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by Nadia Higson
I chose to revisit the Journals from the 1990s because it was the decade in which I gave birth to my sons, and also the decade in which I joined AIMS, and so I was reading many of these issues as they came out.
At times it has been dispiriting to read about concerns which were current then and remain familiar issues today as discussed below, but there are things that have changed for the better too.
The decade opened with Doris Haire bringing us an “American Warning” (1990, Volume 2, No 1). She talked about the backlash from “a growing number of American women who feel that their obstetricians misled them into a false sense of security regarding the obstetric drugs and procedures offered them” as a result of “general reluctance to call attention to the adverse effects of the drugs which have long been a part of their armament” including pethidine, the local anaesthetics used in epidurals, and oxytocin drips. We now have the NICE guideline on Intrapartum care for healthy women and babies (www.nice.org.uk/guidance/cg190) making recommendations to “Assess the woman's knowledge of strategies for coping with pain and provide balanced information to find out which available approaches are acceptable to her”, to give information about the side effects of drugs and to “support her in her choice”. However, as calls to the AIMS Helpline regularly show, this “reluctance to call attention to the adverse effects” is still apparent amongst many obstetricians in the UK today. Only last year, Linn Shepherd was writing in the AIMS Journal (2019, Volume 31, No 4 ) to warn that “currently no-one is informing women that when synthetic oxytocin is recommended, it is likely to be prescribed and administered in unlicensed dilutions and increments, with regular disregard for the benefits and safety measures built into the licensed instructions”.
One thing that doesn’t seem to have changed is concern over the rising caesarean rate – but back in 1990 Nancy Stewart reviewed a report from the Maternity Alliance revealing that “In 1982 the caesarean rate was 10.5% of all births, but by 1985 it had reached 11.6%” (Volume 2 No 2 1990). The latest statistics for England and Wales from NHS Digital (digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2018-19) showed that it had reached 29%!
Back in 1990 vaginal birth after caesarean (VBAC) was still viewed by doctors and midwives as a risky process. It was commonly described as a ‘trial of scar’ and those ‘attempting’ it were routinely starved and put on an intravenous drip in case they needed a caesarean, as Yvonne Williams found when she decided on this option for her second birth (1990, Volume 2, No 2). Now the NHS website states that “Most women who have had a caesarean section can safely have a vaginal delivery for their next baby” - although doctors and midwives are frequently wary of VBACs taking place outside an obstetric unit or without continuous monitoring ‘just in case’.
In the 1990s, waterbirth was still regarded as a novel practice, and was meeting resistance from many in the medical establishment – one of them warning that “If we become mesmerised by the eccentricities proposed by these aquatic fanatics, we undermine social and technological advances and run the risk of turning the clock back decades” (1995, Volume 7, No 1). Even when labouring in water was considered ‘acceptable’ people were usually expected to get out in order to birth. AIMS scored a success when in 1995, at the request of Beverley Beech, the UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting - forerunner of the NMC) issued a statement recognising that “waterbirth is preferred by some women as their chosen method of delivery of their baby. Waterbirth should, therefore, be viewed as an alternative method of care and management in labour and as one which must, therefore fall within the duty of care and normal sphere of practice as a midwife”.
Although birth-pools were becoming more widely available in hospitals through the 1990s, it didn’t always mean that they were being used. In the middle of the decade ("Waterbirth: False hopes, False promises", p17, 1996, Volume 8 No 3), Jean Robinson reported on findings from a survey by the National Perinatal Epidemiology Unit showing that “nearly half the hospitals that have pools virtually never use them.”
Although we know that access to waterbirths is still patchy, and often limited to so-called ‘low risk’ women and birthing people, at least it is now viewed as a mainstream choice and the NICE guideline on Intrapartum care for healthy women and babies recommends “Offer the woman the opportunity to labour in water for pain relief.”
For all those with an interest in supporting physiological birth and the individual’s right to choose, the big story of the 1990s was the publication first of the Winterton Report on Maternity Services in 1992, and then the Cumberlege Report “Changing Childbirth” in 1993. (1993, Volume 5, No 3). The recommendations gladdened our hearts, for example:
Wonderful! So why did we need Baroness Cumberlege to lead another National Maternity Services review leading to the Better Births report in 2016?
To be fair, some of the recommendations of Changing Childbirth were implemented, but others fell by the wayside. For example, in 1994 Sandar Warshall ("Moving forward on Cumberlege", p18, 1994, Volume 6, No 2) reported on an RSM (Royal Society of Medicine) Forum which celebrated three innovative models of midwifery care: a midwife-led unit in Bournemouth with a 96% ‘normal birth rate’, a case-loading scheme at Queen Charlotte’s providing one-to-one care including to those labelled ‘high risk’, and the South East (London) Midwifery Group Practice, which was to become the inspirational - and much-lamented - Albany Practice. Over the years, further midwife-led units have opened, but some have closed, and access to them is frequently limited to those who fit within narrow guidelines. Innovative schemes offering continuity of carers, such as Neighbourhood Midwives and One-to-One have secured NHS contracts and then been unable to survive. The struggle continues.
Will the Better Births recommendations fare any better than those of Changing Childbirth? This time, the recommendations have been formally adopted into the NHS long-term improvement plan and a national Maternity Transformation Programme put in place to implement them. You can be sure AIMS will be watching, contributing our views and continuing to campaign for genuinely ‘better births’ in the future.
To end on a positive note, towards the end of the decade the Journal’s editorial asked “Where’s the good news?” (1999, Volume 11, No 3) and concluded that “The good news at AIMS is when an individual mother calls and says, “Thank you – you helped me get the birth I wanted.” As an AIMS Helpline volunteer, I can confirm that that’s as true now as it was thirty years ago. Whatever the national picture may be “"It is [still] better to light a single candle than to curse the darkness."
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email email@example.com or ring 0300 365 0663.
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