Denis Walsh

'Weighing up and balancing out': a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries.

Backgroundu2002 In high‐resource settings around 20% of maternal deaths are attributed to women who fail to receive adequate antenatal care. Epidemiological evidence suggests many of these women belong to marginalised groups often living in areas of relative deprivation. Reasons for inadequate antenatal attendance have yet to be fully evaluated.

Essential midwifery practice : intrapartum care

Contributors. Introduction (Denis Walsh). Chapter 1 Evolution of Current Systems of Intrapartum Care (Denis Walsh). Chapter 2 Debates about Knowledge and Intrapartum Care (Soo Downe). Chapter 3 Childbirth Education: Politics, Equality and Relevance (Mary Nolan). Chapter 4 Birth Environment (Denis Walsh). Chapter 5 Labour Rhythms (Denis Walsh). Chapter 6 Evidence for Neonatal Transition and the First Hour of Life (Judith Mercer and Debra Erikson-Owens). Chapter 7 Midwifery Presence: Philosophy, Science and Art (Holly Powell Kennedy, Tricia Anderson and Nicky Leap). Chapter 8 Skills for Working with (the Woman in) Pain (Rosemary Mander). Chapter 9 Complementary Therapies in Labour: A Woman-Centred Approach (Denise Tiran). Chapter 10 Midwifery Skills for Normalising Unusual Labours (Verena Schmid and Soo Downe). Chapter 11 Psychology and Labour Experience: Birth as a Peak Experience (Gill Thompson). Chapter 12 Sexuality in Labour and Birth: An Intimate Perspective (Sarah Buckley). Chapter 13 Spirituality and Labour Care (Jenny Hall). Chapter 14 How Midwives Should Organise to Provide Intrapartum Care (Chris McCourt). Chapter 15 Feminisms and Intrapartum Care (Mary Stewart). Chapter 16 Towards Salutogenic Birth in the 21stCentury (Soo Downe). Index.

Uncertainty around home birth transfers.

Sir, In our Cochrane review of home like places for birth,1 we contentiously noted a trend towards increased perinatal mortality rates for alongside birth centres. We were therefore very interested in the recent paper byMori et al.2 We accept that this is a difficult area to address. However, given the clearly identified limitations of the data in this study, we are rather puzzled by the weight that has been given to the findings, both in the editorial3 that accompanied the paper and in subsequent media coverage. Two crucial aspects of the study prevent the data from being generalisible: the inadequate data sets available and the consequent lack of like-for-like comparison groups. The requirement of reliable data sets is fundamental to epidemiological studies.4 If this cannot be established, error is built into the study from the beginning. The authors outline the problematic nature of their data under headings ‘data collection’, ‘measurement errors’, ‘bias’ and ‘confounding’. Each of these can render epidemiological analysis tentative and equivocal. It is therefore misleading to draw conclusions and proffer explanations as if the results have some degree of robustness. In terms of comparison groups, the clinically significant comparator for low-risk home birth booked women who become higher risk is low-risk hospital booked women who become higher risk. For the same reason, the very low perinatal mortality rate in the home birth booked women who gave birth at home needs to be compared only with women who start and finish labour as low risk in hospital. Two additional aspects confound attempts to understand these data. First, transfers during labour are not distinguished from those occurring antenatally. If the risk is real, we do not know whether it lies in complications of pregnancy or in the way the intrapartum episode was managed. Second, even if problems could be identified as occurring in the intrapartum period, we do not know if this is an issue of midwifery care at home, of geographical distance, of the way transferred women are managed en route or after they enter hospital, or, indeed, if there are a whole range of other reasons. Given all these caveats, we suggest that the only conclusion that can be drawn from the study is that we simply do not know about the safety of labour-related home birth transfers and that future studies (preferably randomised controlled trials) are required. If we are indeed convinced of the value of evidence-based service provision, and of the provision of unbiased information to service users, this should surely have been the message transmitted strongly to the media. In the absence of trials, the current BirthPlace study5 will go some way to providing some of these answers. j

Is maternity care evidence based or interpretation driven? Place of birth as an exemplar

In a recent thought-provoking paper, Melissa Cheney proposed that home birth in the USA was ‘systems-challenging praxis’—in other words, that the practical act of doing home birth provides a concrete, visible critique of the risk-averse American discourse of childbirth (Cheyney, 2008). The commentary of Werkmeister et al. (2008) in this issue of Midwifery illustrates how far collective debate in this area has progressed in the UK. However, some individuals and groups still hold very polarised positions in this area, based on strongly and sincerely held beliefs. As Werkmeister et al. note, even where there is a willingness to agree in principle and an apparently neutral evidence base, these differences require long and patient negotiation if a consensus is to be reached. A recent Editor’s Choice in the British Journal of Obstetrics and Gynaecology (BJOG) offered a fascinating discussion of a range of papers published in that edition (Steer, 2008). These encompassed the risk of intrapartum perinatal mortality (IPPM) for women choosing home birth in the UK (Mori et al., 2008), women’s choice of place of birth in Scotland (Pitchforth et al., 2008), and referral patterns relating to midwifery care in Holland (Amelink-Verburg et al., 2008). The Editor’s Choice offers an insight into how the authoritative interpretation of evidence can be as important as the evidence itself. The authors of this Midwifery editorial are also subject to making interpretations based on our beliefs. We include a member of the recent National Institute for Health and Clinical Excellence intrapartum guideline group (GG), and authors of the Cochrane review of home-like places for birth (SD, DW), which rather contentiously noted a trend towards increased perinatal mortality rates for alongside birth centres (Hodnett et al., 2004). We generally support the provision of

Physiological Positions for Breech Birth

In March this year, the Royal College of Obstetricians and Gynaecologists (RCOG) in the United Kingdom revised its guidance for vaginal breech birth to explicitly include the option of upright breech birth alongside the conventional semirecumbent position (Impey, Murphy, Griffiths, & Penna, 2017). This is hugely significant for a number of reasons. First, it acknowledges the physiological advantages of upright position for both breech and cephalic presentations. These include less perineal trauma in the all fours position specifically for breech presentations (Bogner et al., 2015) and the fact that the kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet (Reitter et al., 2014). In addition, upright postures shorten the first stage of labor by at least an hour (Lawrence, Lewis, Hofmeyr, & Styles, 2013). This particular recommendation has been graded Level 3 regarding strength of evidence which equates to nonanalytical studies (e.g., case reports, case series). Significantly, the guideline also quotes Evans (2012), a well-known independent midwife in the United Kingdom who has been running workshops on upright breech birth for many years. I find it interesting that the guideline is more explicit about the advantages of upright breech birth than the United Kingdom’s National Institute for Clinical Excellence (NICE) Intrapartum Guidance on birth position for cephalic presentations which recommends the rather feeble directive that women should be free to choose whatever position they deem comfortable for giving birth. It fails to highlight the numerous advantages of upright posture from a much more extensive research base than that for upright breech birth. This rather inconsistent approach to the interpretation of evidence highlights the politics of evidence implementation, a subject not often written about but one that is very real for midwifery colleagues who sit on multidisciplinary guideline groups. Of course, we interpret evidence through our own professional filters which shape how we adjudicate the relative strength of evidential claims and crucially how we write up recommendations for practice. Vaginal breech birth physiology was discredited and completely marginalized by the Term Breech trial in the late 1990s. Overnight, the practice of vaginal breech birth virtually disappeared across the world because elective cesarean section became the birth mode of preference. Subsequent follow-up of neonates of vaginal breech birth led to a significant reappraisal of the study’s finding over the next 10 years and a radical downgrading of its conclusions. Fortunately, pockets of vaginal breech practice had been maintained across countries but with a twist—upright breech birth, consistently advocated as superior to semirecumbent breech birth by a small number of obstetricians and a vocal minority of midwives, became the posture of choice. It began to be taught in mandatory, multidisciplinary skills and drills sessions in maternity hospitals across England and thus was disseminated as an option among obstetricians as well as midwives. From 2010, specialist whole-day workshops appeared across the United Kingdom, taught jointly by obstetricians and midwives, and international meetings on upright breech with specialists from Europe, North and South America, and Australasia began sharing research, audit reports, and skills. Around this time, midwifery textbooks began describing vaginal breech presentations as unusual but not abnormal (Schmid & Downe, 2010) and promoted the upright breech position as the best physiological option for birthing. Now, in 2017, in the United Kingdom at least, vaginal breech birth has almost been rehabilitated as a safe option for women where the expertise exists to support it. It is hoped that maternity care systems in other countries will respond positively to this timely development in the United Kingdom.