The Polar Expedition
One thing that I am increasingly noticing is that now I have brought my work, my joy and my abilities into line with my own ethics, is that it is much easier to be gentle with people. To sit with our differences. Midwifery is, and probably always will be an emotionally charged experience. The skills to hold a strong love in the birthroom, and then the strength to occasionally navigate life and death decisions in this place of love and trust is probably unique to our profession. Though maybe one can feel a little like this in other adventures. The silent frozen tundra, captivating and wildly dangerous. The Sahara (in which I once got lost, but my camel, Jimmy Hendrix, found me) again a place of edge magic, beauty and of unstable footing. One mistake could cost everything. The responsibility is, frankly, huge.
As midwives we exist in a liminal space. Right up against the boundaries of tradition and innovation, of responsibility and autonomy. Of individualised care and ‘one size does not fit anyone’ protocols. Of the art of instinct and evidence-based practice. At our foundation we sit between the light and the dark of new life and tragic loss. I returned to the NHS for a few years in 2021 (after ten years of academic life) and the pervasive fear that everyone felt was palpable from the start. A fear often expressed though a new level of the coercion of families into increasing iatrogenic harm. As a wise doctor once told me, don’t just do something, stand there and think about it!
The ecological fallacy is a useful concept here - that something may be true on a population level but not apply to this individual. For instance, the link between smoking and certain kinds of lung cancer is pretty irrefutable now (thanks Doll and Hill) but we all know a Nana who smoked 40 a day and is still the funny and friendly matriarch well into her 90’s. This doesn’t disprove the smoking and cancer link, but it is extremely important to know that there will always be some people who are that Nana. But it works the other way as well, an onslaught of new ‘Nanas’, too many outliers, will change the epidemiological evidence in its turn.
Back in scrubs (or ‘Battle Pyjamas’ as my partner calls them) I saw how people, good people for the most part, took decisions about what care to offer pregnant people, based on a genuine belief that the offer was in that person’s best interest. And often they carried on offering and offering and then got their superiors to offer a bit more forcefully, finally offering the choice between their plan, or a ‘potentially dead baby’. Which is no choice at all. The fabulous Debs Neiger recently did a great article about why telling people to ‘just say no’ is like telling a cyclist that they should just refuse to let the bus swerve into the bike lane and run them over (my example, Deb’s post is a lot less satirical and more grown up).
The removal of the caesarean rate targets, nationally set, was in my opinion theoretically a good thing. An emergency procedure should never be unavailable or staff unwilling because we have had too many this month. Sorry, we’re up to our appendicitis quota, come back in November! That said, one of my local units had a caesarean section rate of nearly 50% last month. We can identify the proportion of the population of women and people needing a caesarean - the WHO estimates this as about 15% of births. What we cannot do is control the near random incidence of an individual turning up on labour ward tonight who will need a caesarean. Even harder, we don’t always know who that person will be until after it is needed or has been done. Therefore, whilst we are all making this decision to move to surgically expedite a birth based on the pregnant woman in front of us, the unconscious collective has decided, one woman at a time, that a 50% caesarean rate is ‘necessary’.
We do not always understand the statistical concept of ‘risk’ in maternity. That literally means, what is the probability of an event occurring. It is entirely possible that if you repeatedly dropped your toast on your cat (I did just that this morning, a bit bleary eyed and her looping my legs) it would land jam side down in her fur 1000 times. Annoyed and sticky cat aside, it is very improbable, but possible that the next 1000 cats would be jammy too.
Random distribution can look like a pattern and humans find that confusing too. I had a lovely colleague who had been a midwife for 25 years. She looked after three women with a uterine inversion in one month. She was taken to task for this, was she doing controlled cord traction too hard? Was she ‘guarding’ the uterus? She never had another one. So that’s about an average number of this rare event over a career course. She just got all her ‘average’ quota in four weeks. Unlikely, but if there were no context specific factors (confounding variables), then one happening exactly every 10 years is just as probable.
But the problem is that because now we are all so afraid of these events, of unit enquiries, of a disciplinary, even of just a Datix, we have become ‘risk averse’. If by this, we mean trying to prevent a random event then it really just becomes about fear. Of course patterns and context matter, Of course a decade of underfunding and underinvesting in the next generation of midwives has created dangerous levels of understaffing. This context is dramatically increasing the risk of families’ poor outcomes and traumatic experiences. I am absolutely not claiming that every outcome is distributed randomly. But because of the fear, and a lack of sector wide understanding about the relationship of the individual to the population, we have collectively raised the threshold by which we deem a vaginal birth to be ‘safe’. In doing so, we have interrupted the psyco-physiology of birth to such an extent that we are beginning to feel that such a thing as an emotionally safe, uninterrupted birth must be unattainable. That means that 35% of women and people in my local unit are experiencing iatrogenic harm for no gain, if the (well grounded) WHO estimates are correct.
What is more worrying is that maternity has completely confabulated a difference between iatrogenic morbidity (and mortality) and ‘natural’ morbidity. So, if I assist at a birth and the woman has a 3rd degree tear, I have to submit a Datix and usually someone will give me a good bollocking for it. If someone else does not experience cervical dilatation as a continuous linear process (rather than step wise, which I’m sure we’ve all seen sometimes) they get hauled out of the pool, put on a bed and on a CTG so we can administer oxytocin. If that someone then ends up with a bilateral episiotomy for a trial of forceps in theatre for suspected foetal distress. Then that someone has a second stage caesarean section, permanently damaging her cervix and bladder, and leading to an MOH, then that’s ok. That’s just what we needed to do to save mother and baby. The baby’s cord gases were absolutely normal, by the way, and the baby required no resuscitation. The mother however, did.
Ironically, and I’m not directly criticising the very necessary unit enquiries here, the urgent need to improve safety has led to an even greater increase in fear led unnecessary procedures and thus iatrogenic harm. ‘Normal at any cost’ is an oxymoron, similar to a Northen Trust who shall remain unnamed who had the phrase ‘Excellence as Standard’ as their branding. Standing in the corridor shouting at signs for being so patently ridiculous does not make you look sane, I found. It’s so annoying isn’t it, that 50% of people remain below average in the Trust Public Relations department.
So much of maternity has become polarised like this, both in the way we conceptualise care offerings and in the way we regard each other. It is beyond childish to say that all births will require no professional support. I’ve worked in places where even basic interventions were not always available and step up care was virtually non-existent. Until a 16-year-old and her baby has died in your arms because we had no theatre staff and she had a major APH, it’s probably wise to be a bit more reflective about such an over-simplified position. This was deeply traumatic and sometimes, I still see her face in my dreams. However, the literally insane extent of over intervention in the UK is also an emergency of our own creation. To much too soon, to little too late.
Similarly, the obdurate discussions between midwives and birthworkers with views on racialised inequalities; gender identities; class and wealth; any topic with need and pain and loss at its centre, is also splitting us in two. All of us unable to hear each other because of the overwhelm of putrefied opinion that has come out of Political propaganda. We’re just gonna be over here with our £3000 glasses guys, you lot make sure you keep those pesky Black women/poor people /immigrants/LGBT+ peeps from stealing your stuff. Not a new idea by any means, but unfortunately still a relevant one.
Years ago, I bought a book for a friend, who had just qualified and got her fresh new midwifery wings. I wrote in it that birth can be the cradle of feminist empowerment or the crucible of gender oppression. I meant it as a slightly show offy little catchphrase. But right now, here in UK maternity, we have a battle between this cradle and the crucible. A battle which is increasingly reducing everything to a debate of extreme positions. This is an emergency. We desperately need to heft some the polar bears down or carry the penguins up (yes, I did have to google which one lived in the North Pole). And even more we need to have a gameplan that includes supporting , sitting with and valuing different people with different views of birth and the strong love of us all. We have become so polarised that we are eating each other alive. Much like the suddenly delighted bears, as they find themselves surrounded by all those tasty little black and white snack birds.
