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'P' is for... Pregnancy and Policies

And the PROBLEM with these!

All to often I hear women recounting birth stories and I catch sentences such as "I wasn't allowed to..." or "I had to have 'x' because of 'y.'" The route of these sentences are usually founded in some sort of hospital policy which meant the women were told 'You can't...' or 'You must...'

And the thing that drives me crazy about this: these 'policies' are problematic and pointless!

Yes - you read that right - POINTLESS!

Let's say you want a water birth. This is a fairly common desire among women I work with and its easy to understand why - pain is more manageable, movement is easier, labour is quicker and more relaxing. Its an easy decision - but getting access to the birth pool if you have ANY kind of risk factor... not so easy! Hospital policy says no.... etc!

Well let me tell you, if you want it - I believe you should absolutely be able to have it! And here is why:

There are 2 main reasons Hospital Policies are problematic:

  1. We think they are law - they are NOT. They in no way govern your birth choices or rights!

  2. They are NOT evidenced based! And may not be in your best interests.

There are many more issues, but let's just keep it simple and stick to these main two.

I have attached links to each part to back up my arguments, which will hopefully help you understand more of what I mean. But if you want to skip to how to get a water birth, scoll down to the bottom.

What do we mean by policy?

The dictionary definition of 'policy' is a document which describes a course of action, principles, procedure or plan to follow. Policies and procedures are mandatory - GUIDELINES are not!

The first problem we encounter with hospital policy is this idea that it is a rule that MUST be followed. This is NOT the case! So lets just change the terminology straight away to GUIDELINES.

Now lets dig through the ones we need to know about.

There are lots of different ones which affect pregnant women with their own acronyms to get your head around.

  • At the biggest, most global level, there are WHO Guidelines - World Health Organisation which offer worldwide guidance. These are good but non-specific to a country or local demographic. This means they are good at a broad level, but unhelpful in a local sense.

  • Then, within the UK, there are NICE Guidelines - these stand for the National Institute of Health and Care Excellence. We like these - these are internationally recognised for being evidenced based and of good validity. Crucially, NICE Guidelines are separate to the NHS but in general, it is good practise for the NHS to follow them.

  • We then have RCOG guidelines - these stand for the Royal College of Obstestricians and Gynacologists and are again universal for the UK - you may see these quoted within hospital leaflets (as below).

  • At NHS level, there is Healthboard guidance, unique to your NHS area.

  • Finally, there are guidelines drawn up for individual hospitals and birth centres within each NHS Health Board.

  1. Guidelines are NOT the law - in fact the Law can go AGAINST them!

We are at fault here a little, for not being well informed. If someone says to you "the guidelines say..." we seem to think "Well if the guidelines say, it must be the way!"

Even if you don't want whatever treatment or intervention is offered. But the guidelines are not the law! And you can say no!

This comes down to your RIGHTS. You have fundamental human rights and on top of them: birth rights. The hospital is not a prison or jail. You cannot be made to do anything you do not want to do. You do not have to give consent to anything you do not want. Midwives and Doctors MUST ask for your consent before ANY procedure - including listening to the baby, taking your blood pressure - ANY procedure. You can change your mind. You can say 'no'. You should never find yourself recounting your birth story saying 'I HAD to...' it should always be 'I CHOSE to...' and EVERYTHING is your CHOICE.

More information can be found here at the Birthrights website.

You have the right to birth your baby where and how you choose. So, if you want a water birth - you have the right to it! However, even if you have the right to a water birth - hospital's don't have to let you use their birth pools, they have 'guidelines'. These guidelines are more about supporting their staff should something go wrong, so to get around this you may have to consider a home birth water birth. Or you can meet with a consultant and argue the points below!

Secondly, despite not being law, the NICE guidelines do recognise and encourage this VERY important fact - that you are in charge.

Guidelines are there for midwives and doctors to follow, to keep us and them safe from harm, but they are not there so that women are all treated identically - which means there is a degree of flexibility and they are not hard and fast rules.

2. Hospital Guidance is NOT based on good quality, up-to-date evidence.

NHS Guidance is often outdated and varies from health board to health board - did you know it is not the same everywhere? Just because you may not be 'allowed' a water birth at Forth Valley, it may be perfectly ok in the Borders! Why?

When you read your hospital guidelines I wan't you to ask yourself a couple questions: Who wrote them? What do they know? When did they write them?

Guidelines are ultimately written by a person. We hope that person is an expert in that field. But NHS practitioners are employed by the NHS. This is a business. And there are major problems with this - the first being they are overworked and do not have time to be wasting on updating paperwork! Some policies are copied and pasted from NHS board to NHS board. They see what others are doing and copy! Some are not updated regularly (see my water birth example below).

Secondly, there is a huge lag in evidence supporting practise. It can be up to 20years, with birth workers and advocates arguing for a change in practise, before this makes its way into the hospital guidelines. This certainly happened with optimal cord clamping and it made the news! A practise that went on for decades before research pushed for a change!

Other reasons for hospital guidelines not to be evidenced based is in part because there is NO EVIDENCE.

For there to be evidence, we need a clinical trial. We need women all the same, for example all 'low risk', to agree to take part in a test of change. For example a practitioner might explore the use of placental encapsulation to support postpartum mood. We need lots of women to do this, and we need lots of practitioners to do this all over the country, in order to find out if this works. Let's say it does - great! But how does that affect a women who had gestational diabetes? An active third stage? Or with a high BMI? They were not in the trial so there is no evidence to say if it would help them?

As women we are all different, and data may not best reflect our own unique set of circumstances or health. For example, I have a high BMI but I am very fit and healthy. I play hockey, cycle, swim, my blood pressure is good, I am strong and have a high muscle mass. Someone else with a high BMI may not be as healthy as me. They may be less active, eat a less healthy diet and have the same BMI score - should we be treated the same in pregnancy based on our BMI?

A classic example of this is women who conceive through IVF. There is 'some' evidence to show that they are at higher risk of still birth. However, this trial did not take into account that women who conceive through IVF may be older, heavier, have other health conditions that made conception harder, that puts them at higher risk of stillbirth anyway. So what is the young, 28 year old supposed to think of this data? Who conceived through IVF because of a difficulty with her partner's sperm and nothing to do with her own health status? Who is in herself, fit and healthy and who would otherwise be considered 'low risk' were it not for the IVF? Should she have to have an induction? There is no evidence because a trial has not been carried out.

This does not mean she should or shouldn't have an induction, it just means she should be able to make her own decisions.

No evidence is not a bad thing, it is just a reflection on the many different ways women and their bodies and babies are different and why individual circumstances should be taken into account.

RCOG Guidelines state "Guidelines are recommendations. They are not meant to dictate rigidly, but to support healthcare professionals in their work. In deciding what treatment or care to offer, the doctor, nurse or midwife will always take account of an individual’s need, local conditions and resources".

RCOG Guidelines are graded as to how robust the data is. How reliable and how much you can trust it. At the top end of the scale are the GRADE A guidelines - with top quality evidence to back them up. Only 18% of the guidelines are Grade 'A'! So 82% of the guidelines are NOT based on Grade 'A' quality evidence!

And 40% of the guidelines are NOT based on evidence at - just good practise in the authors expert opinion.

So now you are an expert in understanding the minefield of bureaucracy - how can you take this understanding into campaigning for a water birth?

What do the guidelines say about Water Birth at NHS Forth Valley?

Here you can read the NHS Forth Valley Water Birth information leaflet. The first thing to notice - it was written in 2014 and was due to be updated in 2020. Obviously, the COVID pandemic must have pushed this back a bit, and we can maybe give them a year or two grace period, but in the medical world, staying up to date with research is important, and this leaflet is now 4 years passed its 'use by' date! And 10 years have passed since it was written - that is 10 years of research and evidence that will NOT be included!

Now look at the references - can you see them all?

There is only one reference! It is from 2006. I don't know about you - but when I did either of my degrees I wouldn't get away with just 1 reference and for it to be 8 years out of date then, and 18 years now, is not good enough! This is the reference below - it is not research but a guideline!

Reference - Royal College of Obstetricians & Gynaecologists/Royal College of Midwives (2006) Joint Statement Immersion in Water During Labour and Birth.

They have used this reference to make these statements:

  • There are many benefits for using the water for your labour. This includes less painful contractions, making it less likely that you will need a pain relieving injection or request an epidural, a shorter labour and less need for the drug (oxytocin) to help make your contractions more effective. (RCOG/RCM 2006).

  • Unfortunately, there is not enough evidence from research trials to tell us all we want to know about birth in water (RCOG/RCM 2006).

  • More research is needed about the risks and benefits of having the 3rd stage of labour under water (RCOG/RCM 2006).

So that is it? Now let's read the most important part of it: Can I have a water birth?

I mean... what does this mean? What makes a pregnancy uncomplicated? What medical illnesses are you referring to? The only point they have been specific about is BMI where they have plucked the number 35 out - where did that come from? Where is the research for that? What if you go passed your due date?

If you compare this leaflet to others - such as this one from NHS Borders you will see striking differences. Note how many more references there are for starters. It is more up to date and includes far more information. And if we take a look closer at BMI we see the number is now 40? It also does not rule out those with medical conditions but explains how reasonable adjustments can be made.

So the guidelines vary from health board to health board and are not 'fair'. Are the doctors and midwives in the borders more skilled in water birth? Unlikely. Someone has just done a better job with a keyboard in drawing up the leaflet. But if midwives at your appointment are falling back on this Forth Valley leaflet as 'rules' then we have a major problem!

What about the NICE guidelines?

Here are two below:

1.6.10 Offer women the opportunity to labour in water for pain relief.

1.9.24 Inform women that there is insufficient high-quality evidence to either support or discourage giving birth in water.

Despite this, NHS Forth Valley states un-referenced risks such as the baby drowning, the cord rupturing and infection. Enough to discourage many from experiencing it!

In fact, if they updated their guidance and included evidence they might find:

There is insufficiant evidence to assess the effect of hydrotherapy on other outcomes such as blood loss, perieneal tears, and neonatal admission, there is no evidence to suggest it has an adverse effect on these outcomes and it is generally felt to be safe practise. (Nutter et al, 2014; Cluett et al, 2018).

Tommy's website also helpfully reassures and answers this question:

Can my baby drown if I give birth in water?

Many women wonder whether there is a risk of their baby drowning if they give birth in water but it is very unlikely to happen.

Babies do not need to breathe when they are in the womb because they get oxygen from the blood that comes from their mum through the placenta. When they are born in water, their body behaves as if they are still in the womb until they take their first breath of air, at which point their lungs open up. As a baby comes from water (in the womb) into water (in the birth pool), the lungs are not open and no water can enter.

After your baby is born in the water, you and your midwife will bring them to the surface slowly. Your baby will only be under water for a short time and won’t take a breath until they are out of the water. 

Your baby is only at risk:

  • if their head is brought above the water and brought down again

  • if their oxygen supply from the placenta is affected

  • if their temperature changes suddenly.

Your midwife will be careful to make sure this does not happen.

So you want a water birth, the NICE guidelines make a good case for it, and you feel in your individual case you should be allowed one. What next?

  1. Talk to your midwife and explain your choice and why it is important to you.

  2. If you are under consultant led care - talk to your consultant. It is important you do this well before labour and birth so a plan can be drawn up for you.

  3. If both the midwife and consultant are saying that it is not possible in their facility, you can look to other health boards - there is nothing that says you must birth within your local authority. You can choose which health board you birth in, and being in Central Scotland we are close to many others that may be more accommodating.

  4. The law states that "that your right to choose where to give birth should only be restricted when there is a good reason to do this, and where the decision is ‘proportionate’. This is for the hospital to prove - not you!

  5. Finally, you can choose to birth at home, hiring a water pool, and have the midwives support you in your home where you are not governed by an out-of-date, un-evidenced hospital policy.

Always remember, you have the right to birth where and how you choose. The hospital policy is not in charge - you are!

Here is my take on the NHS leaflet:

Hospital policies are guidelines at best. They are trumped by your Birth Rights which make many of them pointless. They are often not based on good quality evidence. They are often out of date. They are not laws.

When it comes to making decisions around your birth - the person who knows best is you. Trust in your instincts. Ask the questions. Challenge the guidelines.

Still not feeling empowered enough to do that? It's ok, most of my clients do! Client's who have taken a course with me often say how empowering it felt - how much they grew in confidence to take charge of their birth experience.

"I am SO glad I signed myself and my husband up to The Stirling Birth School’s 2 day hypnobirthing course. Having been previously very anxious about all things birth, I have ‘graduated’ from this course feeling so empowered, knowledgable and most notably for me- excited about the upcoming birth of my baby! All thanks to Heather, who is so lovely, well-informed and made us both feel so at ease. It was such a calm but fun atmosphere, a great balance of information, practical and relaxation- and it was great to meet other expectant parents. My husband and I feel it has brought us even closer as a unit and has given us such a positive outlook on birth. Thank you, Heather!"

It's no wonder so many of my clients feel empowered after taking a course - they learn all there is to know about birth and how to set the odds in their favour of getting the birth they wanted. As well as covering birth, my courses cover birth rights, birth planning and how to advocate for your birth choices. All with your birth partner by your side. If you want to find out more - hit the button below!

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