Full Transcript for 'Evidence-Based' Maternity Care: Limits, Bias, and How to Navigate It with Guest, Midwife Beth Russell

evidence that's informing our practice varies massively. 00:06:04.590 --> 00:06:16.590 So um the kind of population of pregnant women and birthing people are quite a difficult population to do research studies um for and on, um, because there's certain things that just aren't ethical to do. 00:06:16.590 --> 00:06:23.629 Um, one example might be, you know, um CTG machines were wheeled in without any kind of evidence behind them. 00:06:23.629 --> 00:06:43.230 Now that they are used, and um, in some circumstances are, you know, can be really, really helpful and beneficial, um, and we have we are building evidence around them, it's quite unethical to then just say, okay, we're gonna do like a uh um trial and look at what happens with this um, you know, perhaps quite high-risk population of people. 00:06:43.230 --> 00:06:52.669 If we um don't monitor them with the C2G monitor, and we do monitor some people, and let's see what happens because you're potentially putting women and birthing people and babies at risk. 00:06:52.669 --> 00:06:55.870 So there's those kind of ethical challenges that come in. 00:06:55.870 --> 00:07:03.549 Um, and lastly, I think, and there are probably many more challenges than this, but these are the kind of key things that come to my mind. 00:07:03.549 --> 00:07:11.789 The way that we talk about um evidence can have a massive impact on the person that we're sharing that information with. 00:07:11.789 --> 00:07:19.549 So if I say to you, Megan, um, okay, if you do X, your risk of Y happening doubles. 00:07:19.549 --> 00:07:26.350 That perhaps feels quite emotive and um and maybe feels like that risk increases massively. 00:07:26.350 --> 00:07:42.990 Whereas if I say to you, um that risk increases from one in 200 to 1 in 100, that to you might feel like a massive increase, or it might feel like, okay, well, I I think I still feel okay about that, because it's still, you know, 1% or less than 1%. 00:07:42.990 --> 00:07:45.230 I feel I feel okay about that for me. 00:07:45.230 --> 00:07:53.230 Um so, yes, we can practice evidence-based medicine, that is what's happening in midwifery and in maternity services. 00:07:53.230 --> 00:07:58.429 But what that actually looks like under the surface is really complex. 00:07:58.429 --> 00:08:07.950 And um, I think all healthcare professionals are trying to make sure that they're practicing with the best available evidence and that they're practicing evidence-based care. 00:08:07.950 --> 00:08:22.990 But what that feels like to be on the receiving end can vary massively depending on what's influenced that person that you're sat in a room with and what evidence it is that they're actually looking at, and how they're imparting that information to you as the person trying to make the decision. 00:08:22.990 --> 00:08:39.629 So it is, you know, maybe sounds really simple, but I think is one of the most complex and uh difficult things to navigate as um a person, you know, trying to make decisions

about your own birth and your own precious baby and what you want to happen in your experience. 00:08:39.870 --> 00:08:53.789 Yeah, I think that I mean there's so many threads that I could pull on from everything that you've just kind of covered, but I think hopefully something that people will be picking up on already is that it's it's not as simple as it sounds. 00:08:53.789 --> 00:09:07.870 And so your own opinions and priorities and wishes for your birth are a really, really important factor into what the right decision ends up being. 00:09:07.870 --> 00:09:13.389 It's not as simple as saying we've got evidence to say that this is the right thing to do, so everybody should do it. 00:09:13.629 --> 00:09:15.309 Yeah, absolutely. 00:09:15.309 --> 00:09:26.750 That I it's something that I think is so interesting because as healthcare professionals, we have a duty to make sure that the information that we're sharing is evidence-based, um, as unbiased as possible. 00:09:26.750 --> 00:09:32.509 Um, but for women and birthing people, you don't have to evidence your decisions to anybody. 00:09:32.509 --> 00:09:47.230 You know, if I as a midwife say to you, okay, um, so you're now, you know, 42 weeks pregnant, um, the recommendation is that I talk through offering induction of labour um to you know bring forth the birth of your baby. 00:09:47.230 --> 00:09:57.550 Um, I have to give evidence on why I'm recommending that and you know why why that um has has you know come to be the thing that I'm sat in a room recommending that you do. 00:09:57.550 --> 00:10:02.269 I also need to talk through with you what are your alternative options, what are your other reasonable alternatives. 00:10:02.269 --> 00:10:04.990 So, you know, could you choose to have a cesarean? 00:10:04.990 --> 00:10:05.870 Could you choose to wait? 00:10:05.870 --> 00:10:08.509 If you choose to wait, do you want to have additional monitoring? 00:10:08.509 --> 00:10:10.269 And what's the evidence around that? 00:10:10.269 --> 00:10:13.149 That's my job and my role to do as a midwife. 00:10:13.149 --> 00:10:24.670 As somebody coming into my you know clinic room to have that conversation with me, you don't need to bring me any evidence as to why you want an induction, don't want an induction, want a cesarean, don't want a cesarean. 00:10:24.670 --> 00:10:32.110 And it may be that to you, the research says one thing, but it actually doesn't really mean very much to you. 00:10:32.110 --> 00:10:43.629 I I know for me when I was navigating my pregnancy and birth, there were things that I thought the research and the evidence would matter a lot more to me, but actually I had this sense of no, this is what is right for me. 00:10:43.629 --> 00:10:51.629 I know, I know that you know there might be risks associated with X, Y, and Z, but I feel very strongly that for me and my baby, this is what's right. 00:10:51.629 --> 00:10:59.310 And I couldn't necessarily have articulated exactly why, but that's what I knew I was going to do, and I didn't need to explain that to anybody. 00:10:59.310 --> 00:11:06.430 Um, and nor should you know anybody listening to this podcast that is um expecting a baby and planning and preparing for what that might look like. 00:11:06.430 --> 00:11:11.710 You don't need to evidence um why you're making decisions to your midwife, to your obstetrician. 00:11:11.710 --> 00:11:22.509 If it helps to talk it through, great, do that, but don't feel under any obligation to come in with research papers to say I'm making this decision for X, Y, Z and other um, because it's about what's right for you. 00:11:22.750 --> 00:11:30.670 Yeah, and as you say, there are, there may be reasons that aren't scientific as to why you want something. 00:11:30.670 --> 00:11:46.190 And this is sort of when we talk about evidence-based research or evidence-based practice in our modern maternity system, that is coming from a place where scientific research trumps everything else ultimately. 00:11:46.190 --> 00:11:57.790 Um, and what is deemed to be kind of good high-quality research is deemed to be good, high quality within the eyes of kind of data, numbers, yeah, statistics, that kind of thing. 00:11:57.790 --> 00:12:04.110 But in reality, there's all sorts of other evidence um that might inform somebody's decision. 00:12:04.110 --> 00:12:09.710 That might be anecdotal, previous personal experience, like pass down cultural wisdom. 00:12:09.710 --> 00:12:13.629 Um, and this is often kind of discounted. 00:12:13.629 --> 00:12:19.629 And that research can, in the same way that scientific research, that research can help. 00:12:19.629 --> 00:12:23.790 And it may hinder somebody's choices or experiences. 00:12:23.790 --> 00:12:31.870 Um, but you are allowed to kind of be informed by a wider circle of information than just data. 00:12:31.870 --> 00:12:44.190 I think we can get really hung up in the kind of modern world of birth when, and you know, I'm well aware that I kind of contribute to this with podcasts and sharing lots of information, but it can be very like information heavy, data heavy. 00:12:44.190 --> 00:12:45.070 What's the research? 00:12:45.070 --> 00:12:54.269 And sometimes I think we expect to go to a research paper to look at what that research paper shows and for that to give us the answer. 00:12:54.269 --> 00:13:09.070 And sometimes it just doesn't, like even if the answer appears to be blatantly obvious on the bit of paper that you're looking at, even then you can still go, but this happened to my mum or that happened to my friend, or they got this and I want that, or whatever it is. 00:13:09.070 --> 00:13:15.870 And we're not arriving at birth as these kind of like blank computers ready to have data input into them. 00:13:15.870 --> 00:13:25.389 We're coming as like whole human beings with a world and a life full of experience, and we cannot help but be informed by all of that as well. 00:13:25.629 --> 00:13:26.190 Exactly.

00:13:26.190 --> 00:13:37.550 And also, I think when you go to look at a research paper, for some people that's going to be really easy because maybe that's what they do for work and that's the way that their mind works, and they find that really interesting. 00:13:37.550 --> 00:13:42.750 Um, I think for many people, trying to look at a research paper can feel really challenging. 00:13:42.750 --> 00:13:49.550 I sometimes think that some research is written so that it's really difficult to read. 00:13:49.550 --> 00:14:12.430 Like it's written using some really complex language and um trying to, even you know, as a as a midwife, as somebody who has had some training in this, and I would say, you know, as midwives, we get some training, but we could do with a hell of a lot more, as I think probably could our obstetric colleagues and other, you know, professions in uh other professionals working within maternity services. 00:14:12.430 --> 00:14:27.710 Because sometimes you go to look at a paper and it's really tricky to rapidly look at that, take from it the data and information that you want, whilst also being aware of any potential biases that have come into that research. 00:14:27.710 --> 00:14:39.629 Um, and so for you know, women and birthing people trying to make decisions, it's really it's really difficult if you're trying to wade through all of that to try and find an answer that resonates for you and works for you. 00:14:39.629 --> 00:14:58.190 And equally, much of the research that we have maybe looks at kind of specific circumstances, and we are, as individuals, interesting, wonderful people with lots more about us than just these particular risk factors that perhaps are being studied. 00:14:58.190 --> 00:15:06.670 There's lots more that kind of um affects how we feel about ourselves, affects how we feel about the decisions we're going to make, and that affects our like our health outcomes as well. 00:15:06.670 --> 00:15:13.230 And sometimes those just aren't accounted for necessarily in some of the research that we might be kind of looking at. 00:15:13.230 --> 00:15:21.230 Um, so yeah, I think that's it is um incredibly difficult when you're trying to kind of make sense of all of this data and figure out what's right for you. 00:15:21.470 --> 00:15:21.629 Yeah. 00:15:21.790 --> 00:15:39.389 And I think actually, you know, people like you out there sharing information on podcasts, it is so helpful because it makes some of that kind of research and conversation accessible to women and birthing people, where actually sitting down to try and read a paper is is going to be really difficult or is just not something that they want to do. 00:15:39.389 --> 00:15:46.269 But actually, you know, driving to work or on the train or on a walk, you can listen to a podcast and you can kind of take in perspectives. 00:15:46.269 --> 00:15:53.389 Um, but that's the key thing, I think, is you whenever you're listening to something or reading something, thinking about okay, where is this coming from? 00:15:53.389 --> 00:15:56.110 Um, you know, what's what's this person's kind of interest? 00:15:56.110 --> 00:15:57.550 What's the work that they've done? 00:15:57.550 --> 00:15:59.629 Um, does this align with my values? 00:15:59.629 --> 00:16:00.910 How do I feel about this? 00:16:00.910 --> 00:16:05.310 Like, we should never take anything um at face value. 00:16:05.310 --> 00:16:09.710 Like, we always need to kind of uh question a little bit, like what's what's gone into this. 00:16:09.710 --> 00:16:17.310 So I always say to you know, women and birth and people I support, both in the NHS and outside the NHS question everything, question the things that I'm telling you. 00:16:17.310 --> 00:16:21.710 If I'm telling you something and you're like, yeah, but like why or where does that come from? 00:16:21.710 --> 00:16:22.509 Ask me. 00:16:22.509 --> 00:16:31.710 Just because I'm saying it doesn't mean that it's right, and you know, I am human the same as everybody, you know, that you you're going to come into contact with in your journey. 00:16:31.710 --> 00:16:38.670 So ask us all the questions so that you can take from that the information that you need and make the decisions that are right for you. 00:16:38.670 --> 00:16:44.509 And that goes for you know, social media, listening to podcasts, um, you know, reading research, reading guidelines. 00:16:44.509 --> 00:17:08.509 Um, it be aware that that is um it's relevant to the kind of circumstance that it's I don't know if I'm kind of explaining that very well, but it's yeah, it you need to not take it at face back and consider the perspective from which that might have been written or spoken about um because bias is everywhere, it forms part of the human experience. 00:17:08.829 --> 00:17:09.389 Yeah, exactly. 00:17:09.389 --> 00:17:23.230 Um I always say it's yeah, considering the world view of the person that has written or created whatever, do they have uh another agenda or purpose for creating what they have created? 00:17:23.230 --> 00:17:39.629 Did they uh I was reading recently, um, Beth, you'll know, but if people are unfamiliar, there's a paper that came out recently called The Big Baby Trial, which was like a trial to see whether or not induction of labour improved outcomes for babies that were predicted to be large or not. 00:17:39.629 --> 00:17:50.750 Um, and when you kind of actually dive very deep and really, really break down the research, you can see that it was flawed and didn't show what they kind of had anticipated or hoped that it might show. 00:17:50.750 --> 00:17:59.789 Um, but even when you read the like write-up of it, it sounds like you're like, okay, so it does, it does do what it says. 00:17:59.789 --> 00:18:02.750 And then when you really break it down, you're like, but I don't think it does. 00:18:02.750 --> 00:18:06.110 Um, and there's there are some fantastic midwives who do this so well. 00:18:06.110 --> 00:18:06.750

So um Dr. 00:18:06.750 --> 00:18:13.150 Sarah Wickham, who's been on the podcast before, um, I think she did a fantastic breakdown of the big baby trial. 00:18:13.150 --> 00:18:22.269 So it's if you can find your reliable sources that don't have any agenda other than to be like, look, this is what it actually says. 00:18:22.269 --> 00:18:28.110 Um, that's they're the kind of places that you can go to go, okay, it looks like it says this. 00:18:28.110 --> 00:18:29.309 Is that really what it says? 00:18:29.309 --> 00:18:38.990 Who are my kind of trustworthy sources to actually see that research broken down um to understand what it actually means for me? 00:18:39.230 --> 00:18:45.230 Um my understanding of the big baby trial was that what they were looking at was is inducing a bit earlier. 00:18:45.230 --> 00:18:53.390 So I think it was at 38 weeks or between 38 weeks uh and zero days and 38 weeks in and three or four days perhaps. 00:18:53.390 --> 00:19:17.549 Um, it was looking to see if inducing uh women and birthing people whose babies were measuring over the 90th centile at that point was more beneficial, reduced the chance of shoulder dysotia, I think was the big one they were looking at compared to standard care, which for an overwhelming majority of the people that had standard care meant that they ended up having an induction of labour by around 40 weeks. 00:19:17.549 --> 00:19:25.069 So um it wasn't comparing induction of labour at early induction of labour at 38 plus four with waiting, really. 00:19:25.069 --> 00:19:43.230 So it's not, it doesn't give us the evidence that we might want to compare what happens if I wait for labour to start spontaneously versus if I'm induced at 38 plus three or four, it's looking at what happens if I'm induced at 38 plus three or four versus if I wait and perhaps have an induction at 40 weeks or even just a few days after that. 00:19:43.230 --> 00:19:50.589 It makes sense that even though they didn't find exactly what they were looking for, that they still published the research and tried to find things to kind of publish. 00:19:50.589 --> 00:20:00.670 But I think what's really difficult is that because there were certain expectations for the researchers about what they were going to find, that's then impacted how that's been written up. 00:20:00.670 --> 00:20:02.750 So it's really helpful, I think, having people like Dr. 00:20:02.750 --> 00:20:04.029 Sarah Wickham and Dr. 00:20:04.029 --> 00:20:23.309 Rachel Reed as somebody who I like often go to for like look looking at that kind of alternative perspective, particularly from a midwifery perspective, because a lot of the research that we've got and a lot of the research that um informs um guidelines is quite kind of um obstetric focused. 00:20:23.309 --> 00:20:38.670 There's some really great midwifery research that's gone on throughout the years, but we don't have as midwives, like the um obstetricians have the uh Royal College of Obstetricians and Gynecology green top guidelines, and they're really helpful for midwives as well. 00:20:38.670 --> 00:20:56.110 But the majority of the people that kind of author those are obstetricians, and as midwives, we don't really have sort of an equivalent, and so it's really helpful, you know, to me, certainly, as like somebody kind of trying to practice midwifery in this complex space that we're working within to have people like Dr. 00:20:56.110 --> 00:20:57.710 Sarah Wickham and um Dr. 00:20:57.710 --> 00:21:13.470 Rachel Reed to just give that kind of alternative perspective that has that they've you know got they've got that real um kind of academic knowledge and that ability to think critically and deeply about research, but they're also coming from that kind of midwifery perspective because it because it is slightly different. 00:21:13.470 --> 00:21:20.350 You know, the reality of what we do as midwives is different to what our obstetric colleagues do, and it's no better, it's just different. 00:21:20.350 --> 00:21:30.029 It's like you know, we're both caring for women and birthing people with the same ultimate aim to make sure that women and birthing people are um kept safe and well supported. 00:21:30.029 --> 00:21:43.150 Um, but the kind of the route to doing that is different because obstetricians are generally supporting people who have more complexities within their pregnancy, birth, or postpartum period, and so need that kind of um additional support. 00:21:43.150 --> 00:21:50.750 Um but yeah, we don't really have an equivalent of the RCOG guidelines that's kind of midwifery focused and really looking at midwifery research. 00:21:50.750 --> 00:21:54.350 And that I think that does affect does affect things. 00:21:54.350 --> 00:21:59.789 It affects the evidence that's available and the evidence that kind of makes it into guidelines as well. 00:22:00.110 --> 00:22:28.110 Yeah, and and on the sort of sticking on that topic of this big baby trial, for example, and this can be um, you could roll this out to pretty much any research that's been done um that might be quoted at somebody in their pregnancy, influencing a recommendation that might be made to them, is that when when clinicians are conducting research, somebody somewhere has to decide what it is they want to research. 00:22:28.110 --> 00:22:33.710 And usually that is comparing two different pathways of care, for example. 00:22:33.710 --> 00:22:44.269 Um, so in the big baby trial, for example, that would be comparing an earlier induction with the option of waiting, which would also include induction for other reasons. 00:22:44.269 --> 00:22:47.470 And that was the kind of two things that they chose to compare. 00:22:47.470 --> 00:22:57.470 Um, another research paper that this comes up for a lot of women is being recommended kind of um hands-on perineal support at the moment that a baby is being born. 00:22:57.470 --> 00:23:09.950 There was a trial into this kind of recently um called the

OACI trial, um, and they chose to compare hands-on support versus not hands-on to support to see if that made a difference in outcomes for tearing. 00:23:09.950 --> 00:23:16.190 So somebody somewhere has sort of hypothesized that these would be the two best things to compare. 00:23:16.190 --> 00:23:38.829 Now, somebody else could very easily have said, why don't we compare outcomes for babies that are predicted to be big based on whether they give birth in hospital or whether they give birth at home, or outcomes for tearing, whether women choose their own position or they are directed into a position by their midwife, or both of those things, whether they have continuity of care or meet a new midwife in labour. 00:23:38.829 --> 00:23:46.509 There are so many different variables that you could pick to make a comparison about whatever outcome it is you're trying to explore. 00:23:46.509 --> 00:24:08.110 And I think sometimes when we're presented with information, so say, let's say we're now recommending an induction of labour because we think in this bit of research that was shown to help, um, or we're recommending hands-on perennial support because there was tiny, tiny, minute difference that showed that that is going to be beneficial to reducing tearing. 00:24:08.110 --> 00:24:19.150 It is sometimes presented to women as if this is the end of science, as if this is the only thing that is going to impact those outcomes or those variables. 00:24:19.150 --> 00:24:35.309 Whereas in reality, there are so many other variables that will also be, you know, you're not giving birth in like a vacuum where the only thing that's happening is induction or not induction, or hands-on support or not hands-on support. 00:24:35.309 --> 00:24:48.589 Um and so I suppose it's just being wary that when something is presented as kind of a blanket, yes, do this, don't do that, that actually we we weren't comparing induction with home births. 00:24:48.589 --> 00:24:59.630 If you're planning a home birth and your baby's big, how helpful is that research to you, some as somebody who's wouldn't actually sit in the comparable group, if that makes sense. 00:24:59.950 --> 00:25:00.269 Absolutely. 00:25:00.269 --> 00:25:21.390 And I think particularly with that example, it's a really different thing having a hospital birth where your labour has been um induced or augmented with um perhaps intravenous oxytocin, um, where maybe you have an epidural on board or maybe you don't and um are giving birth on the bed. 00:25:21.390 --> 00:25:25.309 Like there's lots of other elements there that might increase the chance of tearing. 00:25:25.309 --> 00:25:35.870 The um, you know, induced labour meaning that your uterus is contracting differently to how it would if that had happened spontaneously, and so the force with which your baby is moving down is different. 00:25:35.870 --> 00:25:52.509 Um, the positions that you're in might mean that there's more stretch across your perineum, which maybe increases the chance of tearing, um, that uh not being able to kind of instinctively follow the position that you want to be in, like all of those things affect um the chance of tearing. 00:25:52.509 --> 00:26:16.269 And I think we do women or birthing people a disservice when we don't look at the nuances and consider, okay, this is what the recommendations are around hands-on or hands-off, but what feels right for you in your in your experience, that's what we as healthcare professionals should be doing is kind of looking at the women or birthing person in front of us and really asking, what's going to be right for you in this situation? 00:26:16.269 --> 00:26:18.910 We've got this bit of evidence, we've got this bit of evidence. 00:26:18.910 --> 00:26:20.990 Um, how does that how does that feel for you? 00:26:20.990 --> 00:26:24.589 And this is what I can see as really pertinent for you in your circumstances. 00:26:24.589 --> 00:26:36.509 But sadly, the reality is that as healthcare professionals working within the NHS, we often don't have time to make sure that we are as up to date on all of that evidence as we should be and as we would like to be. 00:26:36.509 --> 00:26:44.269 Because I think that there are a huge majority of healthcare professionals that really blooming well try to be up on that research and evidence. 00:26:44.269 --> 00:26:46.829 Um, but it is incredibly challenging. 00:26:46.829 --> 00:27:05.789 I think since having my daughter, I feel all the more aware of just how challenging that is because before she was born, I spent an inordinate amount of time reading and you know, like immersed in things to do with midwifery because I I love it and I find it fascinating, really interesting, and I wanted to make sure that my care was as up to date as possible. 00:27:05.789 --> 00:27:10.029 Now I have much less time available to me to do that. 00:27:10.029 --> 00:27:39.470 And so if it's my legal obligation to provide evidence-based, unbiased care, surely my, you know, the the NHS and the NMC and all of the kind of bodies that are there to support healthcare professionals and therefore support women and birthing people should make it possible for us to have that information at our fingertips, have the time to sit and really look at the individual in front of us, listen to what's going on for them and make sure that they can make choices that are right for them. 00:27:39.470 --> 00:27:44.430 Um and sadly, the reality is that often isn't happening because appointments are short. 00:27:44.430 --> 00:27:55.870 The kind of headspace that we have as professionals to critically analyse or critically kind of think about what's going on for a woman or birthing person is more limited than it should be. 00:27:55.870 --> 00:28:04.990 And also, you know, um, as healthcare professionals, we are navigating a space where there sometimes are quite difficult and challenging things that happen. 00:28:04.990 --> 00:28:24.910 And so we may have

either experienced perinatal trauma ourselves as people kind of come in through the system, we may have walked alongside somebody as they have had a traumatic experience, and that really impacts how certain risk factors perhaps feel as a professional in the same way it does as a women or birthing person. 00:28:24.910 --> 00:28:38.269 If something's happened to you before, happened to somebody that you love, and it it and it feels very present, whilst the statistical risk might feel small, how it how it actually feels for you as an individual is going to be much, much bigger. 00:28:38.269 --> 00:29:05.390 And that's the same for healthcare professionals, and we're not really afforded the space to kind of um debrief and um unpack when we've been involved with you know difficult circumstances that have happened for families we're supporting or in our personal lives, because of the nature of the NHS, there isn't really that space to truly unpack it and to make sure that the next person that we're going to support, we're not bringing all of that baggage into the room with us. 00:29:05.390 --> 00:29:12.269 Um and I think that can be quite a hard thing to hear as women and birthing people kind of entering the system. 00:29:12.269 --> 00:29:15.150 And I wish that that wasn't the case. 00:29:15.150 --> 00:29:23.950 I wish that people didn't have to think about how do I protect myself if I'm being given information that is biased or I'm being pushed in one direction or another. 00:29:23.950 --> 00:30:04.430 But sadly, the reality is because healthcare professionals aren't often as well supported as they should be psychologically and in terms of having the information at their fingertips, it benefits us as women in birth and people moving through the system to do that for ourselves as much as possible so that we can take the bits of information that feel helpful from that healthcare professional, reflect on the bits where maybe we've thought something didn't just didn't feel quite right to me there, so that we can kind of go away and reflect on the information available to us and make decisions that feel right for us rather than um feeling kind of pushed one way or another um by by the system. 00:30:04.430 --> 00:30:08.110 I wish, I wish we didn't have to do that, it shouldn't be that way. 00:30:08.110 --> 00:30:11.710 Um but sadly I think that is the reality at the moment. 00:30:12.029 --> 00:30:13.789 Yeah, I yeah, totally agree. 00:30:13.789 --> 00:30:23.630 And on that sort of you we we can go in assuming that everything we're gonna be receiving is going to be ultimately within our best interests. 00:30:23.630 --> 00:30:31.630 And I I know that I sometimes offend midwives and doctors when I say this, but not all the guidelines are written with women's best interests at heart. 00:30:31.630 --> 00:30:41.390 Some of them are written with financial interests or economic or systemic or whatever it is else that's influencing the recommendations that are being

made. 00:30:41.390 --> 00:30:53.309 Um, and something that kind of simultaneously makes me laugh and eye roll at our maternity system is how it claims to be evidence based, yet it repeatedly ignores like sound evidence showing. 00:30:53.309 --> 00:30:54.990 How to improve outcomes. 00:30:54.990 --> 00:31:07.309 Like continuity of care, facilitation of out-of-hospital birth have been shown time and time again to improve outcomes for all women, as in all demographic, all demographics of women. 00:31:07.309 --> 00:31:13.710 And yet they aren't accessible for most women giving birth in this country at this moment. 00:31:13.710 --> 00:31:27.630 And it is, you know, that's of course not a fault of the individual clinicians practicing within the system, but this much wider conversation that is happening at the moment from kind of government and funding level downwards. 00:31:27.630 --> 00:31:39.150 But we say we run this evidence-based system and we ignore the kind of real nitty-gritty of like, well, this is a very simple way that ultimately would save the NHS money. 00:31:39.150 --> 00:31:47.150 Um, but we don't practice it because of that bias that is influencing the people that are at the helm of decision making. 00:31:47.470 --> 00:31:48.190 Absolutely. 00:31:48.190 --> 00:31:52.589 And I think sometimes the NHS is quite short-sighted. 00:31:52.589 --> 00:32:02.110 There will be things brought in at the drop of a hat to um respond to um a serious incident. 00:32:02.110 --> 00:32:21.390 Or I remember um when there was the draft Nice Guidance that came out, I can't remember what year it was, probably about five years ago now, where um you know it the MACE um statistics had shown that black women were five times more likely to die in in childbirth than their white counterparts. 00:32:21.390 --> 00:32:26.829 And this draft Nice Guidance on induction of labour was happening quite soon after that, I think. 00:32:26.829 --> 00:32:33.309 And one of the responses was okay, so let's induce black women because that will reduce the child. 00:32:33.309 --> 00:32:47.390 And by doing that kind of knee-jack reaction, just completely failed to see the much, much, much bigger problem that systemic racism is ever present in our maternity services. 00:32:47.390 --> 00:32:58.190 And actually, that recommendation was a part of the problem because it was saying, you know, black and brown women and birth and people's bodies are dangerous somehow, which of course is absolutely not true. 00:32:58.190 --> 00:33:06.269 It is the systems and structures that black and brown women and birth and people have to move through that are the risk, dangerous thing. 00:33:06.269 --> 00:33:12.350 It's the inherent bias that is at play within systems and within practitioners as well. 00:33:12.350 --> 00:33:18.269 Because I think if you asked most um healthcare professionals, they'd say, No, I'm I'm not racist. 00:33:18.269 --> 00:33:22.990 I, you know, do my absolute best to make sure that

everybody in my care receives good treatment. 00:33:22.990 --> 00:33:33.309 But yet we see, you know, in the the most recent MBA statistics, yes, there's some improvement, but not when you look kind of deeper, not really. 00:33:33.789 --> 00:33:37.470 Yeah, because it's more that's that was more actually with failing everyone a bit worse. 00:33:37.470 --> 00:33:39.950 So the difference has become less, but yeah. 00:33:40.350 --> 00:33:41.230 Actually, yeah. 00:33:41.230 --> 00:34:04.350 And then um you look at the most recent um black maternity experiences survey that five times more did, and there's still those same recurring themes of black women asking for pain relief and not receiving it, um, looking around the ward and seeing their white counterparts being provided with more breastfeeding support, more uh time. 00:34:04.350 --> 00:34:35.309 And so, you know, maternity stuff might have the very best intentions, but there's more, much, much, much more that needs to go on at kind of structural and systemic levels to make sure that actually the care that's being provided to all women and birth and people is equitable, and that's not by putting high-risk labels on black and brown women or by you know putting in blanket policies that um you know mean that people are set on certain pathways. 00:34:35.309 --> 00:34:47.309 It comes back to that individualised care, and um it's a it's a duty that all of us have because our duty as healthcare professionals is to make sure the women and birthing people in our care are kept as safe as possible. 00:34:47.309 --> 00:34:59.710 So we all, every single one of us that works within the system, have a duty to kind of look inwards and do the work to make sure that we are the safest pair of hands that we can be for the women and birthing people that we serve. 00:34:59.710 --> 00:35:25.069 Um, and I think that we see that same bias play out in research in that there are um demographic groups that are not um don't form a part of certain big research studies, which then how can you then apply that research to somebody who um who you know never formed a part of the um the demographic of people that were studied? 00:35:25.389 --> 00:35:26.349 Yeah, absolutely. 00:35:26.349 --> 00:35:48.349 I've been rereading this book at the moment called Closure by Becky Reed, um, which if you're if you're listening and you're not familiar with this story, this was about the closure of um something called the Albany Midwives Practice, which was a kind of continuity team of midwives um in London, which was shut down a decade or so ago, um, despite it improving outcomes for women across the board. 00:35:48.349 --> 00:36:11.469 And something that really stood out to me in that story is that the vast majority of women cared for by this group of midwives were from a very socially deprived area of London and were black or mixed race, and the care that they received from these midwives reduced preterm birth, Nico admission, intervention rates, tearing, literally improved outcomes in every measurable way. 00:36:11.469 --> 00:36:19.069 And here we are 10 years or whatever later, with a government asking, how do we improve outcomes for black women? 00:36:19.069 --> 00:36:29.789 And you're like, there is quality evidence staring us in the face, and we're ultimately choosing to ignore it. 00:36:29.789 --> 00:36:40.989 And then there was another bit of research recently that's showed very similar thing that continuity of care in particular for um minoritized ethnic groups improves outcomes reduced stillbirth. 00:36:40.989 --> 00:36:45.549 Like it was it's there, and we're not acting upon it. 00:36:46.189 --> 00:36:51.709 And it's infuriating because what what could be what could be more important, you know? 00:36:51.709 --> 00:37:10.109 Like that's the I think continuity has kind of got a bit of a bad rap over the years because uh the way that it was implemented in across the country um varied quite significantly and uh the experiences for midwives varied quite significantly. 00:37:10.109 --> 00:37:15.789 And I think my I've had some experience working in a continuity of midwifery care team. 00:37:15.789 --> 00:37:33.709 Um, it was the happiest I've ever been as a midwife, but it also broke me a little bit because I tried to continue giving the level of care that I wanted to give in a system that didn't really give me the time and ability to do that, which ultimately led to me you know burning out. 00:37:33.709 --> 00:37:39.149 Um that's a lesson learned and something I will always do my best never to never to kind of do again. 00:37:39.149 --> 00:38:09.149 But um continuity is uh incredible for women and birthing people and can be incredible for midwives, but I think how um it's done is so important that there needs to be kind of real structure in place to support um midwives to make sure that their time um that they're given the time that they need to provide the level of care that continuity um asks, and you know that is so important that that is made available to women and birthing people. 00:38:09.149 --> 00:38:30.429 Um but but yeah, I I think it is um something that needs massive, massive investment, more investment than was um kind of made available in the last kind of attempt at rolling out continuity across the country, and and that's so often the thing is uh when we look at it, it often in some way comes back to money. 00:38:30.429 --> 00:38:38.589 It is expensive to um to roll out really effective continuity of care teams across the country long term. 00:38:38.589 --> 00:38:44.269 I'm sure we would see incredible improvements in outcomes for all women and birthing people. 00:38:44.269 --> 00:38:57.789 Um the the challenge is as usual that if it's not kind of measurable within a really short space of time, it's um the next thing comes along and there's more you know focus and emphasis put on the next thing. 00:38:57.789 --> 00:39:20.989 Um I think something that's important

to kind of know for people kind of navigating the system is that if you if there's a reason that you really need continuity of care, um perhaps you've had really difficult experiences um in the maternity system before or in the health system generally, it's something that you can ask for and the trust should do their best to kind of support you with. 00:39:20.989 --> 00:39:27.709 If there's not the kind of models of care available where you can have the same midwife through pregnancy, attend your birth and then postpartum. 00:39:27.709 --> 00:39:29.230 Perhaps there's other ways. 00:39:29.230 --> 00:39:40.349 Perhaps you have as much as reasonably possible one or two midwives that you see during your pregnancy, one or two, maybe three midwives postpartum, because it can that can be tricky with shift patterns and things. 00:39:40.349 --> 00:39:55.149 Um, but kind of a minimal number of midwives that you see that you are able to build up a bit more of a relationship with, and having the opportunity to go into the hospital to um just kind of know what it's like walking through those doors to be greeted by the maternity staff there. 00:39:55.149 --> 00:40:02.909 Um, because yes, maternity units were often so big that you couldn't possibly know every member of staff that might possibly care for you during labour. 00:40:02.909 --> 00:40:14.429 But perhaps if you've been there and you've seen some smiling faces and people show you round to kind of talk through, yeah, this is where you would come initially, and then you know, these are one of the rooms that we take you through, so you can see what that might look like. 00:40:14.429 --> 00:40:18.029 In a system where at the moment continuity isn't widely available. 00:40:18.029 --> 00:40:29.709 Sometimes those kind of small ways can be really helpful, particularly if you've you know had previous birth trauma, or there are things that are kind of really affecting your mental health and well-being when you're considering preparing for your birth. 00:40:29.709 --> 00:40:48.349 It's so important that you're enabled to feel safe and well-supported as you're approaching your birth, because you know, it we only do each birth once, and every single one of us deserves to be made to feel phenomenal throughout that experience. 00:40:48.349 --> 00:40:56.669 You know, it's it's such a huge transitional time, and it's a time that some people absolutely love and some people really don't, and have a really hard time through. 00:40:56.669 --> 00:41:01.869 And whichever end of that spectrum we're on, we deserve to be held and well supported through that. 00:41:01.869 --> 00:41:15.389 And although the system is um not functioning in the way that we would want it to in many aspects, in many aspects, there are ways to kind of navigate it to have the most positive experience possible. 00:41:15.389 --> 00:41:27.069 And there are so many midwives, obstetricians, anethetists, maternity support workers that so want for you to have

the best experience and will do everything they can to make that happen. 00:41:27.069 --> 00:41:39.549 Um, I think that almost all maternity care professionals go into this because they they love it, they want to really support women and birthing people, but they are practicing in really challenging circumstances. 00:41:39.549 --> 00:41:45.149 And um, that shouldn't be your responsibility as somebody navigating the system to manage. 00:41:45.149 --> 00:41:52.269 But I think knowing about that can help you to kind of then figure out, okay, yeah, when I met with that midwife, I felt really heard. 00:41:52.269 --> 00:42:01.709 Maybe I can ask to see her again, or yeah, when I had that appointment with that obstetrician, I felt like they really listened to my choices, and the way that they explained the risks and benefits of the options made a lot of sense to me. 00:42:01.709 --> 00:42:08.750 Maybe I can ask to see them again, or maybe they could just like print out what they wrote down about our consultation so I can go over it in my own time. 00:42:08.750 --> 00:42:22.750 Whatever it might be, there are these small ways that we can um use the system to our advantage to really make sure that our experience is a positive one, whilst knowing that it is imperfect and it has been for a really long time. 00:42:22.989 --> 00:42:36.829 Yeah, no, I think that's it's a really helpful place to kind of start to start to wrap up, I think, is actually just really understanding the kind of practical ways that you can step into an imperfect system and get the most out of it. 00:42:36.829 --> 00:42:43.389 Because the, you know, if you're still listening to this podcast, it's because you're giving birth within the maternity system, you haven't decided to reject it completely. 00:42:43.389 --> 00:42:59.549 Um, and going, okay, these knowing that you can kind of pick and choose which bits you feel helpful to you and which bits you don't, it is not like, oh, I don't know, it's like a Victorian school where you have to turn up and if you don't do exactly what that you're told, then you're gonna get in big trouble. 00:42:59.549 --> 00:43:07.869 Like it is a service that is working for you, as you're not a kind of minion working within it. 00:43:07.869 --> 00:43:11.230 You are somebody that is choosing to receive this service. 00:43:11.230 --> 00:43:17.549 Um, and in the same way that you could walk around a shop and pick and choose which things you're gonna take and which things, you know, pay for. 00:43:17.549 --> 00:43:22.429 Um, but like take the bits that feel helpful to you and kind of leave the rest. 00:43:22.429 --> 00:43:33.389 And just, yeah, those little tricks of, you know, it might be that that that your local trust don't offer a continuity team, but it might be that Beth, the midwife, is does a clinic every Monday. 00:43:33.389 --> 00:43:39.389 So if you book in for your appointments every Monday, you're gonna get continuity without it being called a continuity team. 00:43:39.389 --> 00:43:45.149 And so if you meet a midwife that you click with and you say, Oh, do you always do this clinic on a Wednesday? 00:43:45.149 --> 00:43:50.829 Then say, Okay, great, can I book into your clinic on a Wednesday for my next appointment? 00:43:50.829 --> 00:44:06.589 And it's it's sort of sneaky things like that that can help us benefit from these things that have been kind of clearly evidenced to be good, um, even if they're not kind of on paper on offer. 00:44:06.589 --> 00:44:14.829 And I think the other thing is actually even if you're not getting continuity from your midwife, it's extraordinarily rare to get continuity from an obstetrician. 00:44:14.829 --> 00:44:20.909 Um, actually, I did have that in my second pregnancy, and oh my god, if everybody could have that, it is so good. 00:44:20.909 --> 00:44:25.869 Um, but the it's about getting continuity from somewhere. 00:44:25.869 --> 00:44:38.429 So whether that's like actually trying to arrange appointments so that your birth partner can come with you or a person can come with you that's kind of see that's kind of um what's the word for it? 00:44:38.429 --> 00:44:44.029 Seeing, observing, witnessing your experience of pregnancy. 00:44:44.029 --> 00:44:53.230 So that when you're going into birth, if that person is with you, they they know what you've been up against, they know what decisions you've made, they know how you've been feeling. 00:44:53.230 --> 00:45:09.709 And it's that that communication and that relationship building can come from other places, not just the kind of clinical care team, but it might be that you've been able to hire a dualer, or it might be just a yeah, a kind of friend or family member that has provided that. 00:45:09.709 --> 00:45:11.629 I always think it's helpful in labor as well. 00:45:11.629 --> 00:45:24.269 Somebody that's seen you from the beginning of labor the whole way through has a very different understanding of where you're at to if you're turning up in the full throes of labor to a birth centre or a labour ward or a midwife's arriving at your house. 00:45:24.269 --> 00:45:29.789 Um, it's somebody else understanding the whole picture so you don't have to hold that on your own. 00:45:29.789 --> 00:45:30.589 Yeah. 00:45:30.589 --> 00:45:31.709 Amazing. 00:45:31.709 --> 00:45:33.469 Well, I think we might wrap it up there. 00:45:33.469 --> 00:45:52.429 I think hopefully that hopefully that was an easy to understand unpicking of like why we need to be thinking a little bit more critically, a little bit more holistically about the information that we're receiving and yeah, what we can do to remain kind of centered in those decisions, making sure they're really kind of personal to us. 00:45:52.429 --> 00:45:54.909 So thank you so, so much for joining me. 00:45:55.149 --> 00:45:56.349 Oh, well, thank you, Megan. 00:45:56.349 --> 00:45:59.549 It's been such a privilege to be able to come on the podcast. 00:45:59.549 --> 00:46:08.829 It's the podcast I listened to in my pregnancy to support me, and it's um the podcast that I've recommended to many women in birthing people that I've supported in my practice as well. 00:46:08.829 --> 00:46:10.989 So, yeah, really, really honoured to have had the chance. 00:46:10.989 --> 00:46:11.230 Thank you. 00:46:11.629 --> 00:46:12.589 I really appreciate it. 00:46:12.589 --> 00:46:13.869 Thank you so much. 00:46:13.869 --> 00:46:15.389 Bye. 00:46:15.389 --> 00:46:27.069 Thanks so much for listening to the BirthEd podcast. 00:46:27.069 --> 00:46:34.109 I know you're already feeling how much of an impact these conversations are having on your own pregnancy and birth plans and parenting journeys. 00:46:34.109 --> 00:46:39.549 And I want that impact to be as far reaching as possible, but I can't make it happen without your help. 00:46:39.549 --> 00:46:50.589 If you've got two minutes now to five-star rate and review the episode or send it to a friend, this is what helps us creep up the podcast charts and into the ears of more and more parents to be. 00:46:50.589 --> 00:46:54.429 Together we really can change the face of birth as we know it.