Books for Midwives, 2003, 269 pp
Mavis Kirkham, Professor of Midwifery at the University of Sheffield, has assembled a convincing range of experts to provide a sweep of different perspectives on the growing birth-centre movement around the world, including the UK. All that's missing is a chapter by a dedicated opponent!
The book is divided into three sections covering various birth centres in England and the Edgware Birth Centre, and birth centres in the wider world, including France, Texas, Stockholm, New Zealand and Australia. Although primarily directed towards students and midwives, AIMS members will find plenty to interest and instruct.
The first section looks at several birth centres in England, how they were established, how they are run now and the challenges faced on the way. The powerful message that comes across is: Where there's a will, there's a way.
Birth centres do not spring unaided from NHS policy directives; they have to be fought for. Consequently, there are enormous discrepancies across the country, with approximately as many free-standing maternity units in the South West and South East as in the whole of the rest of England. For the past few years, around 37 per cent of babies in West Wiltshire have been born either at home or in one of the seven midwife-led units. Sadly, the local Primary Care Trust is currently trying to address an inherited budget deficit by closing the Devizes midwife-led unit and sending women 21 miles or more to the obstetric unit. Despite the Department of Health mantra of choice for women, stand-alone units are invariably seen as an easy target when looking for ways to save money. NHS budgetary systems do not give fair weight to increased expense for families or the likely costs of higher intervention rates in obstetric units.
Anyone wondering why their locality is missing out should read the chapter entitled 'Users in the driving seat', which chronicles the campaign leading to the establishment of the Edgware Birth Centre. In this case, lay members of the local Maternity Services Liaison Committee and the (now abolished) Community Health Council eventually convinced the local health authority that a stand-alone midwife-led unit was viable. The research and evidence base amassed by the campaigners, together with their close attention to detail, won the day. The assertion that 'women will die' by the then clinical director has been totally disproved. The innate conservatism of the medical profession can preclude a rational assessment of birth centres.
If, on the other hand, your local midwife unit is threatened with closure, this book provides clinical evidence, professional opinion and consumer encouragement-all the ammunition necessary for a successful campaign. As Baroness Cumberlege points out in her Foreword, birth centres provide "a different and kinder service". They also demonstrate what is possible in maternity care: good outcomes, user satisfaction, cost-effectiveness and, in the words of the editor, "a positive model for change . . . an alternative to a single industrialised model of birth".
Reviewed by Jean Robinson
Many years ago when we were on holiday in Dubrovnik, my husband suddenly became seriously ill. After we finally got to hospital, he was whisked away, and I sat for an eternity in the waiting room, unable to communicate with those around me, not knowing if any of the staff with him spoke English. My relief when I was at last able to talk to the doctor was indescribable. Ever since, I have tried to imagine what it must be like to labour and give birth, surrounded by people, babbling in a foreign tongue, who could not understand what I was saying about my needs or symptoms.
Yana Richens was awarded the annual scholarship commemorating Mary Seacole (the 19th-century black nurse) by the Department of Health to carry out her (badly needed) study of Pakistani mothers' birth experiences in the West Midlands. Women of Pakistani origin have the highest perinatal mortality in the UK, and twice as many of their children die before they are a year old. The glib explanation given for this is that they marry relatives and the children therefore have a high rate of abnormalities. But this, in fact, does not explain the discrepancy, and quality of care is likely also to be a factor.
Particularly important information came from three women who had given birth before they could speak English, and who had another baby after they had learned the language. They had no doubt that non-English speakers had worse treatment from midwives: "They were just so horrible ...they don't talk to me properly...I was crying and in a lot of pain. They were cruel in the way they were talking to me." Another, who said midwives were nice to her in her second labour, said, "Before, they thought, I can't speak English-I can't tell anyone."
Even those who spoke some English might not be confident enough to ask questions and got too little information, which made them feel scared and not in control. When they did ask a question, they did not always get a reply: "I was asking the midwife questions, but she wouldn't really answer them... just walked off." They really appreciated midwives who were kind. Even smiles and kindly gestures were greatly welcomed.
Yet, four women had negative experiences with Asian midwives: "She was really stuck up... she was like, you know, I am Miss High-and-Mighty".
There were some examples of how poor communication might put women and babies at risk. One woman who told the midwife about her reduced fetal movements was told to go to hospital, but did not go until two weeks later because she was scared she might need a section.
The basic need for women to have interpreters is clearly not being met, and the disadvantages of relying on relatives, who may be selective in what they choose to interpret, are pointed out. One husband simply kept telling his wife in labour, "You are fine".
Some women were indignant that they had been asked to interpret for strangers in the doctor's waiting room by the receptionist, and they resented the breach of confidentiality and feared that they would be labelled gossips in the community. They also knew of cases where people had missed medical appointments because interpreters had not arrived.
Hand-held antenatal notes-lauded as a great communication aid-meant nothing to Urdu speakers, who said they might just as well have been blank sheets of paper. They wanted them translated into their own language.
Like the rest of us, these women wanted choice. But they didn't get it. However, there seemed to be no pent-up demand for home birth. Even women who had previously had home births in Pakistan with a midwife (no husbands allowed) and enjoyed them did not want them here. They preferred a hospital birth where the husband could be there. However, the service often prevented women's own support systems from working, but did not provide a sensitive system of its own. Even the need for Muslim babies to have the Azaan (call to prayer) as the first word to reach their ears could be quite unnecessarily prevented.
The study was not large. It was based on focus groups, and included both women who spoke English and those who did not. I would like to see the work extended and carried out in other districts, as I am sure we would identify many examples of how communication and bias reduce quality of care. Above all, our failure to provide interpreters is shameful. I hope midwives will read the study and start reflecting on their care-especially those who had taped a biblical text in large letters to the wall of the labour ward where I sat recently.
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