Aquabirths’ birth pools are designed to provide space and support for an active birth, but for women who do not want to use a birth pool but still want a hospital birth, or for the very rare woman for whom it’s not medically possible to use a birth pool, this fabulous video provides ideas of ways to use the hospital room space to lean, rock and move. Don’t miss it!
Alongside midwifery units are defined as midwife-led units which are on the same premises as an obstetric unit (OU). They are usually next to the OU and may have come about following restructuring of the OU.
A follow on study from Birthplace 2011 investigated the way that alongside midwifery units are organised, staffed and managed, as well as the experiences of the women who use them and the staff who work in them.
The researchers looked at 4 different alongside midwifery units. They interviewed midwifery staff and service users, and also those in a management and organisational role. What became clear from the study was the fact that midwives working in alongside midwifery units were able to practice more autonomously, using their own clinical judgement. This is how all midwives, who are all autonomous practitioners, should be able to work, but obstetric units often discourage or reject this aspect of the midwifery role. Midwives also reported how they valued the work environment and culture, although the study did acknowledge that there was a need to ensure that midwives were supported to continue to develop their confidence, which is not a surprise as so many would have been trained in a far more repressive environment.
Another challenge for the sustainability of the alongside midwifery units was the fact that of all of the women who were considered to be good candidates to birth there, only a third ended up doing so. This study does not look at why this might be, but we know from feedback from women that very often they are simply not made aware of the midwife led unit in their area, so they did not have the opportunity to consider it for their baby’s birth.
Ultimately, Aquabirths would like to see the facilities which are commonplace within a midwife led unit such as birth pools, birth couches (link to softbirths), mats and birthing balls, as well as the environment which is designed for calm, and to promote oxytocin, available as standard within all types of units, including obstetric units. There is no reason why these facilities could not be used by far more women, and we strongly believe that if a better birth environment was available to all, that more women would birth their babies with fewer unnecessary interventions. We hope that more research like this will encourage designers of all types of maternity units to create spaces which support both women and midwives to work together for better births.
An Australian study has looked at how midwives there perceive the value of waterbirth, and how well they are able to support it within their working environments.
The study outcome was very positive, with midwives reporting that both water labour and birth were very helpful to women, and they “documented benefits of reduced pain, maternal relaxation and a positive birth experience”.
Despite this, the midwives also reported, “…that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women’s informed choice.” , a situation that we see so often over here in the UK. It is time to support women to access the many benefits to them and their baby that comes with immersion in water for labour and birth, and to treat each woman as an individual rather than as a “risk factor”.
The Australian study mentions that “negative attitudes” are a barrier to providing access to birth pools. Quite rightly, there would be an outcry if “negative attitudes” prevented women from being able to have an epidural, and yet the risks of an epidural are well documented, whereas labouring and birthing in a birth pool has an extremely small list of concerns. One is, of course, what to do if a woman collapses while she’s in the birth pool. Tried and tested management guidelines are well established for this situation, which itself is extremely rare, but there is a worrying trend for women with higher BMIs to be denied access to a pool because they might be harder to bring out if they are unconscious. Another is the challenge of judging blood loss, but this is a skill that midwives who support waterbirth quickly learn. In “Revisiting Waterbirth”, Dianne Garland – expert waterbirth midwife – gives a helpful explanation of how the water should look when blood loss during or after a waterbirth is within normal ranges although of course there are many other factors such as how the woman is looking and feeling.
In summary, it is great to see a study showing midwives who are so positive about waterbirth, and the study seems to show that this is representative of many midwives in Australia, as is the case in the UK. The barriers come from attitudes from medical colleagues who need to be made aware of the work already done to deal with the concerns that they may have.
Each birthing room at the Auckland based “Birthcare” birthing centre in New Zealand has been upgraded to take the bed away from the focus of the room, and instead create a harmonious birth space with the pool and couch as the main furniture items.
Including mood lighting (choose the colour that you like best), sound systems, bean bags and birth balls, these stunning birth rooms provide a secure and comfortable space for women to birth their babies safely.
The Birthcare centre offers services seldom seen in even the best UK birth centres, such as an onsite paediatrician to avoid unnecessary transfers to hospital for non-emergency treatment, and an in-house lactation consultant service which women can self-refer back to after discharge should they need more assistance with breastfeeding.
Many of our own UK birth centres have these wonderful facilities, including our own Aquabirths birth pools and Softbirths birth couches, mood lighting, sound and the obstetric bed either absent or hidden. We urge more trusts to follow this route, support birth centres and also support these facilities within the obstetric unit, to help more women to have physiological births.
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In Part 1 of this blog I discussed how companies need to build innovative products together with clinicians, in order to work out what helps them and their patients, rather than companies making assumptions about medical needs which may not actually be valid, which can create barriers to innovation.
Another barrier to innovation in the NHS which was raised in the Nuffield Trust’s report (link) was that, “Products are sought which lead to short-term savings, rather than transforming care pathways leading to more efficient services”.
Stories of NHS managers introducing cheaper versions of products which turn out to be more expensive overall are rife: examination gloves which split, and two or three are wasted before a useful pair is found. Paper towels which don’t come out of the dispensers properly, and end up being wasted on the floor. But far more worryingly – spending money on areas which do not improve care, and can actually hinder it.
Last year, Jeremy Hunt announced that he would be putting millions of pounds of investment into more CTG machines, despite there being zero evidence that continuous monitoring is safer than intermittent monitoring. Imagine instead if that money had been allocated to increasing midwife numbers to implement Continuity of Carer? Unlike CTG machines, Continuity of Carer has been shown to reduce stillbirth, as well as costs to the NHS such as caesarean births.
Far cheaper investments, such as birth pools, also leads to significant cost savings. Labouring in water increases the rate of spontaneous vaginal births, reduces the need for instrumental delivery, reduces the numbers of 3rd and 4th degree tears, lowers the chance of a woman wanting opiate pain relief or an epidural, and increases women’s positive experiences of birth which might lead to lower levels of PND. (1) ALL of these mean that the NHS spends less money on fixing the consequences of these interventions, as well as the cost of the intervention itself.
Let’s see the NHS looking at the wider picture with every new innovation or investment. We call upon commissioners to look past the cost of installing new equipment which supports women to birth more easily, and instead see the full spectrum of ways that an investment in a birth pool, or other normal birth promoting products, can save the cash-strapped NHS money, while leading to better outcomes for women and their babies.
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While many barriers to new innovation in the NHS are well documented, the Nuffield Trust has released a report which looks at areas which have received less focus, and yet which are key to change.
Two of the main barriers listed were:
- Lack of clinician time to identify problems, and to work with companies to provide solutions
- Products are sought which lead to short-term savings, rather than transforming care pathways leading to more efficient services – I will discuss this in the next blog.
Lack of clinician time to identify problems and to help to work with innovators to find solutions is a problem which is certainly not limited to the NHS. All industries provide insufficient resources to allow staff the time, space and training to sit back and look at where problems are, and to work on solutions to those problems. In the NHS this leads to solutions being offered by companies which have not always been designed together with the clinicians, or the users of those products.
Sometimes a problem is identified and the solution put forward does resolve a problem, but causes another because the designer doesn’t work within the care setting. Although this isn’t a clinical product example, it underlines the problem well: In the 80s, some female nurses still wore starched fabric caps (male nurses were not required to as the fashion followed nurses originally being primarily nuns, and then the Victorian era of women needing a head covering). I well remember my own mother spending hours over the ironing board spraying starch onto her nursing caps. One day she told us that they were moving from the fabric cap to a disposable cardboard version (at a daily cost of 2p per cap to the NHS). Rather than working out whether the cap was a relic from the past which interfered with clinical care and should be removed from the uniform, the solution to the complaints of female nurses that they spent hours getting their caps stiff and sturdy was resolved with an expensive and pointless alternative product.
Aquabirths is lucky to have worked with midwives right from the start of the design of all of our birth pools. Pictured is our heart shaped birth pool which was designed together with midwives from Leeds, Yorkshire, UK. They requested featured such as:
- A freestanding pool to enable midwives and birth companions to be able to easily support the birthing woman from any side of the birth pool.
- A larger birth pool to offer comfort and support to even the tallest women.
- Smoothed edges to ensure comfort for women and midwives leaning over the edge of the birth pool, often for long periods of time.
- A single surface birth pool to ensure that it can easily and thoroughly be cleaned.
Aquabirths continues to work with midwives and birthing women to ensure that our birth pools are designed just how the users of our pools need them to be, and we hope to see more of a trend across the NHS to working this way with product manufacturers.
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Oldham Birth Centre – A Place to Want to Labour!
Oldham, in Greater Manchester, UK, has created the most stunning, supportive and effective birth centre which is family-centred and woman friendly. Designed to nurture women and birth, creating a safe, positive and caring space for the whole family – including other children, who can be present at the birth of their sibling.
Designed to support the physiology of birth from the ground up, the Birth Centre rooms do not centre around an obstetric bed. Instead, they feature slings, balls, mats, Softbirth couches, adjustable lighting and the stunning Aquabirths birth pool, with a large family bed available for parents and baby to rest in after their little one is born.
The Oldham Birth Centre’s philosophy of care is key to the success of this midwife-led maternity unit. Midwives are trained in hypnobirthing techniques, aromatherapy, acupuncture and using water to support positive, safe, physiological birth. Minimising adrenaline is key to maximising oxytocin, and maximising oxytocin is key to birth progressing well, so the whole room is designed to be calm and to help everyone to relax. An aromatherapy diffuser by the door greets the birthing family as they arrive, and the scents in the air, the dimmed lights offset by coloured bubble lamps and the Aquabirths birth pool gives a sense of walking into a spa.
Midwives describe seeing women sitting in a chair and looking around, and visibly relaxing. A kitchen is available for all to use, so birth partners can help themselves to drinks, and they can make their own snacks. Midwives make it quite clear that this space is for them to use, which is an important part of helping everyone to relax and continue to reduce any adrenaline levels.
The Oldham Birth Centre is not an extension of the labour ward, but instead is designed as a birth centre for the families of the city. While there are strict criteria for straightforward access to the unit, if a woman wants to birth there she can attend a Birth Options Clinic where their choice of place of birth is discussed, and the woman will be supported by the midwives.
The unit itself is nothing without its midwives, and the midwives at Oldham are hand picked for their inbuilt nurturing nature – not a trait which can be taught. Diane watches the student midwives who show an interest in physiological birth and support women’s choices. Those who wish to become part of the community/birth centre team are encouraged to apply.
Oldham Birth Centre is not unique, but it is unusual and it is beautiful. The women and families of Greater Manchester are extremely lucky to have this wonderful facility with its fabulous midwives.
The unit has a video on You Tube which showcases the birth pool and other facilities: https://www.youtube.com/watch?v=2wOHqJfLhGg
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Powys: Supporting women and supporting Better Births.
In the heart of Wales, in one of the most rural areas of the United Kingdom, lies the beautiful county of Powys. In this stunning region the recommendations of The Birthplace Study and Better Births are being wholeheartedly implemented. In extraordinary contrast to some areas of the UK, Powys has determined to ensure that Midwife Led Units are recommended as the optimal birth place for healthy women and babies, provided they are happy to birth there – supporting women in their decisions and supporting Better Births. 20% of women give birth in a midwife led unit in this area, compared to 14% for the rest of the UK.
Powys has 6 midwife led units across the county, limiting the distance that women need to travel in labour, increasing safety for women and babies and reducing the stress on families at a time where the birthing woman needs to be able to focus on her job at hand. In addition, Newtown, one of Powys’ towns with a birth centre, has recently celebrated the huge achievement of obtaining funding to run sonographer services local to where women are, reducing the travelling distances for women by 3000 miles a year!
Newtown has also used its funding to add in a permanent Aquabirths birth pool, and a double bed so that new parents can snuggle up together with their baby after the birth, rather than being separated at one of the most profound times of their lives.
Well done Powys – you are an inspiration!
Guest blog by Emma Ashworth
Softbirth Birth Couches – How Trusts are using them in Midwifery Led Units and Obstetric Units
Warrington and Halton NHS Trust have thrown out some of the traditional mechanical beds in both the Midwifery Led Unit (MLU) AND the obstetric unit and replaced them with Softbirth Birth Couches! Knowing that women have the best chance of a positive birth in an environment which best supports a birthing woman’s biological need to move and change position, MLU Manager Carys Hammond, Head of Midwifery Dr Tracey Cooper and their teams have created a hugely positive change in their Trust.
Carys said, “We realised that not every woman needs the mechanical obstetric beds. We wanted to change the rooms, make them physically different, so that midwives would offer the birthing couch room to women. They use pieces of the couch to adapt to different birthing positions and be upright and mobile. It totally changes the ambiance of the room. It’s not right for everyone, and women’s needs are evaluated individually in partnership between the woman and the staff, but the birth environment is really important. Midwives are excited about them!”
Carys reported that the Trust was supportive of the changes. Senior management helped the midwifery team to work through the infection control and governance procedures and getting their support was key to this project.
The Trust midwives are ensuring that women are aware of the options of the birth couch in both the obstetric unit and the MLU. This is done in a variety of ways, including their monthly “Maternity Voices” meetings, their Facebook page (link: https://www.facebook.com/WarringtonAndHaltonHospitalsNhsFoundationTrust/) and on the tours around the wards which are offered to pregnant parents.
“These changes are evidence based,” said Carys, “and it’s what women are asking for. Remember who is important – the women.”
To find more about introducing SoftBirth birth couches into obstetric units or midwifery led units, please get in touch.
Barbara Harper, founder/director of Waterbirth International reviews the second edition of Dianne Garland’s textbook ‘Revisiting Waterbirth: An Attitude to Care’ in the context of waterbirth practice around the world.
It is no secret that water is healing and that the use of water is an effective medium to facilitate changes in actual brain wiring. It is with excitement and great pleasure that I welcome the publication of the second edition of Revisiting Waterbirth: An Attitude to Care. Dianne Garland has continued to provide waterbirth education and training not only throughout the UK, but around the world. Our mutual passion brought us together for conferences, workshops and presentations many times. It has been my privilege to work closely with Dianne as a teaching partner in China, Spain, the Czech Republic, Israel, India and the United States. Her excitement about demystifying waterbirth is contagious, and the reader, whether midwife, doctor or mother, will experience that enthusiasm within the pages of this book.
There has never been a time in our combined history when the message and knowledge within Revisiting Waterbirth: An Attitude to Care has been more necessary. The misinformation surrounding waterbirth that Dianne and I have witnessed in different parts of the world is sometimes distressing and occasionally humorous. This book gives every practitioner an effective, informative guide to start a waterbirth practice and integrate that practice into any clinical setting. It also provides concrete examples and stories from those with whom Dianne and I have worked. The inclusion of detailed stories from practitioners and parents is a wonderful supplement to the new edition of Revisiting Waterbirth.
The use of water for labour and birth has increased exponentially since Dianne and I first started writing letters to one another in 1989. When we finally met in person 26 years ago in Kobe, Japan, at the International Confederation of Midwives conference, we excitedly shared documentation of the efficacy and safety of waterbirth. The demand for accurate, useful information and descriptions of experiences has also increased. When we first started our collaboration, waterbirth was referred to as a fad or a trend that would soon be gone. Women seeking the ease and comfort of water will continue to increase in every part of the world. Waterbirth is part of a world movement that seeks a more humane and gentler approach to childbearing.
The use of warm water immersion has long been seen as an aid for labour, making it easier for the mother to enter into and remain in a state of hormonal bliss. Today, there are well-designed studies that prove the efficacy of water for labour and the safety of water for the birth of the baby. Dianne’s experience as a hands-on midwife attending waterbirths, as well as her design and documentation of research, makes her the perfect person to lay the foundation of education for those who want to incorporate the use of water into maternity care settings. This book is also a guide for those who have already started waterbirth practice to improve their experience.
The message in this book is simple, straightforward and very hopeful. It is hopeful in the sense that more and more women are asking how to make labour less about ‘enduring the pain’ and more about creating a good, healthy and loving experience of birth for the baby. Women understand that creating a new human being is one of the most important jobs on the planet. The providers who serve those women need the encouragement that this book offers to step out of the routine medical care and become open to the possibilities that water can, indeed, change the course of a labour and should be utilized as a valuable tool for almost all women. The attitude with which professionals view a woman’s ability to give birth can either enhance or detract from her experience.
In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) launched a campaign to put doubt about the usefulness of waterbirth into the minds of nurses, doctors, midwives and the public. Some US hospitals paid attention to the published and widely distributed ACOG opinion paper and halted their successful and incident-free waterbirth programs. Dianne and I travelled together to hospitals in Cleveland, Ohio, and Minneapolis, Minnesota, shortly after the article was published, to educate hospital staff and help reinstate waterbirth policies in these facilities. We were welcomed in these places and our efforts were rewarded when the practices were put back into place.
It is my sincere hope and desire that practitioners throughout the world are guided by the message in Revisiting Waterbirth: An Attitude to Care and start implementing protocols in more hospitals. All women should be offered the choice and opportunity to labor in water and birth their babies with the ease, safety and pleasure that water so beautifully provides. I also hope that our tandem careers continue to bring this message to every corner of the globe. As founder and director of Waterbirth International, I have relied on Dianne Garland to provide a multitude of research and documentation from the UK and have used this book in its earlier editions as a teaching tool and recommended reading for nurses, midwives and doctors.
Barbara Harper, RN, CLD, CCCE, CKC, Midwife
Founder/Director of Waterbirth International