Response to ‘The global implications of the current UK “normal birth” debate’ by Soo Downe

This blog is my response to this article, by Prof Soo Downe.

The blog states that there is ‘little controversy about the benefits of normal physiological birth for healthy mothers and babies’. In fact, there are controversies  around some of the claims that are promoted about the benefits of ‘normal physiological’ birth.

This paper from December 2014, titled “Is society being reshaped on a microbiological and epigenetic level by the way women give birth?” (which Soo Downe co-authored), opens with the following quote:

“Intervening in childbirth is like throwing a pebble into a pond. The ripples keep on going and you don׳t know where they will end up – but you can bet that on some distant shore there will be an effect. It is only relatively recently that we have been looking beyond the throw of the stone to the distant shore. What we see is very, very scary”

This paper goes on to describe ‘two leading theories.’

The first theory relates to the neonatal microbiome. The theory describes that during pregnancy and birth, the neonatal gut acquires flora that has been inherited ‘across generations from Neolithic times’, and that ‘…a co-dependency has built up between these organisms and the human immune system.’ The theory is that babies born by C-section miss out on a vital route of colonisation (vaginal delivery) and are therefore left ‘…vulnerable to later atopic and auto-immune disease’ as a consequence. But there is no high-quality evidence to support this theory. In fact, the latest scientific study found no ‘lasting association between caesarean delivery and a distinct microbiome community or its function in infants beyond the neonatal period’.

The second theory relates to epigenetics.  The paper states ‘…intervention in childbirth could be regarded as a potential environmental trigger with epigenetic consequences that may alter the human epigenome.’

If  there was robust scientific evidence that proved that the method by which a baby was born had a real, measurable genetic effect on babies, I would agree that women and families should be informed of the evidence so that they could take the facts into account when making decisions and choices about childbirth. However, just as in the case of microbiome literature, there is  no evidence at all that proves this theory.

This however, does not stop the authors of the paper making some pretty bold statements about what these theories mean.

“..it has been argued that, on the day of birth, a person is at a higher risk of death than for any other day until they are over 90 years old. Those who might argue for increased intervention during labour and birth in the name of safety might also pause to consider that the preservation of physiological birth as far as possible might be the passport for the lifelong health and well-being of not only an infant, but also for its future offspring. The day of birth may turn out to be one of life׳s most defining events.”

But  let’s just consider what is being proposed here. The authors are actually suggesting that the way a baby is born could be ‘…the passport for…lifelong health’ not just for the infant but for generations to come. Further, the suggestion is that people who argue for ‘increased intervention’ during labour and birth in the name of safety, might ‘pause for thought’. Really?

Firstly, the notion that anyone is arguing for ‘increased intervention’ in the name of safety is a misrepresentation. The direction of change towards safer maternity care is around improving training, risk assessment and multi-disciplinary work so that better decisions are made around when to intervene – not simply blanket ‘increasing’. Secondly though, the idea that when it comes to the safety of childbirth and preventing catastrophic, life changing consequence like death or serious harm to a child, surely no family, midwife or obstetrician should ‘pause for thought’ because of non-evidenced messages such as these?

Sadly, such messages clearly do have a real impact on women as comments in this article show.

“I was devastated when I was told I wouldn’t be able to have Diego naturally…Suddenly I felt very out of control. I was worried my baby would not get the health and emotional benefits of a natural birth…Babies born vaginally have a greater diversity of bacteria in their guts than babies born via c-section. I believe the benefits of a diverse microbiome are a better immune system, less risk of allergies, obesity and neurological diseases such as depression, anxiety and autism. I just wanted to give Diego the best start, like I did for his brothers.”

In summary, whilst no one would argue or advocate for unnecessary interventions in childbirth (or the risks associated with them), I do think that the benefits and risks are not always presented clearly and papers like this, which use language such as ‘very, very scary’ are less than helpful. After all, the Queen was born by C-section and her children, grandchildren and great grandchildren seem to be doing ok!

The RCM Campaign

The blog then explains the origins of the RCM’s ‘normal birth campaign’ describing it as a campaign ‘to enhance the capacity of midwifes to support women who wanted such a birth’. It’s worth reflecting for a moment that safe maternity care involves a multi-professional team. Nearly all women will need a midwife, some of those women will need an obstetrician and other healthcare professionals but the RCM campaign seemed  only aimed at midwives. For example, the RCM produced a document titled ‘the Top Ten Tips for Normal Birth’ which included tips for midwifes such as ‘wait and see’, ‘trust your intuition’ and ‘justify intervention’. 12 years after the campaign started, rates of intervention in childbirth have increased and there is strong evidence that an approach of pushing ‘normal’ childbirth too far has contributed to avoidable harm and death. Surely the conclusion from this is that currently, we are getting decisions about interventions wrong at both ends and we need sensible policies to address both issues, in context of a proper appreciation of benefit and risk and consequences?

An independent investigation commissioned into the maternity services at Morecambe Bay found that 11 babies and one mother died avoidably. The report identified that an “over-zealous pursuit of the natural childbirth approach” was a factor in the deaths.

The blog points out that a number other failings were also identified by the report. Whilst this is of course true, let’s be crystal clear; children at Morecambe Bay would be alive today were it not for this approach.

As for claims that the situation at Morecambe Bay was unrelated to the RCM campaign, you can read what the Chair of the Morecambe Bay Investigation, Bill Kirkup has said.

“One of those elements that crops up is the misunderstanding or misapplication of national guidance on promoting normal birth. I can’t say for sure that the RCM’s previous advice contributed to this, but some of the messages, particularly about waiting and seeing and trusting intuition, had clear echoes in what we heard at Morecambe Bay.”

I think a balanced view of the evidence would at least point towards a real possibility that the RCM campaign contributed to the approach at Morecambe Bay. Therefore a responsible response would surely be to redouble efforts to ensure this couldn’t happen in the future?

Listening to other voices 

In recent weeks, many women have been sharing their experiences. Natasha Pearlman bravely wrote the following in the Times last week about her experience of childbirth.

“…looking back I would have expected to have been talked through some options: to be given a room, offered an induction, even just some simple advice on how to turn the baby. The midwives did nothing. It seemed as if they had made the decision, without consulting me, to push me to the absolute limit to deliver the baby naturally.”

A solicitor from the legal firm Leigh Day wrote about her experiences of talking to families affected by avoidable maternity deaths.

“I am sorry to say I have met too many parents who did feel that their midwife’s ideology of achieving a ‘natural birth’ without any medical intervention, rather than their wishes or their and their babies’ safety, dictated the way their labour and delivery was managed.”

“… in a significant number of cases parents have reported to us that their midwife made them feel, or in some cases explicitly said, that a transfer to a medical ward or the need to consult a doctor would be a ‘failure’ and so avoided both until it was too late. There was a definite impact of the push for a ‘natural’ birth on patient safety in those cases.”

Responding to the claim that the issues at Morecambe Bay were a ‘one off’, the blogs states “…the cases I have seen did not occur at Morcamebe Bay and to me that suggests that this ideology has been pursued past the point of safety, not just by the odd midwife, but by at least a number of midwives across the country.”

When I read this blog, I wasn’t surprised at all because the experiences described  echoed the many conversation I’ve had with women and families who have lost children due to failures in maternity care over the years.

The blog argues that there is no evidence ‘of a rise in neonatal brain injuries in the UK’. In fact the number of claims relating to brain damaged babies increased by 23% last year. Of course, no one is suggesting that one single issue is responsible for this, but  other countries such as Sweden have achieved remarkable improvements in maternity outcomes, whilst UK has lagged behind.

Recent work by the RCOG found that in 2015, around 800 babies either died or were severely disabled where better care could have resulted in a different outcome.

The blog argues that ‘…the absence of the campaign since 2014 does not seem to have had any effect on mortality.’ This is flawed logic for several reasons. The most obvious being that the campaign for normal birth did not stop in 2014. The normal birth campaign website remained active until May this year and other documents, including the ‘top tips for normal’ birth were simply transferred to a new website. In any case, the influence of a campaign such as this is through the messages permeating midwifery training, education, conferences and events.

There are now hopeful signs that these messages will change and a new approach with an emphasis on collaborative, safe and personalised care will spread.

Progress at Morecambe Bay 

The blog is  critical of maternity services at the Morecambe Bay Trust. This is a Trust where it’s maternity services have gone from being described as ‘dysfunctional’ to now being seen as an exemplar for others to learn from. The team at Morecambe Bay have done remarkable work to turn services around and rebuild the trust of the local community. The last event considered by the Morecambe Bay investigation was in July 2013 yet the blog is critical of the Trust having relatively high intervention rates in 2014-2015, suggesting that this something the media should be reporting.

As the father of a baby that died at Morecambe Bay, I have to say that I find these criticisms quite hard to comprehend. I think it’s unwise to draw conclusions about interventions rates at any specific unit without looking much more carefully at local information. But the big picture here is that a unit where mothers and babies were needlessly dying is now much safer. Is the blog suggesting that a possible increase in intervention rates at Morecambe Bay is too higher price to pay?

Fortunately, there does now seem to be a consensus on the direction of change needed to make maternity services safer. There is universal agreement that the recommendations made by the each baby counts report are right and that collaboration and teamwork is the key to safer maternity care.

There is some really good work happening right now; Southmead, East Kent, Morecambe Bay are just some examples. As the tweet below states, let’s continue to work together for safe births, regardless of the mode of delivery.

prompt

James Titcombe – 11th September 2017

 

 

 

Advertisements

Responding to a blog

This is a post to respond to a recent blog written by Sheena Byrom.  The blog makes four points which I felt compelled to respond to. I address each of these points below (original message in black text and my response in blue) .

1.The Royal College of Midwives discontinued the Campaign for Normal Birth (CNB) THREE YEARS AGO. I was actually part of that decision, and it was due to the fact that the College felt it was important to encompass antenatal and postnatal care within the initiative, and public health. So ‘Better Births’ was born. It had nothing to do with the Morecambe Bay Report, which was published after the decision had been made. But even though the ‘Campaign’ ceased, the support for normal birth has not. The RCM have a normal birth resources page. Some of the resources developed for the CNB have been removed following a request, and will hopefully be replaced with more up to date material. Since writing this post, Cathy Warwick CBE, CEO of the RCM, has written to confirm the College’s continued position to support midwives to promote and facilitate normal physiological birth.

Response:

Whilst the RCM introduced its Better Births campaign 3 years ago, the RCM’s normal birth campaign website was kept live until May this year. There was no announcement by the RCM about removing the website in May. Key documents however, including the RCM’s ‘top tips for normal birth’  were transferred to the new Better Births website. Only in the last few weeks was this document, along with others removed.

For me, the most interesting and ‘news worthy’ parts of the reporting in the media were the quotes from the RCM CEO Cathy Warwick. These included the statement that the normal birth campaign “had the potential to be misleading”. Cathy also called the ‘top tips for normal birth’ document “just not professional enough” adding “..they have gone; they won’t be reintroduced in any way and we’ll have much more professional, evidence based guidelines for midwives.”

Cathy also acknowledged that the language of ‘normal birth’ could make some women feel like failures saying: “It does seem that this word ‘normal’ is particularly contentious . . . it is simpler to use a non-value-laden word. Because of the inferences that are drawn there will be instances where you’re explaining your position better by using terms like ‘physiological birth”.

As far as I have seen, most people have welcomed the news as reported and the comments from Cathy as being sensible and helpful.

When I tweeted the headline in the Times newspaper on Saturday 11th, comments from most were welcoming and positive. At Morecambe Bay for example, the response was ‘great news’ and confirmation that through listening to mothers, they had made changes in their language and approach some time ago.

Sascha

2. THERE IS NO EVIDENCE that the RCM’s Campaign for Normal Birth had any direct influence on the tragedies that occurred at Morecambe Bay, or any other service. The adverse events at Morecambe Bay were attributed to five elements of dysfunctionality, one of which was the ‘over-pursuit of normal birth’. The report does not apportion blame to any one of the five individual elements, but to the whole five. In any case – why is the one element linked to resources supplied by the RCM?

Response:

I take strong issue with this.

An independent investigation was commissioned into the maternity services at Morecambe Bay which reported in March 2015. This found that 11 babies and one mother died avoidably at FGH. The report identified (amongst a number of other serious issues) that “care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care”. The report also quoted one midwife as saying “…there were a couple of senior people who believed that in all sincerity they were processing the agenda as dictated at the time… to uphold normality.”

It isn’t ever going to be possible to make a direct link to a campaign and individual cases of harm, but I have always believed that the RCM campaign has been an influencing factor in some of the clinical problems that developed at FGH. I have written about this long before the Kirkup report was published.

Today however, the Chair of the Morecambe Bay Investigation himself has intervened and published a letter in the HSJ which specifically addresses this point:

“One of those elements that crops up is the misunderstanding or misapplication of national guidance on promoting normal birth. I can’t say for sure that the RCM’s previous advice contributed to this, but some of the messages, particularly about waiting and seeing and trusting intuition, had clear echoes in what we heard at Morecambe Bay. The change in position [from the RCM] is welcome, and should not be undermined by optimistic and unlikely denial that such problems exist. We should continue to be explicit about the need for effective team work, explanation of risk, and looking and learning when something goes wrong.”

I would argue that as Bill Kirkup himself has highlighted the very messages in the RCM campaign “had clear echoes in what we heard”, it would be extremely unlikely that the RCM campaign was not an influencing factor.

The blog also states there is no evidence of this issue impacting on care in “any other service”. Actually there is evidence that that parents who have lost children and professionals dealing with claims relating to brain damaged babies feel that this exact issue is a real and significant contributory factor.

For example, please read this blog from Leigh day solicitors or this report and the comments from families whose babies died following failure in care at SaTH.

In the last week, I’ve been amazed at how many families have shared their stories. If you doubt me, read the responses to this tweet – Yes, of course this is anecdotal – but is it right to just dismiss the experience of all these women and families?
 
A final relevant link is here. This was shared with me today by a mother who lost her baby son in the Netherlands. Please read it. It highlight very similar issues in a country whose equivalent of the RCM (the KNOV) have implemented a very similar normal birth campaign.

3. I believe in choice, autonomy, and safety. Out of our 9 grandchildren, none have been born ‘normally’. They needed expert medical intervention, medical support, and I am eternally grateful for the attention they received. I also understand the evidence that physiological normal birth is the optimal way to give birth for most women, and that most women want it.

To make informed choices women need to have accurate information, including honest information about risk not misrepresentations as described here. Information must also be unbiased and not leading, as discussed here. Top down messages aimed at only one profession vital to ensuring safe maternity care, such as ‘wait and see’ and ‘trust your intuition’, surely don’t help ensure women and babies receive timely lifesaving interventions when needed.  I have never argued against the very valid and important objective of aiming to reduce unnecessary interventions (great work happening in places like East Kent for example)- I have argued that this objective must be implemented in a way that doesn’t increase the risk of catastrophic outcomes for some. 

I wrote this blog in 2014 which describes a number of reports into the causes of adverse neonatal outcomes (death and serious injury). The themes are clear.

No one disputes that ‘physiological’ birth will be the optimal way to give birth for most women. The issue here is that it is never possible to know for certain if a safe, physiological is possible until after the birth. Before then, there is only a spectrum of risk. The World Health Organisation (WHO) estimates that in 12-15% pregnancies, women suffer life-threatening obstetric complications. My argument is that the RCM’s normal birth campaign and documents like the ‘top tips for normal birth’, should be replaced with more balanced messages involving all professionals needed to deliver safe maternity care.

4. I hear and fully respect that some women feel that the word ‘normal’ in relation to birth is divisive, and upsetting, leaving them feeling like they ‘failed’. I can understand this, that women may feel disappointed if they wanted a particular birth experience, worked towards that goal, then it didn’t happen. But that’s it. I would like to suggest that it is the end result is the disappointment, more than the word. Would women feel less disappointed if birth was called physiological? I liken this debate to infant feeding. If a woman has problems and ceases to breastfeed her baby, she feels disappointed – no matter what the term is. Normal birth is a normal physiological bodily process – as is normal respiration, and digestion. The terms physiological, natural and any other are fine too, but let’s not blame a word for disappointment. We need to listen to the experiences of women when they are unhappy with their birth experience for whatever reason, then aim to change services so that optimal childbirth is the goal, for a healthy mother and baby. I will not stop using the term ‘normal birth’ and I will support midwives to facilitate women’s choices safely.

Response:

I would respectful disagree that the reason some women feel like they have ‘failed’ is simply because they are disappointed by the ‘end result’. As a man, I’m not in a position to know how women feel, but I have read dozens of comments from professionals and women in recent days and I have listened to what they say. Themes include what woman are told in anti-natal classes through to actually been told they have failed because they needed pain relief or intervention.

more1rNatalie

A respected consultant obstetric anaesthetist, Doctor Bogod wrote the following letter in the Times last week:

Bogod

This letter was dismissed as “rubbish” on twitter by one senior NHSE employee, but is this really an entirely made up issue? In a compassionate, kind and caring NHS,  shouldn’t the experiences of woman and other healthcare professionals be listened to? If women and healthcare professionals are asking for different language and saying that they feel ideology is getting  in the way of unbiased information, being truly empowered to make their own choices,  and the safety of their care, shouldn’t those working in maternity services be open to listening?

22rimage1

image2image8

  

FullSizeRender

James Titcombe – 21/8/2017

 

 

The Campaign for ‘Normal Birth’ and why change is welcome

Fake news?

Over the last week there has been lots of news relating to safety and maternity services. This was initially triggered by media stories relating to the Royal College of Midwives (RCM) signalling a shift away from using the term ‘normal birth’ and confirming that their normal birth campaign website was quietly taken down a few months ago. The RCM also confirmed that their much criticised ‘top tips for normal birth’ document was very recently removed from their current website and that neither this guidance or the normal birth campaign will be re launched.

This news was reported in the New Scientist, the Times and the HSJ last week.

The media reports quoted the RCM chief executive, Cathy Warwick stating that the normal birth campaign “had the potential to be misleading” and referring to the ‘top tips for normal birth’  document as “just not professional enough” adding “..they have gone; they won’t be reintroduced in any way and we’ll have much more professional, evidence based guidelines for midwives.”

Cathy also, for the first time I think, acknowledged that the language of ‘normal birth’ could make some women feel like failures saying: “It does seem that this word ‘normal’ is particularly contentious . . . it is simpler to use a non-value-laden word. Because of the inferences that are drawn there will be instances where you’re explaining your position better by using terms like ‘physiological birth”.

I’ve written about the RCM’s response to the Morecambe Bay Investigation which tragically made a clear link between the ‘..national agenda as dictated at the time…to uphold normality’ and the deaths of 11 babies and a mother here  and more recently here. So in this context, when I read the comments from Cathy it felt like a very welcome and positive shift in emphasis.

The reaction to these media reports has been overwhelmingly positive, but there has been a strong backlash from some with accusations that the media reports were ‘fake news’ because of the fact that the RCM replaced it’s ‘normal birth’ campaign with it’s new ‘better births’ initiative three years ago.

Whilst this is true, I think it would be hard to argue that the normal birth campaign had really ceased until very recently. The campaign website was active until May this year and other documents, such as the RCM’s  criticised ‘top tips for normal birth’ were  transferred to the new website.

Old news or not, it’s clear most people weren’t aware of these changes, which have been welcomed by organisations such and Sands, Action Against Medical Accidents (AvMA), the Birth Trauma Association (BTA) and most importantly, women and families.

Sands

Personal Experience

Joshua Titcombe

My son’s death in 2008  was not related to the mode of his delivery (he was born a healthy baby following a vaginal birth), but his death was  characterised by midwives not communicating and involving doctors earlier.

After Joshua’s inquest in 2011, the Coroner wrote what was called a ‘rule 43’ letter, now known as a ‘prevention of future deaths’ report. I’ve copied a key extract of this letter below.

Rule 43
As the Coroner alludes in his letter, this was the second time he had had to raise similar issues. The other case the Coroner refers to is that of baby Alex Davey-Brady, who died at the same maternity unit where Joshua was born, just a few weeks earlier. This article  from 2011, talks about what happened to baby Alex.

An independent investigation was commissioned into the maternity services at Morecambe Bay. In 2015, the investigation report was published.  This found that 11 babies and one mother died avoidably at FGH (these figures included Joshua and Alex). The report identified (amongst a number of other serious issues) that “care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care”.

Denial

This finding of the Kirkup report has been met with denial from some. For example these words  from the former RCM President, Lesley Page:

“The press has picked up on the report’s emphasis on “the ethos of normal or natural birth ‘at all costs’ at the unit which resulted in inappropriate and unsafe care” I searched carefully to find out what was the basis of this emphasis but couldn’t find much.”

The RCM have since clarified that they do formally accept the Kirkup report findings relating to Morecambe Bay, but they are adamant that their normal birth campaign was not a factor. This despite one of the witnesses quoted in the Kirkup report as saying “…there were a couple of senior people who believed that in all sincerity they were processing the agenda as dictated at the time… to uphold normality.”

A small,  but influential group of individuals have responded with hostility and anger to the recent media coverage, for example Sheena Bryon writes here:

“…this post is referring to recent ludicrous press claims in several newspapers, of a non-existent ‘cult of normal birth’ by midwives, and that mothers and babies are suffering because of it. These stories are fear-mongering untruths, aimed at damaging a profession, and limiting women’s autonomy and choice. And, they are adding to the fear amongst pregnant women, that already prevails. Shame on you all.”

The blog post above is wrong to claim there is no evidence to point towards this issue either being real or not impacting on the safety of care elsewhere.

Parents of babies who died at Shrewsbury and Telford have relayed their fears that this issue was a factor in the tragic outcomes for them.

Recent media reports have highlighted that the number of claims for newborns suffering cerebral palsy or brain damage in 2016/17 was almost 4 every week, an increase of 23% from the previous year.

Of course, there are many factors that influence these outcomes. Staffing levels, continuity of care, availability of senior obstetricians and a culture of learning and supporting staff is vital. Safe and effective maternity care also relies on effective multi-disciplinary team working. However our experience, and the experience of many families I’m met over the years, is that there are some elements within the midwifery profession that don’t engage with the wider multi professional team soon enough, and this is sometimes influenced by an over zealousness to achieve a natural birth experience without any medical intervention

It would be wrong to claim this issue was the only important factor, that midwives alone were responsible or  not to acknowledge that in some maternity units this may not be an issue at all. However, it is also completely wrong to dismiss the issues as ‘fear-mongering untruths’.

One of the most positive outcomes of the recent media reports around these issues, is that so many women and families have been speaking about their experiences. To improve care, we need to listen to experiences like these, not dismiss them.

Jane Merrik

We also need to listen to and not dismiss, the views of other professionals critical to providing safe maternity care – like those of Dr David Bogod who wrote the following letter in the Times this week.

Bogod

Amongst the most powerful responses I’ve read, was this blog by Nicola Wainwright, a partner in Leigh Day’s Clinical Negligence team and sadly someone who works daily to understand why the most tragic outcomes occur. Nicola writes:

“…I am sorry to say I have met too many parents who did feel that their midwife’s ideology of achieving a ‘natural birth’ without any medical intervention, rather than their wishes or their and their babies’ safety, dictated the way their labour and delivery was managed….”

My plea for the future

I’ve been saddened by some of the responses I’ve seen in recent days, some of it directed at me. There is some irony that the people who claim that the recent media reports highlighting these issues are nothing more than ‘fear-mongering untruths, aimed at damaging a profession…and adding to the fear amongst pregnant women’, are the same people who promote phrases such as ‘obstetric violence’. Whilst it’s vital to recognise there are real and serious issues relating to intervention and consent, this language must terrify women and instil mistrust.

My personal belief however, is that the vast majority of midwives, doctors, women and families, recognise that whilst these issues aren’t everywhere, they do exist and change is welcome and needed.

My plea for the future is that midwives, obstetricians, paediatricians and anaesthetists work together collaboratively in the best interests of the safe delivery of the new born child, and that no unnecessary risks are taken because of any deeply held ideology. A natural birth is the aspiration of many – but not at any cost, and not at the cost of a mother’s or new born’s wellbeing.

There is a huge amount of good work currently happening to improve maternity services. The end of the RCM’s normal birth campaign can only help.

 

 

 

Do we need a review of Midwifery training?

I have been given permission to share this message by the experienced midwife who sent it to me. The midwife wanted to remain anonymous, which I think is a sign of an issue I’ve certainly experienced –  that there is a real fear of raising and debating these issues as when people do, it often generates defensive / hostile responses from some.

Much of this rings true for me, having lost Joshua due a lack of awareness of the midwives looking after him in very basic signs of neonatal sepsis and also being contacted by many families who have experienced loss and harm and listening carefully to their stories.

 Maybe it’s time to review midwifery training to incorporate these lessons? 

“James I am really concerned that part of the problem with low risk perception in midwifery is that the majority of our workforce are no longer dual trained midwives. Those of us left who are also registered nurses will be mostly retired in the next ten years. 

The transition of this workforce to direct entry midwives has coincided with a greater number of women with increased risk factors. This includes women having first pregnancies at a later age. The average age for mothers in 2014 was 30.2 years. There are higher levels of obesity and increased levels of pregnancy induced diabetes. Over a quarter (27.0% of live births in 2014 were born to mothers outside the UK). This greater ethnicity has brought an increase in indigenous physical, mental and social health issues. There are a greater number of women who have moved away from their support network or are unsupported from partners. There is an increase in female smoking, alcohol and substance misuse. There are a number of women having babies who may not have previously survived childhood illnesses or ever contemplated pregnancy (e.g. renal, cardiac disease and some neurological conditions). This explains part of the the reason there has been a reduction in maternal mortality from pregnancy related conditions in the last ten years but three quarters of women who died had a pre-existing medical or mental health condition before they became pregnant. This was mainly pre-existing heart disease, neurological conditions or mental health problems. With the possibility of complications in any mother or baby, midwives need extensive knowledge of co-morbidities and the skills of meticulous monitoring we had to develop as nurses. I for instance cannot listen to a fetal heart without feeling the maternal pulse and assessing its volume, rhythm and character whilst looking at the mother’s skin tone and respirations. Noting her skin temperature, breath smell, temperament, body odour and basically scanning her visually as a six sense before even carrying out any further observations. Hearing a blood pressure with your ears rather than reliance on an electronic sphygmomanometer provides so much more reliable information.

 I would not think of caring for any woman without carrying out meticulous observations of both mother and baby at every point of contact because they are so vulnerable: every step of the way. It is not about medicalising a pregnancy, it is about the fact any woman potentially can develop complications at any stage in the pregnancy, during labour and postnatally. Early recognition, detection and prevention of an adverse outcome is key. I just wonder without an extensive nursing training, that many what I would term as red flags, go undetected.
Of course the same goes for caring for a newborn. That six sense of meticulous observation and assessment. I can never understand how some midwives do not even do observations and teach the mothers at the same time how to recognise abnormality in their babies. As a registered nurse we had to do placements in medical, surgical, paediatrics, maternity, psychiatry, A/E, community, orthopaedics, elderly and social care and ITU…..this does not happen anymore in nursing. There is no longer a paediatric, maternity and psychiatric placement..as these are covered by individual qualifications. Another gap in knowledge risk for the workforce.

For those of us left who are dual or triple trained, we had to be a state registered nurse with qualified experience as a registered nurse before doing midwifery. Hence we were a naturally older workforce starting training. We had the same if not more education input but it was within the midwifery unit. We were paid as registered nurses and were already a highly skilled workforce on starting our training which was a further 18 months on the 3 years training we already had. There were no long uni holidays just the same as everyone else. Tutors all on site working alongside you and those who were mentoring you would turn up often unannounced, day and night. Taking midwifery to university put a halt to the apprenticeship style of learning. We did not just have one of two mentors; there was a crowd effect of learning, nurturing and supervision.  

I totally agree midwifery and nursing should be recognised as a degree level course but education should be moved 100% back to the midwifery units (this is where the education team should sit). Separating theoretical education from practical experience can cause break down of communication and disjointed learning. I have not posted this as a general comment as there are very strong opinions to the contrary. My fear is it will worsen now midwives have to pay tuition fees…..it’s a big financial commitment to study for an additional course and this will further deter nurses from entering the profession. 

This could all be changed by valuing the workforce. Midwifery and nursing students should be paid for working: a band 4 salary. Registered nurses should be encouraged to take up midwifery with the incentive of maintaining a band 5 or 6 salary throughout their training (this should be an additional 18 months). This would solve part of the crisis of lack of recruitment, staff shortages and massive gaps in availability as seen in our current supernumerary student workforce. Bringing back 7.5 hour shifts will reduce the high incidence of sickness, burn out, mistakes because of tiredness and it will also reinstate that valuable shift change over period where so much learning took place. It also allows greater continuity for patients.”

Recent actions of the NMC – a fit for purpose organisation?

th

Recent actions of the NMC – a fit for purpose organisation?

I had hoped that the days of needing to write blogs like this were over, but reluctantly I’ve decided that writing about this publicly is the right thing to do. This is a long blog, but if you are interested in culture and patient safety in healthcare, please read it.

Since Joshua’s death in 2008, which was finally comprehensively investigated by Morecambe Bay Trust late last year,  the number of organisations I’ve come into contact with has been huge. Many of these organisations failed to respond to Joshua’s death and related events at the hospital where he was born in a reasonable way. The Morecambe Bay Investigation report published in March 2015, sets out serious criticisms of organisations including the Parliamentary and Health Service Ombudsman (PHSO),  Care Quality Commission (CQC), North West Strategic Health Authority (NWSHA) and the Department of Health in some detail. Combined, system wide failures led to serious risks to mothers and babies at Furness General Hospital (FGH) ongoing for several years, resulting in the preventable deaths of 11 babies and 1 mother.

One organisation that didn’t come under much scrutiny in the Kirkup report was the Nursing and Midwifery Council (NMC). One of the reasons for this was because there wasn’t a lot to say about them, as at the time effectively they hadn’t taken any regulatory action what so ever, despite being made aware of the failures relating to Joshua’s death and other babies’ deaths as far back as early 2009.  Following the publication of the Morecambe Bay investigation report, the NMC gave assurances that they would rapidly progress the Morecambe Bay cases they had open and that they would also review the Kirkup report itself to see if any further action was necessary.

Sadly, the NMC’s action since has been described as ‘lamentable’ by Bill Kirkup and heavily criticised by the Professional Standards Authority (PSA) who described the NMC’s handling of the first 2 cases relating to Joshua’s death last year as ‘deficient’.

In a manner that many who have experienced avoidable loss in the NHS will recognise, the NMC’s response to these criticisms wasn’t to say sorry and commit to learn, but rather it was simply to declare that the NMC and the PSA had a ‘difference of opinion’ and to reject the criticisms.

Whilst these issues are disappointing, more recently the actions of the NMC have crossed a line that in my view ought simply not be tolerated.

The Kark Report 

In 2016, a midwife involved in Joshua’s death who  had been under deferred investigative processes by the NMC for several years, was sacked by the Morecambe Bay Trust following the tragic death of another baby. Subsequently, the NMC issued the midwife with an Interim Suspension Order (IO) to ‘protect the public’.

At this point I had a number of serious concerns about this situation. Firstly, the midwife in question was someone who I felt strongly had not only failed in her care of Joshua, but who had also been dishonest about what happened (the latter concern being the issue I would expect a professional regulator to take seriously). This particular midwife was also the author of an email which contained a draft report relating to Joshua’s death,  which she titled ‘NMC Shit’.

It is important to note that very recently the Morecambe Bay trust finally carried out a full investigation into Joshua’s death which concluded the following relating to the actions of this midwife:

“When Hoa called for help at around 2.30am on 28th October 2008, because of concern about Joshua’s breathing, it was ‘highly improbable that there were normal neonatal observations present’ at this time. This is at odds with the statement from the midwife responsible for Joshua’s care at this time who maintained that detailed observations were taken and that all Joshua’s observations were normal.  Whilst there are no records of any of the observations taken of Joshua at the time, (as Joshua’s yellow observation chart has been lost), the Trust acknowledges that this is not a credible version of events based upon the expert view.”

After writing to the NMC to express my concerns, Jackie Smith wrote to me to confirm that she had commissioned an external review. At this time, the NMC publicly said:

“Having now received a new complaint in relation to [the midwife], we feel that it is right that we review the actions that we have taken to date. As an organisation that is committed to continuous improvement we have asked an external adviser to help us undertake this review.”

At this point, I was reassured that the NMC were acting in a reasonably open and transparent way, believing that they had commissioned an independent review to look for opportunities to learn from these circumstances. However, when the review was completed, the NMC publicly commented to say that the review found that “…at no stage during the numerous reviews and investigations which took place was the threshold for applying for and imposing an interim order passed.”

However, when I made a formal request under the Freedom of Information (FoI) Act for the report to be released, the NMC stated that the report was subject to ‘legal privilege’ and they refused to release it. It has since been established that the report was actually carried out by Tom Kark QC (at a cost of more than £12,000 for 1 week’s work).

The concerns I have about this are as follows:

1) When the review was announced, the NMC publicly stated that they had asked an ‘external adviser’ to help undertake the work as they were an ‘organisation that is committed to continuous improvement’. This seems to indicate something quite different from commissioning confidential legal advice from a QC, which could be interpreted as a defensive act, rather than being about transparency and learning.

2) Having completed the review, the NMC have publicly reported on what the apparent positive conclusions of the review were; that at no stage “was the threshold for applying for and imposing an interim order passed”. However, at the same time, the NMC are using legal privilege to withhold the review’s criticisms.  In subsequent phone calls with the NMC, they let slip that actually the Kark report did contain serious criticisms , including an ‘over reliance on the Local Supervisor Investigation (LSA) into Joshua’s death, something I’ve been constantly raising with the NMC for a number of years.

The decision of the NMC to keep this review secret is truly bizarre and has received wide spread criticism.  In my view, these actions demonstrate that there is something wrong with the culture and leadership of the organisation.

The NMC still have one outstanding case open relating to Joshua’s death. It is now fast approaching what should be Joshua’s 9th birthday. These ongoing processes mean that we do have to relive what happened to Joshua – a death that was horrific. The NMC processes last year were perhaps the hardest and most upsetting thing my wife and I have had to do since Joshua’s death. Surely as an organisation, the NMC should be reaching out to families affected by their actions to share any understanding and learning they have and seeking to restore trust through being open and honest and demonstrating learning?

Are these really the actions of an ‘open and transparent’ organisation?  Is it right that registrant fees should be used by the NMC to carry out reviews that are then only partly published, whilst other parts that presumably the NMC’s PR team think don’t flatter the organisation, are kept secret?

More secrecy and defensiveness at a vast cost to registrants

Due to concern about the culture of the NMC and how they have responded to events at Morecambe Bay since being informed of serious issues in 2009, last year I made a request under the Data Protection Act (DPA) for all copies of any of my personal data held by the NMC. After several delays, the NMC eventually provided this information but when it arrived, I was truly shocked at the extent to which the information was redacted. Many documents were completely blank apart from just one or two words. Other documents revealed that the NMC had been monitoring my social media accounts; there were graphs showing the number of my tweets mentioning the NMC and 3 separate emails showing that the NMC had set up a Google Alert for ‘James Titcombe’.

I subsequently asked the NMC under the Freedom of Information (FoI)Act to confirm how much they spent on redacting my personal data, and to my total shock they confirmed that they had paid a top city law firm almost £240,000.

I’ve questioned the NMC on why they needed to use such high level and expensive expertise to respond to a routine request for personal data (all public organisations routinely respond to such requests and doing so certainly shouldn’t necessitate specialist legal advice). The NMC say that this was purely to ensure that the response met their obligations in an ‘open and transparent way’. However, the information released to me has clearly been redacted to a much greater extent than necessary. In fact, it is not possible to make any sense of the vast majority of information provided as in many cases, only a few words per page are all that remains visible.

In these circumstances, I felt that it was important to understand exactly what the NMC instructed the legal firm to do. If the NMC had only instructed them to prepare a fully open and transparent response to my request for personal data, why would releasing their full instructions to their lawyers be a problem?

However, the NMC have refused my FoI request for these instructions, claiming that they are legally privileged.

£240k is the equivalent of over 2,000 annual registration fees of the Midwifes and Nursing who should be able to have confidence and trust in their regulator to act properly and responsibly. As an absolute minimum, shouldn’t the NMC be required to be absolutely open and transparent about the exact scope of work, where the cost is so vast?

Professional Standards Agency (PSA) Investigation

With support from a number of  people, recently the Department of Health agreed to my requests for a fully independent investigation into the NMC’s actions and instructed the PSA to lead this work. It has since been confirmed that this review will include an investigation into the NMC’s secrecy regarding the Kark review, their approach to redacting personal data, the use of £240k of registrants fee’s and the refusal of the NMC to be open and transparent about their instruction to their lawyers relating to this vast sum of money.  Prior to the DoH writing to the PSA to confirm this investigation, the NMC have only ever been secretive and defensive about these issues. However, on the day the news was announced, the NMC put out a press release describing themselves as ‘…an open and transparent organisation, committed to continuous improvement.’

In my view, the opinion pieces from various newspaper reports below are much closer to the mark. What is truly difficult to fathom, is why no immediate action has been taken to restore trust in what is clearly an organisation with dysfunction leadership, badly failing registrants and letting down the very women, babies  and families who they exist to protect.

James Titcombe – April 2017

NMC First

NMC 1

nmc 3

NMC 2

Birth Choice and Information

For some time now I’ve notice a promoted tweet from Which appearing on my timeline linking to a ‘Birth-choice Tool’. The tool is supported by the Royal College of Midwives (RCM), with the Chief Executive of the RCM Cathy Warwick saying that it will “…go a long way towards helping them [pregnant women] make an informed choice and to decide what is the best place for them to give birth.”

The tool has also been endorsed by Julie Cumberlege, the Chair of the National Maternity Review who (see tweet below) also makes a link with Personal Maternity Care  Budgets. (This was a pre decided recommendation of the National Maternity Review).

jc

Providing unbiased information to women and their families so that they can make informed choices about birth-place is clearly important and positive. This is something I can’t see anyone objecting to. But the emphasis here must be on accurate and unbiased information. To this end, I got a bit of a shock when I used the tool and entered various scenarios.

I’ll go through a worked example here.

The first question the tool asks is under the heading ‘Your birth experience’ and asks the question ‘Do you think you will want to use a birthing pool during labour?’.

q1

Of note, the tool cites the benefits of a birthing pool as being coping with pain and being less likely to need an epidural. There is no discussion around published studies around potential risk and benefit.

The next question is ‘Do you think you will want an epidural?’.

My only comment here is that I can imagine for some first time mums they won’t know what to expect or how they will experience pain. Would a better question be ‘do you want to keep the option of having an epidural open’?

On to the next question… ‘How do you see birth’?

q3

I have to say this is the point at which I began to feel really concerned. The tool gives two options.

  1. As a natural event that should take place in a relaxed and private setting.
  2. As a clinical event that needs medical equipment and staff on hand.

It seems to me that the language here is very loaded; ‘natural, relaxed and private’ vs ‘clinical, medical and equipment.’

Is it the case for example that birth in an obstetric led unit can not be ‘relaxed, natural and private’?

The tool then asks the question ‘Are you willing to plan for the possibility of transfer during labour’?

q4

The explanation note does point out that if you plan to give birth at home or in a birth centre you may have to be transferred. It highlights that that such a choice  ‘can reduce your chance of needing medical interventions.’ There is however no mention that for first time mums the transfer rate nationally is 36-40% and there is no discussion about the implications for the safety of mother or baby in the case of a complication arising that necessitates obstetric intervention.

The tool then asks for your age, if it’s your first birth and what your post code is.

In some scenarios, before coming up with the recommended options, the tool will ask an additional question:

q5

‘Do you actively want to avoid the need for medical intervention’?

I have to admit to surprise  when I read this. No matter what choice a woman and her family make about place of birth it surely isn’t possible to ‘avoid the need for medical intervention’. It might be possible to make choices that reduce the chance of experiencing an intervention that may not have been necessary. However, this is complex and in reality, many lives are saved by virtue of mothers giving birth in a setting where risks are carefully monitored and midwives and doctors train and work together to respond to obstetric emergencies promptly. For example, the obstetric unit at Southmead is regarded as one of the safest places anywhere in the world to have a baby.

Nowhere in the tool are the risks associated with childbirth quantified. For example, in 1999 the World Health Organisation (WHO) published research that showed that globally around 15% of all births are complicated by a potentially fatal condition that requires emergency care.

Academic research also that shows that your risk of death is greater on the day you are born, than any other day of your life until you reach the age of 92.

The things that can go wrong in childbirth (for example sepsis, amniotic fluid embolism, haemorrhage, placental abruption, pre-eclampsia) are not things that can be controlled by making a choice about birthplace. They are complications that on rare occasions,  women and babies sadly continue to die from unnecessarily because interventions (sometimes as simple as a single of dose of antibiotics) were denied.

What did the Birthchoice tool recommended in my imagined scenario?

I live approximately 2 miles from Furness General Hospital (FGH). This is a unit that has recently been through a period of significant change and improvement. In many ways, the unit at FGH is now a leading one in terms of safety, quality and experience.

I completed the Birthchoice tool as a young first time mum, 19 years of age with my postcode. I answered all the questions  leaving the slider in the middle (in reality I think the language in the questions is so loaded that I can’t see how it wouldn’t influence the responses). These are the recommendations the Birthchoice tool made:

results

In my scenario, the tool recommended a freestanding midwifery unit in Penrith, 62.8 miles from my home as a better choice than the unit at Furness General Hospital (FGH) which is just 2 miles away. This recommendation is made for a 19-year-old first time mother.

I always find it interesting to observe the wider context when I come across things like this.

Last week HSJ covered this story stating that there will be a doubling of ‘midwife-led births share by 2020’.

A week earlier, I noticed the following tweets from a midwifery conference attended by senior NHS and RCM midwifery leaders.

o-v

v-worrying

The tweet says “Obstetric violence, we have all seen it…” and shows what seems to be a video with a male doctor (presumably an obstetrician) and the words ‘No, no, no. Stay there quietly’. Someone comments that the phrase is worrying and the response is,  ‘it’s very worrying… & exists’.

Last week I also took the time to watch a presentation from Bill Kirkup about events at Morecambe Bay where 16 babies and 3 mothers lost their lives. If you have the time, please watch it also. It is hard for me to reconcile the messages in Dr Kirkup’s report with some of the observations I’ve highlighted in this blog.

I know that there are many fantastic people working hard to ensure safer maternity care is a priority, but is it now time that we saw some national leadership in challenging these issues? If so, would a good place to start be by providing a resource for women and families that really did provide unbiased and accurate information to enable informed choice? Instead of conferences that promote ‘normality’ in childbirth and appear to promote negative messages relating to obstetricians that must be very frightening for women to see, shouldn’t we be holding conferences attended by all professionals involved in delivering maternity care, where we celebrate teamwork, discuss and learn from poor outcomes, listen to all voices and agree actions we can take together to make maternity care safer and better for everyone.

James Titcombe – 8th Jan 2017

A few thanks…..

2016 has been a very busy year personally and for patient safety in England. I wanted to write a quick blog to thank a few people who have made a difference.

In February, a report commissioned by NHS England relating to the tragic loss of baby Kate Stanton-Davies in 2009 was published. The report only came about because of the hard work and determination of Kate’s parents Richard and Rhiannon. The report was shocking for many reasons, including the fact findings  were very different to the initial supervisory investigation carried out following baby Kate’s death and identified failures that had previously not been acknowledged.The report also made the recommendation for there to be a national audit of the quality of similar supervisory investigations following serious incidents/avoidable deaths in maternity services. A big thank you to Richard and Rhiannon for all they have done to push for the truth about Kate’s loss and for there to be national learning. 2017 will be an important year for midwifery and a new model of supervision is being developed, it’s vital that Kate’s story and the results of the national audit feed into the new model.

It’s been approaching 2 years since the Morecambe Bay Investigation report was published. If I’m being frank, I have a growing concern that some of the key messages of the Morecambe Bay report, especially amongst some elements within Midwifery, risk being lost and overlooked. However, since publication, the Chair of the Morecambe Bay Investigation Dr Bill Kirkup has consistently and superbly kept a focus on the issues. This has included articles and talks at high profile events about what happened at Morecambe Bay and what the keys message are.

If you only have 30 mins to spare to learn about Morecambe Bay, please watch this talk from Bill, it’s so important that these messages aren’t lost or forgotten.

I’d like to repeat my thanks to the whole Morecambe Bay Investigation panel, but especially to Bill Kirkup for working so hard to spread the learning from his report.

Another area of significant progress in 2016 has been the establishment of a new Healthcare Safety Investigations Branch (HSIB), which is set to go operational in April next year.  This new body has come about as a consequence of sustained effort from people like Martin Bromiley and the Clinical Human Factors Group (CHFG) and others. A breakthrough moment was when Carl Macrea and Charles Vincent published their paper ‘Learning from failure: the need for independent safety investigation in healthcare’ towards the end of 2014. The paper was read by Bernard Jenkin MP, the Chair of Public Administration Select Committee (PASC) who also became a passionate champion for the creation of the new body and set up a PASC inquiry which made recommendations that the government supported.

Another person who in my mind has made a huge difference in 2016, is the Patient Safety Correspondent at the HSJ, Shaun Lintern. I highly recommend watching this recent talk by Shaun which highlights the mountain that we still have to climb in improving safety and culture in the NHS. I also recommended this piece and hope 2017 will be a year we make real progress in changing this.

Earlier this month, the Care Quality Commission (CQC) published a comprehensive report into the quality of investigations and learning following the deaths of patients in the NHS. This is a report that everyone working in healthcare should read. It wouldn’t have come about without the considerable efforts of the family of Conner Sparrowhawk, whose preventable death whilst in the care of Southern Health (and the appalling way the trust responded), triggered the Mazars report and subsequently the CQC review.

Before 2017 arrives, I’d like to say a big thank you to the Chief Executive of Morecambe Bay, Jackie Daniel and all the staff at the Trust. My relationship with Morecambe Bay has been a turbulent one since Joshua’s death as until recently, I have felt that there has been a lack of ownership for what happen and that questions about what happened to Joshua and why remained unanswered.

I must say that during the past year, Jackie and the team at Morecambe Bay could not have worked any closer with me to resolve this. Jackie has shown huge understanding, thoughtfulness and compassion.

As part of the work the Trust did with me, it was discovered that a senior midwife central to events at the trust and involved in a flawed investigation into Joshua’s death, had received an ‘irregular payoff’ in a deal that avoided an internal trust investigation. Before these facts were made public, Jackie was issued with a legal injunction by the Royal College of Midwives (RCM) to try and ensure the circumstances of what happened were kept secret. I think it shows huge moral courage that Jackie ignored the legal threat and did the morally right thing by releasing the report regardless.

On 4th November 2016, a day before the 8th anniversary of Joshua’s death, the Trust published a summary report of their recent investigation on their website.

The report is honest, thorough and accurate. I now feel that the Morecambe Bay trust genuinely does ‘own’ what happened to Joshua and I  believe that they will ensure the lessons from his death and other tragic events, are never forgotten.

In 2008, it is now abundantly clear that Morecambe Bay was a trust that had much to learn from the wider NHS. As we approach 2017, I honestly believe that it is the wider NHS that has much to learn from Morecambe Bay. Once again, huge thanks to Jackie and the team at Morecambe Bay for all your hard work.

It’s not possible to mention all the other people who continue to make a difference, but thanks to everyone who works to make healthcare safer and wishing you all a very Happy New Year and all the best for 2017.

James Titcombe – 31.12.16