Monthly Archives: August 2017

An email exchange with Julia Cumberlege

To: Julia Cumberlege Cc: xxxxxxxxx

Thank you Julia, I appreciate the honestly in your explanation.

Simon is clearly a gifted communicator.

Forgive me for noticing the difference in sentiment between ‘I respect and value your views and campaigning work’ and ‘…but the article! How does this man have the time to write all this stuff.’ !

All the best,
James

 

Sent from my iPhone

 

Sent from my iPhone
On 18 Aug 2017, at 13:20, Julia Cumberlege <xxxxxxxxxxxxx> wrote:
James I am very sorry. As you know I am on holiday. I wanted to get a reply to you as soon as I could and sought a helping hand. I meant every word I said in my reply to you. When I return I suggest we meet and have a coffee to talk through how we can work together to achieve our shared goals.
Best wishes
Julia
Sent from my iPhone

Begin forwarded message:
From: James Titcombe <xxxxxxxxxxxxxx>
Date: 18 August 2017 at 11:09:08 BST
To: Julia Cumberlege <xxxxxxxxxxx>
Cc: xxxxxxxx
Subject: Re: Midwives and ‘normal’ delivery methods | Comment | The Times & The Sunday Times
Dear Julia,

Can I hazard a guess that ‘Simon’ is the person who helped draft your response to my email and that you meant to forward my polite response to him, to congratulate him on a successful strategy?

It’s very sad & hurtful to see this Julia. One thing I value more than anything else in leadership is authenticity and honesty.

James

 

On 18 Aug 2017, at 10:33, James Titcombe <xxxxxxxxxx> wrote:
Hi Julia,

I think this response was intended for someone else called Simon and that you have sent me this by mistake?

I don’t know who Simon is but hope your comment ‘how does this man have time to write all this stuff’ isn’t referring to me?

If it is, happy to explain that losing a baby and wanting to ensure no one else goes through the same is quite a motivating factor.

Best Wishes,
James

 

Sent from my iPhone

On 18 Aug 2017, at 10:26, Julia Cumberlege <xxxxxxxxxx> wrote:
Simon. I think you have succeeded again, for the moment but the article! How does this man have time to write all this stuff.
Thanks again
Julia

Sent from my iPhone

On 17 Aug 2017, at 23:28, James Titcombe <JamesTitcombe@outlook.com> wrote:
Dear Julia,

Thank you for your response. I do very much respect your experience and commitment to making things better.

As you say, there is common ground.

The last few days have been interesting listening to what others have been saying & I’ve written a few more reflections here, including my hopes for the future.

https://patientsafetyfirst.wordpress.com/2017/08/17/the-campaign-for-normal-birth-and-why-change-is-welcome/amp/

If all maternity units could emulate the approach Morecambe Bay have adopted in recent years, all my hopes for system learning following Joshua’s death will have been realised.

I do really hope we can have more balanced messages around ‘normal birth’ and that you might consider helping to influence this.

Kind Regards,
James

Sent from my iPhone

On 17 Aug 2017, at 10:49, Julia Cumberlege <xxxxxxxxx> wrote:
Dear James

Thank you for your email.

I want to say how much I respect and value your views and your campaigning work, albeit that we do not agree on every point. I am not sure I will persuade you to see things differently, and you certainly know my own views.
We do, I believe, agree on familiar but crucial points that have once again been highlighted by The Times editorial and subsequent discussion.
Medical intervention that ensures the safety and well-being of a woman and her baby, in circumstances where that safety would otherwise be in jeopardy, is absolutely vital. Equally, unnecessary medical intervention is not in the interests of women and babies.
We agree on the importance of continuity of carer, specifically of midwife. Continuity is a pivotal factor in safer births. It is a real challenge given the pressures that exist in the service, but we must continue to strive for it.
We agree, I believe, on the importance of women being empowered to make choices about their pregnancy and birth. They must, of course, have access to good, impartial information and support in making their decision.
Like you, I do not want any woman to be labelled a failure because of her birth experience. I want women to have a safe and happy experience in pregnancy and childbirth, throughout to receive the best possible care and support, and to make choices that are in her – and her baby’s – best interests.
I know there will continue to be points on which we disagree, but I hope we will find a way to work together again on the many points where we do agree.
Best wishes
Julia
Baroness Cumberlege
National Maternity Review

From: James Titcombe <xxxxxxxxxxx
Sent: 15 August 2017 02:14
To: BARONESS Cumberlege
Cc: xxxxxxxxxx
Subject: Midwives and ‘normal’ delivery methods | Comment | The Times & The Sunday Times

Dear Julia,

I was saddened to see your letter in the Times in response to the leader (“Born Free”, Aug 12), which I’ve attached for ease of reference.

https://www.thetimes.co.uk/article/midwives-and-normal-delivery-methods-czgjkmk2q?shareToken=4253f934f47f3e0d5c6be90b8ccf88e7

I thought the Times column was well written, balanced and made some important points that you don’t seem to acknowledge.

You make a point about WHO stating that 80% of women should be low risk at the start of labour and cite WHO again, talking about the ‘uncritical adoption of a range of unhelpful, untimely, inappropriate and/or unnecessary interventions’ being a risk ‘run by many who try to improve maternity services.’

I struggle to understand the point you are making. No one would argue that the ‘uncritical adoption of a range of unhelpful, untimely…etc…’ interventions was a good idea.

The Times column makes 2 clear arguments. The first being that the phrase ‘normal’ can lead to some women who do need interventions feeling ‘as if they have failed’. As a man and having only experienced my own children being born without intervention, I have no direct experience of this. But I have heard literally hundreds of women express these concerns. If you look at my timeline on twitter you’ll see many examples of women saying exactly this.

I note that alongside your letter, David Bogod, a consultant obstetric anaesthetic provides further testimony to this issue.

“…it leaves women needing epidural pain relief or caesarean section feeling that they had failed in what many, rightly or wrongly, regard as their most fundamental biological role.”

You may also be aware that after extensive work listening directly to mothers, Morecambe Bay changed their language and ceased using the phrase ‘normal’ some 18 months ago. To Cathy Warwick’s credit, she was quite frank about acknowledging these issues in the interview with the Times that triggered this media interest.

Your letter makes the point that ‘changing the name of birth will not improve outcomes’, of course it won’t – but the article didn’t attempt to link language to outcomes. Nor has anyone else.

I find it odd that your letter conflates this issue when the column was so clear. Is it the case that you don’t accept the point relating to how the language makes some women say they feel? Why not speak with the head of midwifery at Morecambe Bay and ask about the work they did with mothers there?

I would be very grateful if you would be kind enough to clarify this.

The second part of the Times column however, did discuss safety.

Your letter states ‘Midwives work on the basis that “normal” births are preferable for mother and baby where it is safe.’

It is of course, up to women to decide what kind of birth is ‘preferable’ for them – and women should be given the full facts, including (as the montgomery and lanarkshire case made clear) information about the risk of vaginal delivery. But the concept of ‘safe’ isn’t a binary. It isn’t possible for the birth of a child to be labelled ‘safe’ until after the event. Before then, there is only a spectrum of risk and uncertainly.

The concern which many people have expressed relating to the emphasis of the RCM ‘normal birth’ campaign, is that it takes a very laudable and worthwhile aim; to minimise the chances of unnecessary interventions, but attempts to achieve this aim with the bluntest of instruments and through only focusing on one part of the multidisciplinary team that we know is essential to providing safe maternity care – midwives.

Messages such as ‘wait and see’ and ‘trust your intuition’ aren’t helpful if we want to foster a balanced approach that succeeds in minimising interventions without increasing the risk of catastrophic outcomes.

Isn’t a better approach not to have a national campaign that only focuses on ‘promoting’ a mode of delivery, but instead focuses on influencing all healthcare professionals involved in delivering maternity care to work collaborative together, not towards some artificial intervention target, but to ensure the care of each individual women and baby is as safe and compassionate as it can be?

It was established beyond any doubt that an over focus on ‘normal’ childbirth was a significant factor in the deaths of 11 babies and a mother at Morecambe Bay. I can tell you that I have heard from literally 100’s of families who tell me they felt a focus on normal birth contributed to their, often deeply tragic circumstances.

Your letter rightly highlights the importance of continuity (not disputed) but then finishes with the statement:

‘Midwives are the backbone of maternity services. Supporting them is crucial to safer services; undermining their confidence is damaging to the National Health Service, parents and babies.’

I really don’t see how either of the points made by the Times column could be seen to ‘undermine’ midwives confidence.

The issue about language was embraced and adopted at Morecambe Bay 18 months ago and as I understand it, the service there is going from strength to strength.

The issue about safety is particularly around moving from guidance such as ‘wait and see’ and ‘trust your intuition’ to improving training (including obstetric emergencies), teaming work, multidisciplinary working and seeking a second opinion if there is any doubt.

Far from undermining the confidence of midwives, such approaches will build confidence, aid learning and improve safety.

The real risk of damage to the National Health Service, parents and babies, would be if progress wasn’t made to improve these issues.

As someone with a key leadership role, my view is
that you should be reinforcing the need for change and supporting this direction of travel. Just as charities like Sands, organisations like Morecambe Bay and the Secretary of State for Health have.

Accusing an article making important points that many people feel very strongly about of ‘undermining midwives’ and ‘damaging the NHS’, only fuels division and makes positive change and the job of saving lives, harder.

Best Wishes,
James

 

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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

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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.