staff use phrases such as…

“the physician violated her”

“a perfect delivery turned violent”

“unnecessary roughness with her perineum”

“felt like an accomplice to a crime”

“I felt like I was watching a rape.”

….to describe the guilt that ensued when they felt like they had failed women or they did not speak up and challenge/question…

Article 51 establishes that: The following acts implemented by health personnel are considered acts of obstetric violence:

  1. Untimely and ineffective attention of obstetric emergencies
  2. Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available
  3. Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breastfeeding immediately after birth
  4. Altering the natural process of low-risk delivery by using acceleration
    techniques, without obtaining voluntary, expressed and informed consent of the woman
  5. Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman

(D’Gregorio 2010)

trauma

Yet whilst people do bad things, it is important to remember that they are not necessarily bad people…

This work explains how professionals may exert obstetric violence due to:

  • Lack of technical skills to deal with emotional and sexual aspects of childbirth.
  • Unsolved trauma. The medicalization of childbirth produces more severe iatrogenic
    complications (Johanson, Newburn and Macfarlane 2002; Belghiti et al. 2011). If the
    professionals do not have a supportive space to reflect or to deal with this aspect of iatrogenic care, they may fall into a spiral of continuously increased medicalization as a defensive strategy. Childbirth is then perceived as a very dangerous event, “a bomb ready to explode,” without realizing that interventions cause more unnecessary interventions and pain.
  • Professional burnout in birth attendants will lead to increased dehumanized care and therefore never-ending figures of women experiencing childbirth as very traumatic.

..and so the challenge will be to identify and address these root causes to ensure that maternity staff are able to provide excellence in midwifery care. My work explores how we might support the psychological wellbeing of health care staff may increase levels of humanity and compassion in care. I hope to keep in touch with Ibone Olza and many others around the world who share the same passion for this work. Together we may collectively work towards a time where maternity workers are psychologically safer, and therefore better able to provide the excellence in care they strive to give.

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

References and further reading

  • Soet JE, Brack GA, DiIorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth 2003 Mar;30(1):36-46.
  • Creedy DK, Shochet IM, Horsfall J. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 2000 Jun;27(2):104-111.
  • Ayers S, Pickering AD. Do women get post traumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth 2001 Jun;28(2):111-118.
  • Beck CT, Gable RK, Sakala C, Declercq ER. Post traumatic stress disorder in new mothers: results from a two stage U.S. national survey. Birth 2011 Sep;38(3):216-227.
  • Allen S. A qualitative analysis of the process, mediating variables and impact of traumatic childbirth. Journal of Reproductive and Infant Psychology 1998;16(2-3):107-131.
  • Beck CT, Watson S. Impact of birth trauma on breast-feeding: a tale of two pathways. Nurs Res 2008 Jul-Aug;57(4):228-236.
  • Beck CT. Post-traumatic stress disorder due to childbirth: the aftermath. Nurs Res 2004 Jul-Aug;53(4):216-224.
  • Beck CT. Birth trauma: in the eye of the beholder. Nurs Res 2004 Jan-Feb;53(1):28-35.
  • Ayers S. Delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder. Clin Obstet Gynecol 2004 Sep;47(3):552-567.
  • Olde E, van der Hart O, Kleber R, van Son M. Posttraumatic stress following childbirth: a review. Clin Psychol Rev 2006 Jan;26(1):1-16.
  • Elmir R, Schmied V, Wilkes L, Jackson D. Women’s perceptions and experiences of a traumatic birth: a meta-ethnography. J Adv Nurs 2010 Oct;66(10):2142-2153.
  • Nicholls K, Ayers S. Childbirth-related post-traumatic stress disorder in couples: a qualitative study. Br J Health Psychol 2007 Nov;12(Pt 4):491-509.
  • Ayers S. Thoughts and emotions during traumatic birth: a qualitative study. Birth 2007 Sep;34(3):253-263.
  • Thomson G, Downe S. Widening the trauma discourse: the link between childbirth and experiences of abuse. J Psychosom Obstet Gynaecol 2008 Dec;29(4):268-273.
  • Goldbort JG. Women’s lived experience of their unexpected birthing process. MCN Am J Matern Child Nurs 2009 Jan-Feb;34(1):57-62.
  • Sawyer A, Ayers S. Post-traumatic growth in women after childbirth. Psychol Health 2009 Apr;24(4):457-471.
  • Hodges S. Abuse in hospital-based birth settings? J Perinat Educ 2009 Fall;18(4):8-11.
  • Kitzinger S. Birth as rape: There must be an end to ‘just in case’ obstetrics. British Journal of Midwifery 2006;14(9):544-545.
  • Beck CT. The anniversary of birth trauma: failure to rescue. Nurs Res 2006 Nov-Dec;55(6):381-390.
  • Beck CT, Gable RK. A Mixed Methods Study of Secondary Traumatic Stress in Labor and Delivery Nurses. J Obstet Gynecol Neonatal Nurs 2012 Jul 12.
  • Perez D’Gregorio R. Obstetric violence: a new legal term introduced in Venezuela. Int J Gynaecol Obstet 2010 Dec;111(3):201-202.
  • Callister LC. Making meaning: women’s birth narratives. J Obstet Gynecol Neonatal Nurs 2004 Jul-Aug;33(4):508-518.
  • Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002 Apr 13;324(7342):892-895.
  • Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case-control study. BMJ Open 2011 Dec 21;1(2):e000514.

 

 

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What makes a good midwifery manager? Satisfaction vs Dissatisfaction in the workplace

Reducing stress and fatigue among maternity staff is key to reducing baby deaths and brain injuries during childbirth, according to a detailed new analysis published by the Royal College of Obstetricians and Gynecologists.

This ‘each baby counts’ initiative confirms that “Decision-making is more difficult when staff feel stressed or tired”.

“This report shows that there is a need for additional support for our maternity staff and units so that every mother and every family has the healthiest possible outcome from pregnancy and birth,” said Judy Ledger, founder and chief executive of the charity Baby LifeLine.

This news supports my own research quest, as I work to find new interventions to support midwives in work-related psychological distress.

This state of affairs also suggests that it may be prudent to do all that we can to ensure midwife satisfaction in the workplace. In fact, anything good in the workplace has to be safer/better than the bad stuff right?

At the 31st International Confederation of Midwives’ Triennial Congress held in June 2017, I stumbled upon an interesting research presentation on what could promote satisfaction/dissatisfaction in the midwifery workplace. More specifically, the characteristics of midwifery management behaviors were used to demonstrate what might promote satisfaction and dissatisfaction in managerial relationships. I will translate my brief notes from the session here:

In promoting workplace satisfaction, a midwifery manager:

  • Is supportive
  • Respects, values and appreciates midwives
  • Is an advocate for staff
  • Follows through on promises
  • Facilitates new ventures and learning
  • Cares for staff
  • Is aware of stressors

In promoting workplace dissatisfaction, a midwifery manager:

  • Is punitive
  • Is demanding
  • Is inconsistent
  • Is ineffectual
  • Is ‘Terrible’
  • Tolerates or perpetrates bullying
  • Does not listen

Not a big shock here right?…I mean it’s not rocket science. Nevertheless, this knowledge must be shared in order to promote healthy workplace cultures in the pursuit of excellence in maternity care.

The best midwifery care can only be delivered by midwives at their best…. Can we all begin to set our working day by these rules? Can we all be a little kinder? caring?..respectful to one another?

fist pump

This was just one of the many things learnt at this year’s 

In time, I will try to share more about why 

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤