A question of confidence (1982)

a few months ago in London 5,000 people gathered outside one large teaching hospital to demonstrate their opposition to the hospital's refusal to allow women choice in childbirth in the past 15 years Britain has seen its maternity Services increasingly centralized in large hospitals the experience of pregnancy overwhelmed by technology and the experience of child birth subverted in the name of safety veryable today women reclaim their bodies and reclaim birth as an intimate personal act birth as mystery and wonder birth as a celebration of life that this dissatisfaction found its voice in a demonstration of over 5,000 against the policies of One hospital is a sad reflection of the very real problems that our maternity Services face for many mothers the sense of alienation starts here at the antinal clinic devoted to problem solving or mass these clinics have often defeated their main aim for this deep personalization has made them so unattractive that the very women who need them most are reluctant to attend this film is about a few examples of good practice in anti-natal care that have emerged during the last few years yet so pervasive has this policy of centralization been that we had to go to Scotland to find our only example of a sensible compromise that could be supported by statistics the Edinburgh Skyline 20 years ago the Deep population of this city started from the old properties in the city center and around the port hundreds of people were moved by the early '70s the trickle had become a flood as thousands of families were moved every year to the large Estates that now ring the city two of the largest sill and Wester Hales lie south of the city along the main roads that lead to the airport and the Scottish border of the 23 wards that make up the City of Edinburgh 8 years ago sight Hill had the fourth highest perinatal mortality rate the fourth highest number of children born with a physical handicap and the third highest incidents of congenital malformation Dr Ian mcke is the senior partner of the S Hill Health Center Dr Ran Smith one of our local community physicians did a differential survey of the perinatal mortality rates in Edinburgh and found that although people were going to the same hospitals there was a mammoth difference in perinatal mortality rates between the well off areas and the are areas near the hospital and areas such as ours where there was a high degree of poverty and the patient had a long way to go to the hospital and this was quite important because we don't have much Private Practice in Edinburgh so this was covering the entire community and yet the same Health Service was giving such a differential standard of Care at that time the sill Health Center which cares for almost the whole population of Wester Hales and sill was locked into a system of antinal care whereby most of the mothers were receiving their care at the Simpson Memorial Hospital an expense 6 Mile bus Journey to the Center of Edinburgh significantly 40% of women were late in booking for their first anti-natal appointment word had got round that the system was expensive in time and bus fars poorly organized and most significant for the consumer alienating yet the skills and resources to provide comprehensive antinal care had been back at the sill Health Center all the time historically uh it was not all that long ago that we did an awful lot of domiciliary deliveries and so the community Midwifery service is still geared to deliver a lot of babies at home but of course very few people now do have their babies at home so the midwives were out here already but doing very very little by the same Tradition general practice was used to dealing with a lot of domiciliary deliveries so in the um amongst the general practicians in the area there was a large interest in in obstetric matters but uh over a really comparatively short time all this had been taken out of our hands and we were just left with the rump of it so there were quite a few frustrated workers in the community uh they didn't need to be deployed they were here already about 32 weeks so what we'll do is come and visit you at home and just check see that it's down sometimes just coming to the clinic gets you a we bit for the last 6 years this Health Center had been running its own community-based anti-natal scheme and with the exception of women who are diabetic or who have major cardiac problems no mother is refused entry into the scheme I think the um the idea came in from a variety of different sources more or less at the same time uh as general practitioners we weren't very happy about the situation um but I wouldn't like to claim the credit that we actually got off our bottoms and did something about it uh at the same time that this situation existed out here at Sill uh the some Consultants were a bit unhappy because they could see from their side that this service that was so much money was being spent on wasn't actually coming out with the goods in the end um are you on any medication at the moment any medicines nothing good are you a smoker stopped on the first of August you stopped on the first of August and on the 11th day we takes over we come in and then we look after the baby from for GPS Health visitors and midwives used to an almost totally Hospital orientated maternity service the changeover was difficult the TR there's an awful lot of problems at the beginning because we just weren't used to taking that sort of responsibility nice head just sitting here you can't spend years and years of seeing normal people uh and being conditioned to referring them on to someone else the slightest abnormality you can't get used to that sort of situation and then um find that all of a sudden you've got to take a responsibility making a decision for yourself and it took us um a good few months before we developed enough confidence in ourselves again to take over more and more of of the clinic and I think it's necessary if you're starting up this sort of venture to have a consultant who's quite prepared to Mother you through the initial phases until you've redeveloped the confidence in your own ability to make decisions but it comes back the ability and confidence to take decisions was seen by the senior consultant at the Simpson maternity hospital as being crucial in the handing back of responsibility to the Community Medical Services for every member of the team to feel confident enough to take responsibility a framework or protocol for investigation and management needed to be devised the basis of the protocol at sill is this card at the first interview at the antenatal clinic each mother is formally assessed by noting features of the pregnancy against a checklist of risk factors and evaluating their significance from these factors a planned program of management automatically follows at the end of each Clinic the whole team doctors midwives and health visitors discussed the progress of each mother's pregnancy using the risk card as the basis for decision- making build up a relationship is she she is uh par 1 plus not but her last pregnancy was about 18 years ago um so this one came as a bit of a surprise in fact it was it was the last thing she thought that was wrong with her when she came in with morning sickness and tender breast she's 37 in December so she's candidate candidate for for you know problems of of age um there are two factors there in fact her age that she's 37 so we may run into problems with blood pressure with her she's also had two dnc's I think in 1967 and 73 again which may affect the uh cical competence so she would come under the protocol for for cervical assessment um there's a family history of diabetes I think if her grandfather had maturity onset diabetes if we have a protocol which is just another way saying we've all agreed what to do in a certain circumstance it means that when that circumstance arises even the lowest member of the team such as a Jun practitioner can uh then take a decision with the full knowledge that the protocol is back in him or her up actually by her own date she's at 38 weeks but they taken the scan date put the Min visor on um BPD came in at 9.2 CM which is toning in with 36 weeks I took blood for e and hpl because her last one that she' had last week tended to be a bit on the low the impact of these factors on the standard of obstetric Care at sill has been impressive and it's possible to make a before and after comparison as the scheme has now been in operation for six years and to study objectively the results from a thousand births within the scheme comparing them with the equivalent number that took place from the same area but whose mothers received their care at a hospital the difference is striking so too compared with the rate for Scotland in fact the S Hill scheme has one of the lowest perinatal mortality figures for anywhere in Britain and these figures have been achieved in a predominantly workingclass population more specifically the scheme has shown a dramatic increase in early presentation and a decrease in the default rate mothers are happy with the scheme the number of inductions has been hared so too have forp and premature deliveries and admissions to a special care baby unit and there been been a decrease in low birth weight babies it's been said that a high perinatal mortality rate is linked to poverty and that health workers cannot influence this relationship in an area where the majority of the families are from income groups four and five the example of sight Hill questions this assumption and at a lower cost than a hospital-based scheme I think the important thing quite honestly is to show that things get no worse under a community anti-natal care scheme our figures seem to show that the health of the community is very much better as a result of the scheme but I I I don't think even that's important I think the important things to show that these problems um and and one really shouldn't call antinal care a problem but the problems that can arise in anti-al care in the community are best dealt with in the community and if you can deal with something in the community at least as well as it can be dealt with in the hospital then all common sense screams out that it should be dealt within the community and not in the hospital conventional wisdom May scream out at us but for most mothers living in urban areas there is no choice hospital is where you receive your antinal care and it's at this moment that the sense of alienation with Britain's maternity Services often starts conveyor belt isn't really the right word for though impersonal the word also implies efficiency one thing these clinics are not do hasn't been treating for once the doctor's minions have whisked you through this the waiting starts whilst your case notes join the pile and the whole process is made even more inefficient by the strict provisor printed in large black letters that file full of dark secrets about your own body is shunted from the hand of one expert to another never allowed to be carried by the mother herself even though it would cut the waiting time [Music] substantially however even in a large Clinic it doesn't have to be like that this is the antenatal clinic at St George's Hospital tooting South London large and busy but for a start the mothers at least carry their own case [Music] notes yes that was you and you were 3 months old your mommy's tummy and there's a baby's head the body is here and we're off to the side so there's one one [Music] baby you see the after birth on the back of the of the womb so that uh that's going to be out of the way when it comes to having the baby and then Georgina that's you next and then Susan and then Mari Kane sister Caroline Flint took up post at St George's a year ago with the clear brief to improve the antenatal service right well the very first priority of course was to get the waiting the time that women waited to get that down and I to make it a more reasonable appointment system that was that was the very first priority and the way one did that was a to find out what time the doctors actually arrived in the clinic and and I got the women to come just before they arrived not an hour or half an hour beforeand but just before they arrived that was the first thing the other thing was to communicate with the women more to say I'm sorry you're waiting but we've got two M Brothers off sick today and we've got a Doctor Who's In Theater or to say well just to explain or to say well you've only got three more people in front of you and you're the fourth so they knew what was happening and I'm not shy so I I could I was that was all [Laughter] right the other thing is that I I labeled all the rooms so that wom actually knew who they were going to see and I talk very quickly so if I'd said you're going to see Dr Richmond today and they actually saw it on the door Dr Richmond they could think ah I'm seeing Dr Richmond today and so the next time they came they could actually say to me can I see Dr Richmond again or if they didn't like Dr Richmond they could say can I see anybody else but Dr Richmond so they feel they have an element of choice it was obvious that women are going to have to wait for a certain time no Clinic I'm beginning to think can ever run perfectly smoothly so I thought the important thing was when they are waiting that that waiting time should be valuable and exciting and and stimulating so we show films almost constantly we have women who've had babies here to come back with their babies and to talk about what it's like having a baby here in this Hospital what it's like living with a baby afterwards I found that um lying down I just couldn't feel the right muscles I couldn't work it out yet when I was on my hands and knees sort of on all fours I could feel what muscles are needed to push with and that made a lot more sense we have a crash for the children we have a place where children can play tea and coffee I mean that's that's really very important that they should have some sort of refreshment while they're here and the fetal models you know I've got that those all those those babies in different sizes well they're invaluable women love to see how far their babies got to and they actually can see it they can actually hold it so that's lovely but behind this impressive array of activities lies something less obvious but in many ways more important an attitude in the Care staff that can best be described as openness at this Clinic women feel they can ask questions that feels about right what can you feel though I can feel anything well I'm feeling for the height of your womb how how high comes up to you know yeah compared to your date and if you bring bring your hand up both hands if you put it there can you feel it where just below the umol area yeah that's where it comes to and then if you feel the side you can literally move your womb can you yeah and that's the baby come down I think you wed it to didn't you that's all it takes just a little fit just just a little bit of of resting does that give me yes I think it that you please I don't think we need to rush at an induction you see I mean normally we for a perfectly fit healthy young lady like you we would normally wait at least a week after the due date because we know the due date isn't is never that exact quite I mean it could be a week it could be it could be a week either way and all in all I think it's quite safe to review it again next week will you please and then we'll do it internal and I probably will try and persuade you then to get things started I'll be open to persuation then right thank you very much bye byebye in my mind that the TR is might har the baby you know what I mean and she and she said to me well she said it wasn't that but um it's been pain on my mind ever since cuz I can't remember but D it will play it plays on everybody's mind until you've actually got the baby in your arms you you such a lot of women worry about it it's moving isn't it yeah yeah it moves we heard look at baby's heartbeat beautiful was lovely was yeah yeah yeah I think I'm just letting everything get out of proportion well I me you got a lot on your plate Haven you yes no it won't be long now no won't be loving to see you byebye lovely it may seem strange to highlight these exchanges one would suppose that they were the first priority of All Care staff yet the way most antinal clinics are run in large hospitals makes genuine communication very difficult and the lack of interest in them is the main complaint of the women who have to use them midwives too constantly complain about the role into which they have been forced that of obstetric nurse handmaid to the all powerful doctor it's Little Wonder then that feeling themselves a beleaguered minority they sometimes behave that way a lot of mides have lost a lot of confidence there's no doubt about that it so much depends upon how much support the Midwife herself has got how confident she is the sort of experience she's had in the past and the sort of experience that she has made herself have you see with all experiences you can go through them and you can just exist through them or you can go through them and you can learn every second of the time so in different situations you can actually gain more experience from certain situations by by your own attitude of mind sometimes happens in pregnancy there's you some people get high blood pressure and I looked down to clinics and felt that this was a a superb area where you could actually achieve something and you could really improve what was happening to women and and how women were feeling about it and you could actually do a lot breakast in bed every morning 6:00 or something is it I don't think it's six actually it's about 8:00 come come and P your husband in my office an honest recognition of the shortcomings of a centralized system is the first step to any change King's College Hospital London has a small overcrowded Clinic combined with all the usual features The Waiting rooms that are more like grey hand traps Pokey corridors and overworked staff but recognizing that although they can't find the money to change the system for everyone they have at least identified one group of women who need special antinal care in a supportive setting this small Clinic was set up two years ago to provide a comprehensive service to teenage girls it's staffed by a doctor social worker Health visitor and midwife and they'll give you a flight direct it's your choice but you got to make a choice in awai but you can you mustn't just walk out you just walk out you lose your rights the only way you can be the team here give help and advice on a whole range of problems not normally associated with anti-natal care problems of family tensions welfare rights unemployment and homelessness problems which need the support of a social worker and health visitor as much as the doctor and midwife you also discuss generally how you're getting on at home with your family and okay now Health CS tend to work mainly from clinics child health clinics you find some are attached to GPS I'm just going to check out on here has the head gone down yet I don't I really don't know tell the truth you don't know have you been feeling no Dr meline Saunders has been running this clinic for the past 18 months have a feeling on there and tell me what you think Clinic started in early 1980 basically um one of our ex- house officers in fact was working for the Department of Community medicine during home visits on pregnant school girls and she found talking to them and visiting them that they really were missing out a lot as far as antenatal care was concerned and they sort of fell through large gaps in the standard antinal system which I think is understandable tell me how many times the and they're moving now all right but head is just sitting there okay let's just are you right line flat yeah you're not feeling dizzy one aim of the clinic is to make hospit hospital per se a positive experience so that in the future if they have problems they might well turn to hospital or somewhere they know that at least they can come back M like water sling most of the horses who now more of the there's no way that you know we could take the attitude which many people do and it's been said to me these girls cannot have their babies you have got to take all their babies away they've all got to have adoptions you can't do that and they don't get pregnant to get money I know many many people sa me of course she's only got pregnant to get a council house or to get benefits it's rubbish um certainly some have had very poor home backgrounds no upbringing themselves and I some of them just see that they actually want something to love them and they think the baby's going to do it now however wrong that is you can't dissuade them of that and we just feel that we want to try and get them to see these things in themselves and in their pregnancy so that if we can I mean she kiter is always saying you know the woman should be in the driving seat these girls don't drive their bodies non pregnant let alone with a pregnancy on board so we just want to try and you know get them to grips with themselves in their situation and try and make some sort of positive playing me obviously you have to talk about through with them and so that they understood that they weren't being nasty for many young people often with little idea of what to expect or even how they're going to cope this Clinic provides not just practical and emotional support through pregnancy but but because the girls attend the clinic over a period of months the team can through patient persuasion help the large majority to organize their lives so that they and their newborn babies have a stable well supported environment to go home to and with infant mortality that his deaths in the first year of life among teenage mothers running at a staggering 34 per thousand this kind of planning and support is crucial we're going along down there at one stage a kid could possibly go through pregnancy without letting out problems and suddenly break down on the ward I mean I saw once where I was training a girl on The Ward and the big wardr came around and they said oh everything all right going home today and she said yes and in fact I had talked to her as a student and I said to this consultant look you got the answer you asked for that girl has nowhere to go she has got no home and you have not given her any chance to tell you there was a very interesting set series of articles in nursing times which talked about Communications in nursing and and showed actually how we frequently stop women talking by saying something like you're looking very well and not actually giving them an opportunity to say actually I feel terrible because they're worried about your blood pressure and are you swollen at all it may seem strange to end this film with an obvious comment but it's often the obvious comment that is the least palatable the simple fact is that the one overriding feature that is common to the three examples shown is the attitude of the k Care staff a quiet confidence approachability and openness that women immediately recognize and the benefits are obvious as the statistics from sill demonstrated for if women find coming to an antinal Clinic a positive experience a number of crucial factors will follow early presentation effective screening maximum cooperation lower risk and to put it simply happier mothers and healthier babies but I think that should be okay now baby king for