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Effects of birth care on maternal emotional health – a consumer perspective.
From Jean Robinson (JO), the Association for Improvement in the Maternity Services (AIMS).

Suicide is now known to be the largest single cause of maternal death in the UK: (Drife et al. 1997-9)) The full number affected is still underestimated as the UK covers deaths only up to 1 year after the birth, which is a longer period than in most other countries, and although there is now an efficient method for collecting the data, perhaps in part thanks to pressure from AIMS. As a consumer group we have found the highest risk group for suicide not to be those with postnatal depression but subjects with undiagnosed post-traumatic stress disorder, caused by sub-standard maternity care and often wrongly treated for years.

I first encountered reports of this condition, then undescribed other than as shell shock in World War 1, when working for the Patients Association in the early 1970s. Women were describing nightmares of a severity which rendered them afraid to go to sleep, flashbacks – a term not then coined but later recognisable – and their partners reported their personality changes. Induction and augmentation of labour and the associated management of labour, inevitably with electronic monitoring, appeared to be responsible for the phenomenon; only women who received sensitive and personal care in labour survived the experience unharmed, and the midwives most likely to provide this, those who had worked on the district, were being phased out as high technology labour management was introduced, at that time with little access to epidural analgesia, and long before the cervix could be primed with prostaglandins,. Enquiries made of mother and baby psychiatric units throughout the country confirmed a coincidental rise in admissions.

We have recently analysed data from our helpline and correspondence to identify causes, risk factors, reasons for misdiagnosis, and access to treatment. (Robinson 2002). When compared with the generality of complaints of the health services, the ones relating to the maternity services leap off the page. Memories are intensely vivid, sometimes of births many years previously; poor care in labour had a great negative impact which was very long lasting. A mother admitted in her fourth labour could hear women screaming, and it struck terror into my heart. Women who have experienced inferior care in these circumstances seek home birth, even when in so-called high risk categories; some have said that they were prepared to die rather than go through hospital birth again.

The obstetric literature was and remains remarkably lacking in any information on the subject of PTSD, which presents a genuine risk of suicide, is much more common than puerperal psychosis, and is a significant cause of morbidity affecting the mothers and their families. These women will not watch any television which bears on medical issues, fact or fiction; some have moved house or to another town, and if not they cannot go near the hospital where their trauma took place. One woman is even unable to visit her GP; many avoid any gynaecological contact, even when cervical smears have been positive. Marital breakdowns are common, when excellent husbands run out of patience after some years, leaving their sick wives to care for the children. We believe this to be a major public health issue.

Once the Vietnam literature appeared, we recognized the similarity in symptoms, but found doctors reluctant to connect it with childbirth, since giving birth was a "normal" process and they did not see it as traumatic, as bomb blasts or major accidents are. However, what women described as conveyor belt births - induced or augmented labour - were not found by women to be "normal experiences". Professionals are reluctant to listen to the telltale stories which are inevitably critical of the care provided by colleagues; if they hear it they do not record it. You should be grateful that you have a healthy baby is frequently the message from embarrassed carers, of whom very few have the necessary specialist knowledge. What was happening did not reach the literature until recently, when, for example, effects of emergency caesarean sections were noted in Sweden ( Ryding et al. 1997). We found that intervention alone was not responsible: there was always a strong element of inappropriate staff behaviour. We have had three cases of PTSD from home births managed in the hospital style.

The incidence of postpartum PTSD has been estimated from a prospective study as 2.8% at 6 weeks and 1.5% at 6 months, which could imply 10,000 cases annually in the UK (Ayers et al. 2001). Misdiagnosed as depressives, the PTSD sufferers often take unsuitable medication for years without benefit. The EPDS at present identifies depression where it should point to PTSD, although it is true that many chronically depressed women have histories of traumatic experiences in labour.

It is known that women ruminate extensively on their birth experiences, and that they retain vivid and consistent memories for at least 20 years (Simkin 1992) We suspect that the change in hormone levels women experience around birth makes them more vulnerable to psychic trauma. While some women are particularly vulnerable (e.g. those with histories of sexual abuse or of traumatic experiences) even psychologically stronger women are not immune if under sufficient stress. Certain groups seem to be scapegoated when in maternity care, e.g. travellers, women with psychiatric histories, ethnic groups, or the socially disadvantaged, and placed at further risk - and often these happen to be the groups also found to be at highest risk of maternal death.

As consumers we want mental health outcomes to be included in assessments of maternity care, research on types of staff behaviour which are a causal factor, better training of staff on the psychology of birth, adjustment of the EPDS to include PTSD symptoms, research on the differences between postnatal PTSD and that caused by other forms of trauma, and improved maternity psychiatric services.

1) Drife J, Lewis G (eds) (1997-9) Why mothers die. Confidential Enquiry into Maternal Deaths in the UK. London RCOG Press 2001

2) Robinson J. (2002) Post-traumatic stress disorder - a consumer view. Maclean A, Neilson J (eds.) Maternal Morbidity and Mortality. 313-322. London RCOG Press

3) Ryding E, Wijma K, Wijma B. (1997) Post-traumatic stress reactions after emergency caesarean section. Acta Obstet Gynecol Scand. 76: 856-61

4) Ayers S, Pickering A. (2001) Do women get post-traumatic stress disorder as a result of childbirth? A prospective study of incidence Birth 28: 111-118

5) Simkin P. (1992) Just another day in a woman's life? Part II: Nature and consistency of women's long term memories of their first birth experiences. Birth 19: 64-81.

‘Silent Witness’ – care and communication in the delivery room.
From Professor Keith Greene (KG) and Mrs.Mo Harris (MH), Perinatal research group, Derriford Hospital, Plymouth.

The birth of a baby is a momentous occasion and a time to cherish. It is a life-critical event where emotions can range from sheer joy to abject terror. It can be a time of uncertainty, anxiety and stress for parents, affecting all the family relationships, impairing physical and psychological wellbeing, the consequences often lasting a lifetime. Marshall Klaus likened its significance to a gluepot thrown around the room and sticking to everyone there. The reassuring presence of a personal carer, the simple offer of a hand to hold, or a motherly hug can bring great comfort and a sense of security at such times. Clearly communication involves more than just words and the way care is undertaken speaks volumes.

Psychosocial support reduces the need for pain relief, operative vaginal delivery, and caesarian section (CS), and the Apgar scores are improved (Scott et al. 1999), but only when the support is given by a doula. Our work, supported since 1994 by the Medical Research Council, sheds light on this difference from the care given by healthcare professionals; the funding is now being applied to a multi-centre randomised controlled trial aimed at reducing human error in intrapartum care. What you will see today represents the initial observations of the present care system in labour, and it opened our eyes to deficiencies of care and caring.

We have undertaken a study of direct patient care by audio-video recording within a single delivery room to inform the development of a decision support system for patient monitoring, about to be tested in a randomised controlled trial. Attention will be drawn to how this might free midwives for more meaningful support of mothers. The communication and interaction between midwives, doctors and parents were investigated, informed consent being obtained for all observations. The care of twenty women over 111 hours of first stages and 12 hours of second stages of labour were recorded and digitised to computer files. Recurrent themes were identified, and coded quantitatively and qualitatively.

Mothers were accompanied by their partner for 15 labours, by partner and a female companion for two labours, and by a female relative alone for three labours. All mothers were provided with one-to-one midwifery care. Midwives left the room on average every 15 minutes to be absent for 27% of the first stage of labour, and this was often an anxious time for parents. Record keeping inhibited interaction and accounted for 19% of the midwives’ time. Psychosocial support was not given priority.

Parents were generally excluded from communication between clinicians, yet 108 clinicians took part in the care of the 20 women. 14 out of 20 experienced at least one shift change, and 3 out of 20 two changes. Professional anxiety and uncertainty rather than reassurance were often communicated verbally or by body language. We found fathers were frequently left to support their partners, yet their behaviour indicated that they too needed support. Midwives had little time to talk with mothers and only sat down at the bedside for 15% of the time, but when they did so the atmosphere in the room was immediately transformed, with midwife, mother and partner engaged in animated conversation.

For five mothers a female relative or friend, all experienced women, provided continuous psychosocial support – companionship, simple comfort measures, praise and reassurance. Importantly, the presence of an experienced women can relieve the father from feeling solely responsible for his wife (Klaus et al., 1992). This was observed in the two cases where both partner and a female companion were present. Issues were illustrated with video clips.

The strongest evidence base for reduced CS rates is continuous psychosocial support (Hodnett 2000). One in four births in the UK is by CS (Thomas & Paranjothy 2001) but surprisingly there have been few investigations of support in labour. This study shows that one-to-one care does not equate to continuous support, since record keeping and absence from the delivery room accounted for 46% of midwives’ time. Managerial imperatives to ‘record everything’, regardless of its relevance, created spurious care priorities, frequent departures from the delivery room making some midwives appear to be very busy. Parents have been found to be reluctant to ask questions in such circumstances (McIntosh 1988). Mere physical presence is not continuous support. Midwives who sit at the mothers’ bedside create a setting for focused interaction, as mutual eye contact is important for initiating communication and establishing rapport (Goodwin 1981). This is particularly important, as mothers have rated midwives talking with them as the most important supportive activity (Klein et al. 1981).

A number of studies have found that midwives considered their continuous presence was unnecessary (Bertsch et al., 1990; Hodnett & Osborn 1989). The Audit Commission (1997) found one in four women described being worried when left alone in labour. Supportive care from an experienced woman can reduce the need for intervention. A meta analysis of psychosocial support found the effect was much greater with continuous support provided by doulas (experienced lay women) compared to intermittent support by midwives and students (Scott et al., 1999). The present work found both qualitative and quantitative differences in the care provided by trained healthcare workers and experienced women.

An unobtrusive video camera was placed in the delivery room to observe the care of 20 mothers in labour, with the informed consent of the parents and the caregivers. Images are in black and white to accommodate changing light conditions, and are distorted along with the sound to preserve anonymity; despite this their dramatic impact is undeniable:

         1.  The mother eavesdrops on a professional discussion.
2.  The anxious body language of the father who is left with responsibility during a spell of fetal     bradycardia. Later he told how angry he felt at being left alone with his wife. The mother is not     relating to him; grandmother provides essential support.
3.  A mother who had had a previous stillbirth is left alone.
4.  The professional communicates anxiety; a tired midwife, after midnight, is uncertain what she     should do. No words pass; frequently information is given when monitoring is normal, but not when     it is abnormal.
5.  A mother using gas and oxygen for the first time is ignored by the midwife although having     difficulties. The father tries to help her.
6.  Unjustified written record keeping, every 10 minutes, taking the midwife away from the mother.
7.  The record writing is done at the bedside, with a great improvement in communication between     mother and midwife, eye to eye contact and questioning, and increased confidence.
8.  Only when a mother says – worried by the monitor – It’s scaring me now, does she get attention.     The midwife sits with her for only a minute, although it is known that mothers may, in these     circumstances, believe that their babies are dying, although scared to express this.
9.  It has taken a midwife an hour to familiarize herself with the paper work after a shift change. Their     has been very little conversation between the parents or with the midwife, but as soon she sits     with the mother the atmosphere is transformed; bedside manner is a phrase with real meaning.
10.  A newly qualified midwife given a complex case is too stressed to notice that the mother is having     to rub her own back; the mother is lying naked from the waist down and exposed. Where is respect     for the mother’s dignity? Is good caring practice being neglected in the over-academic training of     today’s practitioners?
11.  59 vaginal examinations were carried out in the 111 hours of observations. This midwife has not     washed her hands; there is no trolley and zero communication. We see a power relationship in     action, with the mother’s humiliation and loss of self esteem a likely result. A negative effect on     parenting is not improbable. Routine procedures have to be carried out with sensitivity.
12.  Grandmother is present during this vaginal examination, good communication and more hygienic     technique result.
13.  The father hides as his partner is prepared for epidural. Often too much is expected of fathers;     they may not understand her needs, may themselves be frightened, and so cannot give support.
14.  The father is left alone with a woman severely distressed by her pain.
15.  A mother the centre of attention and well supported when a friend is with her, and the father has     the confidence to be useful.

The benefits of supportive care and companionship extend beyond the intrapartum period. Hofmeyr and co-workers (1991) found that doula support in labour was associated with a higher incidence of breast-feeding, less anxiety, depression and higher levels of self-esteem. The mothers felt more satisfied with their partners and felt their baby was better, more beautiful, cleverer and easier to manage than the ‘standard’ baby. Surely all mothers should feel this way!

The present work raises questions of how much psychosocial support midwives can or want to give. It also questions whether the present – medico-legal – midwifery model of care provides the support women need. We are continuing to develop the support system to empower parents to be involved in decisions about their care. We think that this study shows that drawing the carer into the magic one metre space which holds the mother, and where interaction can take place, can act as a vehicle to support communication. We also use the partogram as a means of reassurance for parents and less experienced professionals. Sadly the findings of our investigation show that caring for the emotions of women in labour is at present inadequate in the UK. Questions are raised around the effect of stress and loss of confidence on the use of CS, the role of fathers and their education, the impact on the relationships between the parents, and between the mother and the child. Is there a need for experienced woman help (doulas) to support parents and midwives in the delivery room? Our final video clip demonstrates what a great privilege it is to take part in a happy birth event.

References.
Audit Commission (1997) First class delivery. Improving Maternity Services in England and Wales. London, Her Majesty’s Stationery Office.

Bertsch TD, Nagashima-Whalen L, Dykeman S, Kennell JH, McGrath S. (1990) Labour support by first-time fathers: direct observations with comparison to experienced doulas. Journal Psychosomatic Obstetrics & Gynaecology. 11: 251-260.

Goodwin C. (1981) Conversational Organisation: Interaction between speakers and hearers.
Academic Press, New York.

Hodnett ED, Osborn RW. (1989) A randomised trial of the effects of montrice support during labor: mothers’ views two to four weeks postpartum. Birth. 16 (4):177-183.

Hodnett E.D. (2002) Caregiver support for women during childbirth (Cochrane review). In: The Cochrane library, Issue 1, Oxford: Update Software.

Hofmeyr GT, Nikoden VC, Wolman WL, Charmers BE, Krauer T. (1991) Companionship to modify the birth environment: effects on progress and perceptions of labour and breastfeeding. British Journal of Obstetrics & Gynaecology. 98: 756-764.

Klein RPD, Gist NF, Nicholson J, Stanley K. (1981) A study of father and nurse support during labour. Birth. 8 (3): 161-164.

McIntosh J. (1988) Women’s views of communication during labour and delivery. Midwifery. 4:
166-170.

Scott KD, Berkowitz G, & Klaus M. (1999) A comparison of intermittent and continuous support during labour: A meta-analysis. America Journal of Obstetrics & Gynecology. 180: (5) 10541059.

Thomas J. & Paranjothy S. (2001) Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel caesarean section audit report. London, RCOG Press.

Discussion.

Debriefing between mothers and professionals after the birth can pre-empt symptoms of PTSD. Treatment of PTSD can be effective. It often coincides with depression. (JR) Private treatment has the better chance of working, as Trust representatives tend to be defensive. The literature on debriefing is pessimistic; it is too easy for the trauma to be reinforced by recollection rather than relieved. Issues of power and control around the way babies are treated can be very important in the causation of PTSD, especially in neonatal units.

The shock of premature birth places parents at risk of PTSD, and they desperately need support.

A plea from a GP for traumatic episodes to be included in discharge reports, so that the necessary support can be given.

The work patterns imposed on midwives in NHS labour wards are incompatible with the level of care to which we aspire; they need and deserve support to enable them to give good care. As an independent midwife in New Zealand, where good relationships with families were the rule, I was able to give care which came up to the best standard shown here. (KG) Resources are inadequate to enable reduction in work load for our UK midwives, unless doulas can concentrate on the psychosocial support of the mothers. Changes in attitude will need repeated exposure to our video evidence. (MH) Often experienced women, even mothers, came with labouring mothers but were not allowed into the delivery room. (KG) We are using a touch screen for data input at the bedside; this keeps the midwife close to the mother, who these days is familiar with this sort of technology.

Daniel Stern said that a woman in labour needs the support of 17 other women; the fathers are only good for practical assistance at this time.

Videos of labour at home would be an inspiring contrast to the cruelty seen in some of these clips. The medicalised environment of today’s hospital labour wards is itself a discouragement to good care. When there are complaints of poor care, the institution has to be prepared to say We’re sorry we kicked you, not We’re sorry for the pain you got when we kicked you.

A midwife who valued the touching role, but felt that others thought this was skiving, has left this sorry scene, and would regret her vital role of support being replaced by doulas.

As a woman enters a hospital to have her baby she leaves her sense of self at the door, she is disempowered, and this is aggravated when she finds herself needlessly trapped on a labour ward bed.

On empowerment: parents need to be helped to know what and whom to ask when they are in hospital. Mothers need help to ignore the machinery around them and to listen to themselves and tune in to their babies’ movements.

The chair emphasised the need for this news, good and bad, to be disseminated widely and not least among the obstetricians, few of whom attend the Forum’s meetings where they would be exposed to the real world of the touchy-feely.

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