Going Against The Grain…

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Birth is an incredibly special time in your life. It may be something you only do once and those well laid out birth plans can mean so much. It’s your absolute right to give birth in the way that you wish. But what happens when the hospital disagrees with your wishes? Your meticulous planning can suddenly be thrown up in the air after one scan, one blood test, one erroneous number.

Some obstetricians will be more supportive of your choices than others. While I would love to say that all of them have the best interests of your baby at heart, this can sometimes come across in a combative and bullying approach. It is beyond their scope to deny you anything. They do not ‘allow’ you to have the birth you want, you can do as you damn please. But having them on board certainly makes the process a lot easier. Walking into appointment after appointment knowing you have a fight on your hands isn’t beneficial to anyone. How can you overcome this dilemma?

Guidelines vs Policy 

Doctors and midwives are trained to work within the evidence base – basically, research. This research will inform the policies and guidelines that the hospital put it place for staff to follow. The two things are very different and it’s important for you to know this.
Policies must be adhered to. These are things like what uniform staff are required to wear, and how much time they are allowed off sick. Guidelines relate to care given to service users. They form a basis for all decisions made and are based on the available evidence. But guidelines are just that, a GUIDE, and hospital employees are able to work outside these guidelines if they are following “maternal request”. And that’s where you come in. You have absolutely every right to receive the care you want, and to decline the care you don’t. 

Know Your Stuff

If these guidelines are based on evidence you’d think they are pretty robust, right? Well…not exactly. Some evidence is of very poor quality and yet it is still used in national guidance, affecting every single woman.
Example: RCOG guideline for VBAC (vaginal birth after caesarean) state that continuous fetal monitoring should be used (guideline here, page 13) but next to this recommendation is the letter D. This means the evidence behind this recommendation is low quality (with A being the highest). For those who have read my previous blog you will know that NICE updated their VBAC guidelines a couple of months ago and now no longer recommend continuous fetal monitoring for VBAC if there are no other risk factors. Until RCOG update their guidelines, which is not scheduled to happen until 2020, the two guidelines are at odds with each other. So which guideline will your obstetrician choose? Probably RCOG since continuous monitoring is what they are used to doing. Which one would you prefer them to choose? Well that’s entirely up to you, but knowing that the evidence is contradictory means that you can read all sides and make a truly informed choice.

Reading The Research

You can find arguments to support your wishes from a wide variety of sources. Medical professionals are taught during their degree to critique research but there’s plenty of things a non medical person can look out for when looking at the papers. 

Source: the best evidence probably isn’t going to be found on Internet forums or facebook groups, unless they can link you to the original research and from there you can form your own opinion. Books become outdated very quickly so a trawl through the local library may not be helpful to you.
Participants: Did the research look at 5 women, or 5000? The experiences of those 5 women are valuable but the larger numbers means you can more likely apply them to the general population.
Funding: Who paid for the research? This should be mentioned on any good research paper. A breastfeeding survey carried out by a formula company? There’s probably going to be a lot of bias in their findings.
Country: Not all countries have maternity care similar to ours which may mean the findings aren’t transferable. Australia, New Zealand and The Netherlands have similar maternity structures and a lot of research comes out of these countries.

How To Find The Research

Unfortunately not every paper will have public access i.e. you will have to pay to read it. You may be able to utilise your local friendly university student to obtain the paper for you but that’s not always possible. Sometimes you can contact the author directly and they will send you the paper. They’ve already been paid, it’s the journals that make the money from keeping research hidden not the researchers! These are just a few of the best places to get research from:

  • Google Scholar 
  • RCOG (guidelines)
  • NICE (guidelines)
  • Royal College of Midwives (a lot of these will only be available to members – your midwife should be able to get these for you)
  • Cochrane Library – a huge database of evidence and reviews
  • Sara Wickham – an amazing amount of information on this website. Type your topic into the search bar and there’s bound to be articles come up written by Sara. In particular GBS, induction and third stage (which she has also written books on).

 

What If You’re Still Fighting?

What if you’ve got your birth plan, your research papers, and your well reasoned argument for the care you wish to receive but you are STILL fighting for your wishes to be respected? First of all, I am sorry you are going through this. It is absolutely wrong and should not be tolerated. Request a new midwife/obstetrician. You can do this at any point in your pregnancy and even during labour. Staff shortages may mean you have to wait to speak to someone new but you have every right to decline care from certain professionals if you feel they are not listening to your needs and concerns.
Escalate the issue higher. If you are talking to an obstetric registrar then ask to speak to the obstetric consultant. If you are talking to a midwife ask to speak to the band 7 midwife. If your issue is relating to the birth centre then ask to speak to the birth centre manager.
Remember that you are ‘allowed’ to do anything you want.
No means No, it does not mean ‘convince me’.
“I’m just going to…” doesn’t mean you have to allow them to.
Take someone into your appointments who will support you. This could be your partner, a friend or a doula, especially one who has experience of working with women who are going against guidelines.

Ultimately, you hold the power in the situation even when it does not feel like you do. Your body, your baby, your choice.  If you wish for more information or guidance on finding the research you need then do not hesitate to contact me. I am now available for skype/facetime consultations.

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