‘Women in this country would have a better chance of an easier, uncomplicated, intervention free birth if midwives and other health care providers had training in fetal positioning techniques. To reach that goal, we need evidence.’
The MakeBirthEasierCampaignUK was launched a week ago and I’m pleased to say it has generated a fair amount of interest and support. I have received some great comments from midwives such as “Really great campaign”, “Wonderful work you are doing”, and “I love Spinning Babies and send a lot of women to their website. Great publicity!” Midwives seem to be behind what the Campaign aims to achieve – fetal positioning techniques, such as those on SpinningBabies.com, included in the standard training curriculum for all midwives to use as part of routine care.
The first instalment of this blog (if you haven’t read it yet, click here) has been viewed by over 1000 people in the first week, and the Facebook page Make Birth Easier was visited by 2500 people on the first day! Incredible! The number of views is now well over 5000! I’m over the moon – keep on sharing!
So one week in, what is the next step? My plan is progressing…
Step 1: Generate interest and support from mums and the midwife community. This bit seems to be underway and word is spreading steadily.
Step 2: Generate interest and support from the research community. I have started to receive messages from researchers interested in this opportunity which is fantastic!
We Need Research – I Have Questions!
Maternity care, rather than being based in belief, is best when it is evidence based. For the NHS to go as far as include fetal positioning techniques in routine care, there needs to be clinical research. The Royal College of Midwives (RCM) guidelines on malpositions at the onset of labour state that more research studies are needed to examine the efficacy of midwifery developed skills in diagnosing (malpositions) and non-technological approaches to improving outcomes.
I had a blur of questions flooding into my head; What clinical trials are needed? How would trials be conducted? Which exercises should be included? How could the effectiveness of the exercises be clearly ‘proven’ instead of saying ‘this labour could have progressed in this way naturally’? Birthing mothers are needed who are willing to be part of the trials so how would that be managed? To be significant enough, how far reaching would the trials need to be in terms of areas of the country/numbers of births included? Every labour is different so it cannot be known in advance which techniques will/can be tested, how can this be managed? Am I asking the right questions? What have I missed?!
This is such a complex and dynamic issue. Any advice or guidance you clued up people out there (researchers, midwives, obstetricians, gynaecologists, scientists, anyone in the know!) can offer on any of these questions would be very welcome.
I woke up a few days later with some potential answers. The following is for thought/discussion and by no means definitive or a clear plan. Please bear in mind that I am not a medical professional or a researcher.
There is a lot to think about and it would be appropriate to utilise mixed methods to ensure women’s views were taken into account. Given that every labour is different – so it cannot be known in advance which techniques will/can be tested – trying to prove individual techniques may be difficult. Maybe some small pilot studies could be done to look at exercises on this level.
It may be more effective to train midwives throughout a whole birth centre or maternity department with fetal positioning techniques and then compare overall before and after figures for the department. Key target figures such as number of planned csections/emergency csections/number of inductions/epidurals administered/pain relief administered/length of labour etc.
I believe the percentage of births without medical intervention would reduce and the time in labour would also reduce by using fetal positioning techniques. In this way efficacy would be shown and safety of the techniques.
The study could take place over a defined time period (say for example 6months) rather than focusing on individual births while of course still recording the instances where particular techniques were used.
A research team would be required and this team would take on most of the paperwork. Any additional paperwork or notes for completion by the midwives should be simple and kept to a minimum so as not to add to their workload.
There would need to be some form of a control. Potentially, comparison of figures could be done from one department conducting the study against another also taking part, and another not taking part.
Planned csections could be included, as the number of breech/transverse babies requiring planned csection should reduce by using Spinning Babies techniques to turn the baby in advance of labour/planned csection date. This leads on to possible studies including for the use of fetal positioning techniques during late pregnancy during midwife appointments and how this affects the labour. Possibly figures for the number of instances of ECV could also be included. The possibilities are many.
As for reduction in after care, the potential is huge and the money saved by the NHS, well I wouldn’t know where to start. If before and after statistics over a defined period could be gathered for after care required for post natal complications, including post operative infection, special baby care or even post natal depression, this could highlight further areas where fetal positioning could have a direct and positive impact.
With regard to ‘recruiting’ willing participant birthing mothers for the trials, I am unsure of the protocols. I do know that an ethics review is required. Keeping women and their babies safe and fairly treated is paramount. Women put trust in their care providers and if a midwife were to say ‘I know of an exercise which may help your baby come down more easily/turn to a better position for birth’ I can imagine most women who are able to move freely saying ‘ok let’s try it’. I would!
Midwives Under Pressure
It is important to make this process as easy as possible for midwives so it is welcomed by most and readily accepted by the more sceptical. By making it simple for midwives to incorporate it would assist them in carrying out the new techniques and minimise extra documentation on top of an already heavy workload. For the purposes of the studies/trials, it may be possible that training the midwives in fetal positioning techniques could come under Continued Professional Development (CPD) so it would form part of run of the mill training. Eventually, if the efficacy of fetal positioning for better outcomes is proven (which I wholeheartedly believe it will be), training for existing midwives could possibly be undertaken in a similar fashion i.e. as CPD.
With examples such as Imperial Trust now in the process of expanding its birth centre and creating a proper home birth team, and Watford General Hospital refurbishing the Alexandra Birth Centre, it appears the NHS is leaning towards intervention free birthing in the hope of lowering induction and csection rates. I believe the use of fetal positioning techniques could contribute positively and dramatically to these figures.
Where to Start
I appreciate, despite many years of effective use, that without clinical evidence that any of the Spinning Babies techniques actually do anything, or are safe, it may be difficult to obtain approval for a whole department to use them. Testimonials are not enough. The evidence has to come from somewhere though, and if just one department / research facility / hospital could start this process off and gather some data, this could get the ball rolling for larger, more significant trials. How significant would a study need to be for NICE to get involved?
A key issue for starting any clinical trials is funding. This could come through private investment, sponsorship or potentially the NHS. How loudly will I have to shout to get attention from people with the means to get things done?
Please let me know if I am way off the mark with any of this! As mentioned, I am not from a medical or research background. This instalment of my blog is intended as a basis for discussion and calls for input from health professionals and anyone who can contribute.
If I can use fetal positioning techniques myself for both my births with such impressive results (see my first blog post MakeBirthEasierCampaignUK dated 11 May 2015), imagine what trained midwives could achieve using them every day. Women in this country would have a better chance of an easier, uncomplicated, intervention free birth if midwives and other health care providers had training in fetal positioning techniques. To reach that goal, we need evidence.
This is a huge opportunity to invest in a more positive future for maternal care in the UK. I am hopeful that I have your support.
For health professionals and others interested in being part of this opportunity, please leave comments / advice / guidance / offers of funding / offers of research team & research facility (!!) on this blog page.
You can also contact me via my page at https://www.facebook.com/MakeBirthEasier (particularly if you would like to message me privately)
The Campaign is also on Twitter @MakeBirthEasier, #MakeBirthEasierCampaignUK
Blog written by Alix Fernando
The content of this blog is not intended, and should not be read as constituting medical advice, diagnosis or treatment. Always consult your doctor, midwife or other qualified healthcare provider before making any changes to your birth plan or recommended routine.