Avril Nicoll, Kirstin Hoggins and Phyllis Winters reflect on the process of change undergone by the midwives at Montrose community maternity unit where waterbirth is now more than a choice.
On Tuesday 14th September 2004 a workshop partfunded by Edinburgh AIMS was the last part of the journey to waterbirth at Montrose maternity unit. And what an effect it had! The pool passed final checks on 28th September and only two days later little Cara Davie became the first baby to arrive in it. Midwives from the team of 9.8 whole time equivalents were even offering to come in on days off if there was the prospect of being at a waterbirth. Speaking about these early waterbirths the midwives were noticeably moved, and the word "beautiful" continues to be used more than any other when describing them. The pool has proved so popular that, in 2005 at this standalone community maternity unit, 57% of the 156 women had a waterbirth - 45% of them first time mothers - and 111 women used the pool during labour. No woman has ever been asked to leave the pool because the midwife was not confident.
It is sometimes difficult to remember that, when the idea of a birthing pool was first suggested to the midwives during the Keep MUM (a maternity unit in Montrose) campaign of 2000-1, this was greeted with everything from a wry smile to reassurances that women might want it for labour but certainly not for birth. But in citing data from the Edgware Birth Centre (Saunders et al., 2000) which showed such good outcomes - including very low episiotomy rates with no increase in perineal tears - the campaign began the 'drip, drip' that the midwives would ultimately turn into a flood.
Following a disastrous year in 2002 when only 21% of local women gave birth in the unit, Montrose midwives bit the bullet and in 2003 raised this to an unprecedented 49%. The changes they had made included better antenatal preparation for understanding and coping with pain in labour, a more proactive approach to getting 'low risk' women to choose Montrose and providing an environment where active birth was encouraged and supported. As the date for a proposed shift to a new building moved ever further away, it seemed that other units in Tayside would get birthing pools before Montrose. With typical determination, the then lead midwife secured primary care trust funding for a birthing pool and the team fundraised for the substantial costs of a structural engineer and installing a raised, reinforced floor.
Being familiar with disappointing levels of use elsewhere (see for example Campbell-Smith, 2002), user representatives on the Angus Maternity Services Liaison Committee were determined that this birthing pool was going to be used for birth right from the start. This meant we needed to have a study day that most of Montrose midwives could attend and that would be presented by midwives who are present at waterbirths day in, day out. There are plenty of books and articles on waterbirths (see for example Balaskas, 2004). We wanted to use the opportunity of a study day to hear directly from midwives who would inspire with their clinical experience and confidence in the process.
Through the Birth Centre Network UK, Avril had seen contributions from Jayne Shepherd, a midwife at the Jubilee Birth Centre in Cottingham near Hull. They were having 300 births a year, 150 of them waterbirths. Avril was also interested to see their very impressive data on physiological third stages as this just didn't happen at Montrose; there was "no demand for it". Jayne and her colleague Karen Bradbury agreed to come and speak. The brief was for a very practical session with lots of case examples that included descriptions of physiological third stages and set waterbirth within the context of a midwife-led, woman-centred service.
The Montrose venue was free, and speaker fees and costs were covered by generous donations from AIMS Edinburgh and from Dundee University School of Nursing and Midwifery which received 10 places on the course. We put out a flyer to other areas and met remaining costs through a small charge for those midwives and health visitors who responded. The Professional Development Midwife for Tayside took overall responsibility, and midwives and user representatives participated in the planning.
Those attending were asked to put their feelings about waterbirth on a Post-it note and stick it on the wall. Most were "curious" and "excited", but some betrayed real fear. Avril started off, as a representative of AIMS, by explaining the background to the study day, outlining what we hoped to achieve, and introducing Jayne and Karen. Then and throughout the day, it was clear that some of those attending were surprised by the level of strategic user involvement in what happens at Montrose.
Jayne and Karen exuded confidence around waterbirth. Both are great storytellers, and we felt as if we were present at many births, with our understanding of 'normality' extended. They perfectly captured the itch of midwives to be hands on and doing - and said that, in getting used to waterbirth, it can help to sit on your hands. They got across the strangeness of seeing a healthily blue baby with its eyes wide open. Circulation appears to be slower to establish following a waterbirth and babies commonly take longer to 'pink up' despite being in perfect health. Their bluish colour may be a cause for concern in birth out of water but, for waterbirth, Jayne and Karen got across the normality of seeing a healthy baby with a bluish tinge, fully alert, looking around the room. They also conveyed the peace and beauty of waterbirth, where women instinctively shift into positions that would be impossible on dry land, and where they or their partners raise the baby gently to the surface. During a powerpoint presentation of stills from a waterbirth, you could have heard a pin drop.
In amongst this Jayne and Karen also touched on the process of change they had gone through at their unit, which used to be consultant-led. They stressed the need for good data collection, audit and reflection, and for forwarding statistics to research midwife Ethel Burns for inclusion in her International Collaboration (see www.sheilakitzinger.com/WaterBirth_Collab.htm, accessed 10 January, 2006). With the focus squarely on the practical, they talked us through decision making in cases such as an undiagnosed breech where the woman continued her labour and gave birth at the Jubilee while the protocol is for intrapartum transfer to a consultant unit. They also gave examples of different physiological third stages, as they have found routine active management of the third stage particularly jars with the flow of a waterbirth. These scenarios are far removed from the daily practice of many midwives, so it is not surprising that they made some of the delegates uncomfortable.
Afternoon workshops were around care and cleaning of the pool, guidelines for labour and birth, dealing with emergencies, and antenatal preparation. As with the earlier Post-it¨ notes, some of those attending betrayed real fear of waterbirth through a concentration on "risks". For them we have to hope their choosing to come means that deep down they are advocates for normality - and that it started the drip feed of positive stories that will eventually enable them to be advocates for waterbirth.
Around the time of the study day, midwives and user representatives from across Tayside also developed guidelines for waterbirth and a leaflet based around the questions women were asking. Like the feedback from the study day this process was overwhelmingly positive but also exposed the fears and need for control that some midwives have to confront in the transition to woman-centred care and its associated improved outcomes.
With well over half of births now waterbirths, a third of women having physiological third stages and an episiotomy rate of 2%, Montrose midwives provide a startling example of how this can be achieved in a relatively short space of time, within the NHS, and at a standalone community maternity unit 30-45 miles from the nearest consultant units. Their turnaround has been recognised locally, with very few 'low risk' women choosing to go to a consultant unit for birth, and nationally with the presentation of the 2005 Royal College of Midwives' 'Promotion of Normality' award.
The waterbirth study day stands out in our minds for the way it confirmed the Montrose midwives on their chosen path, but Avril also remembers that day because she saw the band Rush on their 30th anniversary tour. It is doubtful that lyricist Neil Peart had waterbirth on his mind when he penned these lyrics, but they seem fitting:
"When the waters rose
In the darkness
In the wake of the endless flood
It flowed into our memory
It flowed into our blood -
When something broke the surface
Just to see the starry dome -
We still feel that relation
When the water takes us home"
(From 'High Water' by Neil Peart, 1987)
Avril Nicoll is a former user representative on the Angus Maternity Services Liaison Committee, and Kirstin Hoggins is its lay chair. Phyllis Winters is midwifery team leader at Montrose Community Maternity Unit. Angus has two community maternity units, one in Montrose and one in Arbroath (www.birthinangus.org.uk). Arbroath is fundraising for a birthing pool and installation costs. The Jubilee Birth Centre, Cottingham near Hull, has a website at: www.hey.nhs.uk/jbc.
Nadine Edwards and AIMS Edinburgh for moral and financial support, Dundee University School of Nursing and Midwifery, Jayne Shepherd and Karen Bradbury for their inspiration, and the fantastic midwives at Montrose for making waterbirth more than a choice.
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