Getting beyond the polarisation of childbirth: Second meeting
Author: Dr Carmen Power on behalf of the organising group for Getting beyond the Polarisation of Childbirth: Finding Common Ground
- Professor Lesley Page
- Professor Sue Ziebland
- Associate Professor Lisa Hinton
- Professor Charles Vincent (Chair)
Supported by the Sheila Kitzinger Programme at Green Templeton College
Process and preparation
A small group of key people, including those who had been invited to the first meeting, were invited to a follow-up meeting in a neutral safe space to discuss where there might be common ground and how to move forward. Once again, these people were experts from charities, universities and maternity practice as well as practitioners, opinion leaders and parents who had suffered perinatal loss. Collectively, they were known to represent divergent views. This meeting was organised to continue the project’s aims of bringing together people from different stand points (who might not normally share a platform) to have a calm discussion.
Invitations for a lunchtime meeting chaired by Professor Charles Vincent from the University of Oxford were sent to the carefully selected group and the invitation letter stated that we were inviting people who were willing to engage in seeking common ground for care that is human rights based, high-quality, safe and just, for both service users and staff. Attendees included Professor Lesley Page (midwife), Sue Ziebland and Lisa Hinton (social scientists and co-leaders of the project), other academics, working midwives, including a rep from Mimosa Midwives (an organisation for ‘culturally safe birth’), a communications expert, representatives from charities supporting parents and families who have experienced stillbirth and neonatal deaths (e.g. Sands), and the Birth Trauma Association, which advises and supports parents who have suffered a traumatic birth experience.
Attendees were invited to reflect on the following questions:
- What do you think the negative effects of polarised debates (in general) might be?
- Where do you think the main points of polarisation around maternity care lie?
- What do you think the negative consequences of polarisation in maternity care might be?
- Are you aware of any ‘taboos’ that may inhibit our conversations about maternity care?
The meeting: 1 October 2024 at Green Templeton College, University of Oxford
All invitees were prominent opinion leaders, and care was taken to ensure that different perspectives and experiences were included and that a safe space was created to support honest and respectful discussion and draw back from the extreme polarities of thinking.
Before the meeting, a couple of opinion leaders with different perspectives on the highly-charged, politically-polarised debate were interviewed using the same four questions to see if they shared any common ground. Reflections from these interviews were brought to the meeting table on 1 October to be shared and discussed. Areas of agreement between interviewees and attendees included the idea that polarisation can be hugely damaging to mothers, babies and healthcare professionals, all of whom essentially want the same outcome: a live, well and happy mother and baby. However, all agreed that ‘good maternity care’ with positive outcomes has become a difficult and emotive subject. There were also some slight differences in opinion between the interviewees. A prominent academic midwife felt that maternity care must be focussed on human rights and based on parents’ right to make informed choices around their birth while protecting the mother’s natural physiology as long as everything is going well and stepping in promptly if required.
Meanwhile, a former obstetrician who currently investigates safety in childbirth felt that the onus should be on healthcare professionals to work as a team, decide the best way to proceed, and present a clear, recommended course of action to the parents. If experts could not make their minds up, this may introduce doubt and uncertainty in parents’ minds when making decisions. However, he also stressed the importance of listening to women and involving them in the decision-making process. He told us this should include presenting a consensus view on alternative courses of action and their benefits and drawbacks to discuss with women.
Both interviewees agreed that scientists should be able to debate topics but that this debate becomes damaging if it gets personal, distracting from the much-needed focus on mother and baby and leading to a loss of confidence in the maternity services and loss of confidence that, as parents, you will be respected and listened to when going into maternity care. The former obstetrician agreed that obstetricians may never actually get to see a normal birth as midwives don’t trust them enough to let them in before it becomes an emergency – they are invited into the birth room ‘as little as possible as late as possible’. This creates obvious problems and might mean that doctors appear more medical, controlling and intervention-focused than they really are because there is no space for discussion by the time they get there. In addition, he pointed out that, as well as physical safety issues sometimes getting neglected in maternity care, women can feel a failure and ‘traumatised’ if they expect a normal birth and end up having complications. Further to this, he has emphasised that the need for safety should never be at the expense of other considerations, including personalised and continuous care, and that safety includes a strong element of mental and social well-being as well as physical well-being. In this sense, the former obstetrician and the academic midwife agreed on many levels. Any differences of opinion here perhaps lay in how strongly the academic midwife believes that – based on scientific evidence – physiological and psychological well-being actually promote physical safety.
The midwife felt that the starting point for overcoming the polarised debate should be to recognise that entrenched, ideological positions are not helpful and that 99% of parents and people working in maternity care, policy, research and education want the same thing: safe, positive maternity care with long-term benefits for women, birthing people, babies and families. However, she admitted that how we reach that point might differ and constructive conversation is the best way to progress this argument. In the meantime, polarised positions can end up forcing a choice between ‘safety’ and ‘personalisation’, whereas actually, these two ‘opposing’ sides of the debate are critical to one another – personalisation of care (understanding each individual mother’s and baby’s needs) is important to providing physically safe as well as physiologically, psychologically and culturally safe care. Maternity care that is relationship-based and personalised in this way is more likely to create a sense of trust and is, therefore, safer in every sense. She felt that one of the main areas of polarisation lies in this understanding of what we mean by ‘safety’ – whether it is an exclusive focus on avoiding death or whether that should be the minimum expectation and parents also have the right to make choices that feel psychologically and culturally safe for them. Shouldn’t safety be about thriving as well as surviving? Preventing trauma is less based on the type of birth a woman has and more on the type of care she received during that birth. Emotional and psychological safety leads to improvements in physical safety. When these human rights are removed for whatever reason (e.g. lack of resources for homebirths or an emphasis on induction for almost half of all births in order to avoid a very slightly increased statistical risk of stillbirth), women might decide that the only ‘safe’ way to avoid a traumatic birth experience or repeated trauma is to have an elective Caesarean section or even a freebirth. These choices may involve their own risks, some of which are not yet known.
The interviewees agreed that polarisation is about agreeing or disagreeing with the fixed position or ‘ideologies’ of another person with equally strong beliefs rather than seeking the positive outcomes everybody wants. Neither thought that maternity care should be about numbers – for example, both believed that Caesarean sections should happen when they are needed or if a mother requests them.
Turning to the wider group, a spokesperson from sands pointed out that, despite the wider aims for a positive birth experience, with potential short- and long-term benefits to mother and baby’s wellbeing, health and happiness, parents who have suffered perinatal loss cannot really be expected to see past the first step – walking away from maternity care with a live baby. And, of course, they will be even more distressed if they feel they might have listened to the wrong person and made the wrong choices. The lack of agreement between healthcare professionals and lack of communication leads to sub-optimal care with potentially devastating consequences. Everyone is unhappy with the current situation, and it does not work for families or for staff. ‘The art of caring for women and babies has been lost’ and, moving forward, we need to listen to women.
A bereaved mother who had three live homebirths and one hospital-based neonatal death (‘a tragic unavoidable accident’) lamented the disjointed care she had received, emphasising the importance of continuity of care – a ‘beautiful round circle’ of care that ‘should be standard’ – where the midwife in the room knows everything about the mother – her history, health and informed choices. She stated that this type of ‘best practice’ needs to be funded. Conflicting advice leads to confusion and blame (including parents self-blaming) when things go wrong.
A Black midwife and mother of a child damaged by NHS negligence talked about the ‘toxic’ blame and litigation culture in which midwives are now expected to work. Working to support Black mothers’ mental health through an emphasis on cultural safety, she argued the need for relationship-based care so that the most vulnerable women in our society are not left to birth alone or be damaged by their experiences (see most recent MBRACE report on 4 X the number of Black compared to white maternal and neonatal deaths).
A Birth Trauma Association spokesperson advocated for listening to women and respecting their choice as a basic human right, whether for homebirth, epidural or C section. In addition, health professionals need to learn to listen to one another – on both sides.
An NHS midwife of 40 years felt that we could be reaching a point where not receiving any interventions is considered as ‘compromising safety’. Women need personalised support to make informed choices based on the evidence rather than on fixed protocols to avoid litigation when things go wrong. Continuity of care has huge benefits of trust and being able to access appropriate care in a timely manner – for example if there is reduced foetal movement. She said, and was met with nods about the room, ‘It should be about staffing women rather than the building.’ If Midwife Led Units are closed down and all women are sent to the delivery suite, this becomes unmanageable. Everything gets sucked into the hospital. She also said, ‘We tell women who have obstetric or medical problems that a home birth is risky, but we don’t tell women who are healthy that they may actually be safer at home.’
A Cambridge University professor pointed out that a system that is so stressful for its workforce naturally loses empathy and kindness. An Oxford University-based social scientist felt there at least needs to be some regulation agreements within the NHS as things differ between trusts, making it harder for parents to believe and trust. Maternity inequalities are surely connected to maternity safety although at the moment these two large bodies of evidence do not speak to one another. Therefore, it is important to join up the evidence. We need to listen not just to parents but also to health professionals and what they want. In an ideal world, doctors could be included in a continuity of care model, but they generally do not have enough time to sit and watch a spontaneous physiological birth unfold. Another person said that when women around the country were asked what they wanted it was three main things: ‘Safety’, ‘Personalised care’ and ‘My ability to choose’. Therefore, a focus on one should not exclude the others. Continuity of care was considered an important way to facilitate all three priorities, but with a lack of leadership and vision this becomes difficult to manifest and, instead, maternity care is ‘dominated by dissonance’.
One of the organisers, Professor Lesley Page (midwife and nurse), felt it is important that we don’t just discuss issues and potential solutions but consider polarisation itself as an issue. Why, when we had some of the most progressive maternity policies in the world, were we completely derailed? We’ve been pushed into trying to solve a really nuanced and complex issue. People from opposing points of view should be brought together to find common ground. The trigger point is showing that we can bring a group of people together to talk respectfully and ensure that every mother, father and baby has the best start in life. However, each one is an individual and has different needs – we need cohesive continuity of care and informed choice. We also need restorative justice – nobody is saying sorry – and we need a fundamental change. Each family needs individual care. We must begin with honesty and reimagine the middle ground. How do we give babies the best start in life rather than simply making sure that every baby survives?
Another organiser, Sue Ziebland, a medical sociologist and Oxford professor, said that the problem with polarised debates is that nobody will admit any degree of uncertainty but ‘gets into a bunker and hurls missiles at the opposite side’. We are not very good at communicating risk and evidence when people have choices (not very good at providing unbiased information). People should be able to change their mind when things change. Women may feel abandoned if given big choices to make on their own. Staff can feel very relieved when the woman makes the ‘right decision’ but, if there is strong evidence, perhaps this should be communicated rather than overloading decision-making on the patients. The Sands spokesperson felt that potential solutions require good leadership, organisation and funding, and women and babies are perpetually under-funded.
Finally, it was agreed that a summary report leading to a policy or opinion piece bringing together disparate groups might be written to illustrate that ‘warring factions’ could be united in some kind of ‘common ground’.
