Misconceptions about maternity care

I thought it would be good to start this section with dispelling some myths and misconceptions about maternity care.

Lots of people have stress and difficulty sorting out their maternity care because of these misconceptions. Understanding how the maternity care system works will help you navigate your care, and feel happy and confident.

1. MYTH: Doctors are in charge of midwives.

Midwives are autonomous, and report to the head of midwifery, who reports to the head of women's and children's services, as does the lead obstetrician. Obstetricians report to the lead obstetrician. Midwives do not get permission from obstetricians. Midwives are in charge of midwife related areas; obstetricians are in charge of obstetrician related areas. They work together in multi-disciplinary teams.

Side note: You can get consultant midwives as well as consultant obstetricians. If you need to get something sorted often the best person to talk to is the Head of Midwifery, or the Consultant Midwife.

Midwifery led units, aka birth centres, are run by midwives, and mostly midwifery led care takes place. Obstetricians do not have a say at what goes on in them, except as part of a wider multi-disciplinary team. The most senior person is a midwife.

Labour wards are obstetric led units. Midwifery led care and obstetric led care take place in labour wards. Obstetricians and midwives decide on the policies for the obstetric led unit. The most senior person is the senior midwife and the senior obstetrician. Senior obstetrician may take a 'ward round' and keep overview of all the people giving birth, which means, in reality, it becomes obstetric led care.

Obstetricians can't 'give permission' to give birth at home or in a birth centre.

So, although a midwife might say to you that you need to see the obstetrician to get the okay to give birth in the birth centre, or at home, what they mean is that it is hospital policy to make sure you have discussed it with an obstetrician, not that the obstetrician gets to say yes or no.

You don't need to have an appointment with an obstetrician to get a home birth, a vaginal birth, a water birth, a birth centre birth. These are all your decision, and these all fall under midwifery expertise. You may wish to discuss various aspects of your situation with the obstetrician, but they are not the experts in those things I've listed, and you do not need to get their permission, or to convince them of the worthiness of your plans, or how sensible you are, or reasonable.

All that being said, sometimes you come across a midwife that is full of fear, and ready to intervene early, and an obstetrician who is supportive of stepping off the standard path.

2. MYTH: If you have a consultant obstetrician appointment you will see the named obstetrician.

The name on the letter relates to who is the doctor in charge of the clinic, but there may be three or four obstetricians, or trainee obstetricians, working at the clinic. You may see a different, less senior consultant, or a trainee obstetrician, or a junior doctor. It is perfectly reasonable to ask for the job title, and to ask to speak to a more senior person, or to get a different opinion.

It is also worth knowing that your appointment time may be given to a whole group of people, for a block of time. So if the appointment is for 10.00am, it may actually be for a block that runs from 10.00-12.00, and you will be seen sometime in that time window.

3. MYTH: If you compromise you can get some flexibility in the hospital policy.

Couples often think that if they compromise then that will show that they are reasonable people and that the doctor/midwife will be more likely to compromise back, and support their plans.

Midwives and doctors usually stick rigidly to hospital policies, even when they contradict each other. They don’t take a holistic view.

If you compromise on something to show willing, in the hope that the doctor or midwife will be flexible, it is unlikely to work.

But just because they are stuck to follow the policy doesn’t mean you are, just say no. "I politely decline." "I understand that is your policy but I still want x,y,z." Don’t argue or battle. Go higher, speak to the Head of Midwifery.

4. MYTH: Obstetric led care is safer.

If you view maternity care as a hierarchy then it would seem that obstetrician led care is best. It is sometimes perceived as being more modern, after all they have all the gadgets, right? But obstetricians are not the experts on normal physiological birth. They are the experts on helping birth when it gets stuck, or supporting women with complicated medical conditions. They are surgeons. Obstetricians' experience comes from intervening when birth is not going smoothly.

Obstetricians are taught that birth is only normal in retrospect. They are ready to intervene, or even to take steps just in case. They don't sit with women. They pop in and out as needed. It is a balance of too much, too early, or too little, too late. They tend to err on the former.

Midwives are taught to keep birth as physiologically normal as possible. They know how birth unfolds. They sit with women for the hours and hours of birth. They know low key steps to take before needing to ask for more specialised help. Their most important piece of equipment is their eyes (followed by their ears, nose, hands, and intuition). They know how to watch and wait. But they don't take risks, they call for back up when needed.

It is good to have both these professionals, both these perspectives. We are very lucky in the UK to have a very well integrated system, where midwives and obstetricians work very closely together.

But midwifery led care is safer. Midwifery led care is linked to fewer stillbirths, fewer premature or low weight babies, and fewer interventions.

We are mammals. Any vet knows that too much interference in the pregnant or birthing mammal can lead to the very problems it was trying to prevent. This is why it is important to get the balance right for you.

This is a great article: Safer birth in a barn? It is a great story of an midwife visiting a stud farm, when a mare was in foal.

Obviously, sometimes birth does need help. Sometimes we have complicated situations where obstetric led care is not only helpful, it is a life saver.

5. MYTH: Hospital policy is based on the best evidence.

Actually a senior UK obstetrician, Amali Lokugamage, did an analysis of the guidelines for maternity care by the Royal College of Obstetricians and Gynaecologists and found that only 9-12% of them were based on the best quality evidence and about 40% where based only on expert opinion, the lowest level of evidence.

Obviously there is value in the expert opinion, but it must be remembered that this will only have included obstetricians, and not the experience and knowledge of midwives and users of maternity care.

Many of the most common interventions in maternity care are not evidence based: episiotomy, continual fetal monitoring by CTG (cardiotacograph), giving birth on obstetric unit (labour ward), restricting food for higher risk women, to name just a few.

Hospital policy is the result of taking population level data from available research and national guidelines, and a group of obstetricians and midwives deciding what in their opinion is the best decision, the decision they would make, reduce chance of litigation, reduce their fear and anxiety, and be easiest to organise.

It is a good starting point, for individual care, but it is extremely paternalistic to insist that this decision is best for everyone. "We've decided what's best for you."

  • Population level data is not relevant to everyone, with different situations, or different ethnicities, for example.
  • You may have other, different factors in your decision making, such as older children, or other caring responsibilities; needle phobia; be a survivor of sexual abuse. And you may give a different weighting to the factors.
  • View risks differently. Some people love sky diving. It's not for me. It is not a risk I would take, but others would. I would not risk the iatrogenic risks of a hospital birth, compared to staying at home.
  • Because doctors only see the births that need help, it skews their perspective. They also are very comfortable with some interventions, because they do them all the time. You may not share that perspective.
  • Hospital policies also factor in practicalities for the institution. For example, gestational diabetes testing. It is easier for the hospital to have a clinic, and get everyone to come in to do a glucose tolerance test (drink high glucose drink, have blood tested before and after), than to do home finger prick testing. Both are equally valid. You as an individual may prefer finger prick testing, especially if transport is difficult, or you have older children.
  • Sometimes good quality research is ignored. For example, there is no evidence that continual electronic fetal monitoring in labour improves outcomes; there is good evidence that it is no better than intermittent auscultation (listening in intermittently with a dopler or pinard), and plenty of evidence that it dramatically increases the chance of a caesarean. Yet it is still used.
  • Some national guidelines are ignored. NICE guideline on caesarean section states that all women should be informed that having another woman with them in labour reduces their chance of having a caesarean. Were you told that? I have yet to meet a woman who has been told this by her midwife or doctor. Yet this is recommendation has top level evidence to back it.

Midwives and doctors sometimes feel under pressure to get 'compliance' to policies. But that doesn't mean you have to comply. If their policy does not have provision for your wishes it is breaking human rights law, consent law, and NHS guidelines. Your individual midwife may feel she has to stick to the policy but you don't. Coercion is not consent.

The Better Births report found that individualised care, rather than blanket policies, led to better outcomes for women and babies.

Have you thought about writing your own policy?  In fact, that's what a birth plan is.

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