Breech: Ordering off the menu

36164523 - new born baby feet. hand of the mother holding the sleeping baby boy little foot up.

I used to not be very adventurous with food. I wasn’t a fussy eater as such I just hadn’t been exposed to different types of food when I was young so I was quite cautious. I was gently introduced to the world of flavour through a korma curry when I was 20, and now elbow people out the way to the hot and spicy counter and love trying new things.  I have even had a go at ordering off the menu, either driven my taste buds or that nothing on the menu was my thing. And mostly this has been a good experience, with me, the customer humoured and accommodated. Occasionally there is a stony ‘no’ (it’s just not possible in pre-cooked greasy burger joints) and on the very rare occasion I was in fear of being ejected from the premises for even daring to imply the menu was inadequate (a rather snotty pretentious restaurant in my view).

Is modern birth services options like a menu? Who develops the menu and how is it presented? How easy is it to order off the menu and what is that experience like?

Practically the menu is mainly the clinical guidelines that help clinical staff decide the best thing to do based on the evidence available.  My experience is that whilst some commonalities can be found, local clinical guidelines vary due the rest of the stuff that has a significant but rarely acknowledged impact on what ends up on the menu. Stuff like personal views, experiences, beliefs and ‘how we do things round here’ impact on what is in a clinical guideline.  I was once, some years ago,  in  a team who were updating breech clinical guidelines at a maternity unit when I was told to tone it down (I think I was including the option of active, upright breech birth section) or I would never get it past the obstetricians. This was despite my arguments that giving being required to give birth on your back in stirrups as per the current guidelines had no research basis at all. My text remained in (stubborn me).

I am aware that in some maternity services the users of that service, the women and their families, have no input into the development of clinical guidelines that directly affect them; the menu is off limits in terms of deciding what’s on offer.  Perhaps a chef would argue that only she/he, the expert, would know what food is best to serve. But of course we are not talking about food, we are talking about birth and who is the expert at birth (my vote is birthing women).

But what if nothing on the menu takes your fancy. Hold the beef and potato stew, I’m hankering after roasted snails cooked with pineapple and paprika today kinda thing. Well, from listening to many women’s breech birth stories, there are mixed responses but a common one is of a sad battle to get their pineappley snails/not on the menu birth choices. Some women are given the ‘no can do’ response (think greasy burger joint) and others are made to feel very alienated, ostracised and even stupid from even asking for their desired snails (think snotty restaurant). Some even leave the entire food joint and go and find a nice chef (in another maternity unit or independent midwife) who will listen, respect and facilitate their choices.

Ordering off the menu is hard work, it can be stressful and women share that it harms their relationships with care providers who won’t consider their needs. Perhaps then we need to look who and how the menu is developed. Including the people who use the service in clinical guideline development is a no-brainer, it is empowering and enabling and forms partnerships of trust and respect. Maternity Service Liaison committees do sterling work in this area. Involving service users in research and building and sharing of knowledge around birth is also common sense. What’s important to those giving birth should be the central starting point for developments and innovations. Ordering from the birth menu that you shaped is much easier than choosing off the chef’s version of culinary heaven.

And finally we need to consider if we need a different type of menu; is there a new way of doing things out there? The maternity services review certainly thinks it’s time for a change. The proposed personal budgets will certainly go some way to empowering women in their birth choice and feel more like the buffet style approach to birth. They offer you to take a plate and fork and add the tasty morsels you desire to build a meal that really tingles your taste buds; your own unique birth journey how and where you want it.

Pineappley snails are not for everyone, but nor is beef stew. Let’s change the birth menu and the mindset of choice.


Giving birth to stars

After having a catch up with a lawyer friend last week I reflected on the desirability of certainty, and its antithesis, the messy reality of uncertainty.  The law, my friend tells me, provides considerable certainty, especially so when considering principles known as the ‘black letter law’. This impressive term is defined as:

‘a principle of law so notorious and entrenched that it is commonly known and rarely disputed’ (Duhaime’s law dictionary)

This is when a belief, view or understanding becomes so resolutely agreed by those who hold the power, in this case judges, it becomes indisputable ‘fact’ and ‘is no longer subject to reasonable dispute’.  Interesting stuff. It must be really helpful to have these entrenched beliefs to guide you as you confidently go through life; they are a given, an absolute, a certainty on which you can pin your colours and not worry again.

This brings me to some thoughts; how attractive certainty is, how you don’t need to worry if you are certain so it makes things a little bit easier. And how fragile certainty is, based on the collective views of others, often those in power, but passed to us as indisputable facts. And how birth can be such an uncertain time in a generally uncertain life.

In midwifery uncertainty is acknowledged and accepted as part of birth. As a midwife I learnt to be patient, to observe and prepare for any eventuality. The many nights waiting to be called for homebirths over the years was a warm reminder of how beautifully unplanned nature was. I learnt from women and their unique and individual birth journeys, spotting the common threads between them that help you to know the few occasions when women or babies needed help.

My experiences of discussing certainty and uncertainty with my obstetric colleagues has been fascinating.  A good example is induction of labour when pregnancy is considered overdue (usually around 41 weeks gestation). I chatted with a doctor a few months ago who was convinced that no women would choose to continue the burden and uncertainty of pregnancy over ‘getting on with it’ induction, with the added benefits of being guaranteed a baby in arms by dinner time the next day-ish (very ish).

But despite the ongoing debate on what really is ‘overdue’ in pregnancy terms and ongoing concerns over the risks / benefits of induction this intervention has been widely adopted, leading to nearly a quarter of all pregnancies being induced (see Rebecca Dekker’s excellent summary here). But perhaps the attraction of induction is the attraction of certainty, for many it must be good to know they are on the final run and there is certainty in being told you will likely be back home with a baby in a day or two or three or four.  It certainly helps with your Facebook status and stops those pesky enquiring phone calls from friends and family.

But what would happen if we turned this on its head and dealt with uncertainty in a different way. Uncertainty can bring stress and unhappiness but can also be the way that amazing things can happen, where we are more than we ever thought we could be.  Women who I have talked with about their breech birth experiences described periods of intense uncertainty where they didn’t know what to do, they felt stressed and often fearful, exacerbated by the fears of others.  Women described navigating this uncertainty finding their way and seeking alternatives and people who would listen and support them.  But they also described the moments where they made their decision on how and where to birth, drawing deep within themselves and from others to reach a place of self-certainty about what to do next.  These women described how they drew strength and confidence in themselves and their babies from their birth experiences, though many expressed how they wished they hadn’t needed to battle so much to have their decisions respected.

Perhaps this tells us that uncertainty allows a time for looking outside the box, ordering off the menu. It also suggests that certainty is very personal, rather than an entrenched notion or concept that is applied to (imposed on) all similar situations and populations. Developing self-certainty can be empowering as it develops from an individual’s own ideals, beliefs and situations, rather than those of others.

This doesn’t just apply to breech birth of course; women are faced with many situations within their pregnancy and beyond into motherhood where uncertainty and certainty go hand in hand.  Certainty through care pathways doesn’t always provide definitive answers or guaranteed outcomes. Uncertainty is not always a negative, but perhaps also an opportunity for liberation and freedom of choice.

‘You must have chaos in your heart to give birth to stars.’  Nietzsche

Whilst we may not desire chaos, uncertainty may provide opportunities to explore, to consider the alternatives and perhaps, even, to give birth to stars



Twitter: @JenD2605