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Words and actions – consequences changing the course of history

Have you stopped to consider the effect of your words or actions as a midwife? Everything has consequences. Jenny Hall, Matflix and Midwifery Forum editor asks us to consider the impact of our practice.



Everything has consequences.

You may have heard of the quote where Edward Lorenz stated that a butterfly flapping its wings in Brazil might cause a tornado in Texas. Thus, was born the butterfly effect principle of chaos theory; that even the smallest change in one system can result in larger changes of state, but we are unable to predict how and when this happens. What this says is, in nature and science things are complex. There are many stories in history where events are transformed by what appears to have been a small human choice at the time. For example, ‘should have been there’ stories for certain disaster events or more positive ‘instinct’ stories of people turning up to help others at the right time.

This should make us all sit up and take notice, as humans giving birth are also complex beings involved in a complex process. As health professionals involved in the birth world we should not take this, or our role in the consequences, for granted. We should be taking notice of what we do, what we say and also what we are not doing or saying. What we do impacts on the woman or birthing people and their family in front of her from the antenatal period, which could impact her labour and birth, which could impact her into the postnatal period and beyond with her relationship with her baby going forward. We must not underestimate the power of our roles.

My thoughts have been formed by a number of things in recent years- being a midwife you see a lot, then becoming a mother yourself and more recently the change to grandmothering. I have listened to women and birthing people, and new fathers over time and heard a myriad of pregnancy and birth stories. I have asked myself; “if the carers who said this or did this in this circumstance knew that what they did or said had this impact on this person, two weeks, four months, twenty years down the line, would they have done anything different? Would I do something different?” When I was a young midwife the advice was given in the hospital for us to pop down to the postnatal ward and see the woman we had cared for in labour the night or day before and find out how things are going and if she had any questions to answer. I suspect this is well-nigh impossible now. I suspect some midwives might be fearful of doing that, in case of what was said. But it helped to learn what we could do better. Of course, if it was a homebirth we would be there in the home twice visiting for the next few days and daily after. This is all lost. Some community midwives have no idea what is occurring in the home in the postnatal period as women are asked to go to clinics. The consequence of this I feel is concerning, with a generation of new parents largely being unsupported in those early days by midwives, and getting mixed messages from families, friends, midwives and social media.

There is no doubt the journey of pregnancy and birth is a delicate, physiological balance and we should always be asking how we get this balance right for this dyad. A simple throw away sentence that we may use, or how we greet a woman for an appointment could transform the way that woman views herself or her pregnancy and the choices she makes and change everything. There are enough stories in recent reports and the press to show how what we do or say matters (and what we don’t do or say). Do we really know what the actions of a ‘stretch and sweep’ are, for example, or that extra drop of syntocinon or even that ‘quick CTG’? Disrespectful care, undignified care ultimately will lead to trauma. I will drop students into this too, that how we speak or support the midwives of the future will impact the midwives they are going to be in the future. Are our behaviours toward them going to change how midwifery will be ten or twenty years down the line?

But there is more. The French obstetrician Michel Odent has questioned for years the impact of increasing medicalised care on children and families both now and a long time into the future. Understanding now of epigenetics (see Dahlen et al 2013, Uvnas-Moberg et al 2020 for examples) points to this. We should be questioning every little thing we are doing that interferes with the delicate balance. It is therefore positive to see that there are moves to investigate information giving for induction in labour to enable informed choice. The increasing use of drugs to induce labour may have higher consequences than we realise. For example, evidence points to introducing prostaglandins suppresses prolactin secretion which will then impact on establishing breastfeeding. Is this information given to women before it is administered? It is further reported that children who were born at earlier gestations (37-38 weeks) have poorer outcomes at school than those at 40 weeks. This should ring alarm bells as some hospitals are increasingly ‘offering’ induction of labour prior to term.

In a wider context alarm bells should ring further on the effect of our lifestyles on birth. Smoking, vaping, ingestion of drugs are all known impacts. The increasing use of plastics that can now get into our food chain, or chemicals via cosmetics or cleaning products may be toxic to women hoping to give birth. They have been identified in placentae, and may cause preterm birth. Our society then may be impacting on our children for generations to come.

Not having enough or the right staff on duty at the right time for the needs of the women and families will have a consequence. Not using interpreters for those who need it could lead to serious impact. Lack of calibration of equipment could mean results on CTG, blood tests, blood pressure, baby weight being incorrect or requiring repeating. I am sure you could think of many other scenarios along these lines.

It all sounds very scary and impossible to get right. On one level it is. We can only do what we can with what we know. I can look back over my career and the interventions we carried out as it was the ‘routine’ or guidance at that time and feel some embarrassment and shame. I can only say sorry for the impact, as we didn’t know any different at the time. But we do know better now, and we know much more. There will be more to be revealed. As examples, we know already that a midwifery continuity model of care has benefits and greater satisfaction, reiterated in the newest Cochrane review. We know that socioeconomics has an effect on birth outcomes. We know place of birth matters. We know that compassionate care has a positive influence and may prevent trauma and that a poor workplace culture does not lead to compassionate care. It is the inaction or poor action when we do have the evidence that should make us challenge ourselves and the system. As the Chief Midwifery officer for the ICM, Jacqueline Dunkley Bent says we should be the best that we can be. That ‘best’, I hope, will be to strive to consider carefully our words and actions before we speak or act, which has the potential to impact the lives of a woman and her family for years to come.

And that includes how we choose to vote in our next election! Everything does have consequences.

April 2024

Dr Jenny Hall

Maternity and Midwifery Forum | MATFLIX

Jenny Hall