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Dear All, please see below the response from Chantelle, ------------------------------ *From:* Chantelle Winstanley <[log in to unmask]> *Sent:* Monday, November 19, 2018 3:01 PM *To:* Rocca-Ihenacho, Lucia *Subject:* FW: Debates on the ‘uselessness’ and costs of having MLU and homebirth in ongoing Italian Congress HI Lucia My message didn’t get sent to the wider team on the research email as I’m not recognised as a user. Feel free to circulate this onwards if you feel it is of some use ……. Hope to see you soon ! C xx Chantelle Winstanley Consultant Midwife St Georges Hospital NHS Foundation Trust Tel: 07825144241 Please note: My working days are Monday and Thursday only *From:* Chantelle Winstanley *Sent:* 19 November 2018 14:58 *To:* 'Lucia Rocca'; A forum for discussion on midwifery and reproductive health research.; Laura Iannuzzi *Subject:* RE: Debates on the ‘uselessness’ and costs of having MLU and homebirth in ongoing Italian Congress Dear Laura I’m coming to this very late following your conference……..thank you, Lucia, for copying me in. Firstly Laura, what a wonderful job you are doing fighting / pushing / questioning / challenging and not giving up your pursuit of a midwife-led unit in Italy ! As Lucia said, it is really hard work and pretty exhausting, especially when the dominant discourse is dismissive of the existing evidence surrounding the benefits of midwifery units, particularly the evidence which highlights supporting women’s choices / positive birth experiences and the differences in environment and philosophies [generally speaking] between an obstetric delivery suite versus a midwife-led birthing area. I loved the comment about speaking with vets about optimal birthing in animals ;) How wonderful it is to see such a rich discussion and fabulous feedback to support your queries from an amazing group of midwifery academics (I must get myself back on this forum!) As Lucia highlighted (and I can only speak from a pragmatic / anecdotal perspective) – I lead an AMU in a very busy teaching hospital in London. We’ve worked really hard over the past 4 years to make this area a welcoming, safe and open choice to *all *women who have a desire to have an optimal / active birth away from the medicalised delivery suite. For the past year, our transfer rates have dropped even lower to an average of 16% in total (nullips and multips combined)– almost half of that is for women who request an epidural or who seek analgesia for a very long and protracted labour whereby we suspect there is an obstruction (and have utilised all of our midwifery know-how to support this situation.) Excluding epidurals, our average transfer rate this year is <10% and serious emergencies make up <0.5% of the total number of births per month. I feel this is something to celebrate! And I know we are not alone…..I’m certain there are other hospitals out there in UK who have similar or even more promising results….these figures are perhaps useful for any future discussions you may be having to drive this change forward? It is worth noting that, under my leadership and with an excellent team around me and clear multi-disciplinary communication, I regularly push for ‘out of guideline care’ for women to support their choice and rights in childbirth; to not exclude birth centre as a choice if a ‘risk factor’ exists and to talk openly and honestly about what this means and what factors, if any , can we put in place to safely mitigate for these ‘risks.’ It is often a challenge [I may make this sound like it’s a walk-in-the-park; it certainly isn’t!] and we have to constantly and diplomatically challenge the current ‘evidence’ presented by obstetricians and midwives alike to deter women from using our birth centre. Nor are we perfect. So our AMU offers care pathways for women who would be excluded by guideline. One could argue that this fact, in itself, will increase the transfer rate. As Soo rightly pointed out, women transfer-in from home into hospital at some point in their labour. There is little difference? For women who opt-out of a home birth, all transfers are positive, right?? Pragmatically, we present a transfer from our AMU to the delivery suite as a *positive *thing…..that there has become a clinical safety issue which means our skilled obstetric team should be involved and share the care…..yet our philosophy should remain as intact as possible; aligning to the bio-psycho-social model of care; dignity, respect, shared-decision making; active birthing, quiet room etc etc. In the majority of cases, women describe a positive birth experience *in spite *of a transfer in place of birth and the possible addition of medical interventions. Again, I feel this is anecdotal evidence to be celebrated and added to this on-going international debate. Keep up the good work everyone! And best of luck, Laura Chantelle Chantelle Winstanley Consultant Midwife St Georges Hospital NHS Foundation Trust Tel: 07825144241 Please note: My working days are Monday and Thursday only *From:* Lucia Rocca [mailto:[log in to unmask] <[log in to unmask]>] *Sent:* 14 November 2018 19:58 *To:* A forum for discussion on midwifery and reproductive health research.; Laura Iannuzzi; Chantelle Winstanley *Subject:* Re: Debates on the ‘uselessness’ and costs of having MLU and homebirth in ongoing Italian Congress Hi Laura, sorry for coming in the discussion late! but you had very comprehensive responses. I can only add from a pragmatic practice view point that in an AMU where I was Consultant midwife with my amazing colleague Chantelle Winstanley, we managed as a team to deom intrapartum transfer from 43% to 19% in 4 months by implementing staff training, support in practive, reflective sessions on transfers and working with the women.... On the other hand we were also telling women that if there was a need to recommend transfer they would have been looked after beautifully by the LW staff who followed a similar phylosophy of care. The women really appreciated this approach. Often if the women feel transfer as a failure, it actually comes form the staff and conflict between areas of work. So we need to work proactively on keeping geographical and professional cross-boundary work positive and build relationships! As for what you say in regard of 'When prejudice dominate there is always a problem for any solution' it is so true....it is exhausting but we nee dto keep pushing with a 'stick and carrot system' we need to work on the new generation of obstetricians to ensure they appreciate interprofessional collaboration. Keep pushing! you are doing an amazing job 💓💓 xx Lucia Dr Lucia Rocca-Ihenacho PhD, MSc, RM Lecturer in Midwifery and NIHR Research Fellow Centre for Maternal and Child Health Research School of Health Sciences City University London 1 Myddelton Street London EC1R 1UW 07989 230313 Skype contact: luciainsky On Wed, 14 Nov 2018 at 17:24, Laura Iannuzzi <[log in to unmask]> wrote: Dear all thank you very much for all your inputs, I tried to say something. At the end of the presentation the problem was moved to ‘MLUs are too expensive we cannot have a team of 6-10 midwives for that number of births when there is a shortage of midwives in labour ward’ (useless to have said that the activities of a birth centre are not only intrapartum and that (unfortunately) many times midwives are moving between areas. By the way maybe it was because there were enough argument to move the debate from the transfer issue ;) When prejudice dominate there is always a problem for any solution :) But at least I tried to make the point that the conversation will be L ways biased if we focus on professionials views instead on women’s health. I enjoyed the opportunity at least to try to offer a different perspective and it was really impressive to me to see all your mails that made me once more again aware that each one of us wherever is and whatever the task has been asked is at some level giving voice to a community is not just speaking for her/himself Thanks for all the support I feel the chair of the session didn’t move from his position at all, but surely I did ! Laura Inviato da iPhone > Il giorno 14 nov 2018, alle ore 15:08, McCourt, Christine < [log in to unmask]> ha scritto: > > Just to add a few points to the already excellent responses: > > - in the Birthplace study, transfer rates were highest in alongside midwife units, where transfer time is very short and usually just a lift or corridor. > - as Laura has said, when you look at the rates from Birthplace, they are different for multips and from different settings but also a large proportion are not emergency > - we also had evidence in the Birthplace organisational case studies that a range of professional and organisational issues could be affecting transfer rates so attention is needed to skills, confidence (so training) but also integration and relationships within a service (so that transfers are based on good professional jdgement of clinical needs/women's wishes not on territorialism or professional conflicts or organisational imperatives such as crowding or lack of staffing) > - the economic evaluation included the costs of transfers in a very comprehensive way > - the analysis was designed to take into account all transfers when considering the clinical outcomes - this means that any such risks were included in the analysis - the findings represent the outcomes of the full continuum of care according to where women planned the setting, defined at the start of care in labour > - the work done on experiences of transfers showed that from the women's viewpoint (and their birth partner's) it is how you manage the transfer that really matters: they could have a positive experience but it did need to be well managed and supported and with appropriately tailored good quality information. Professional conflict or poorly developed transfer arrangements will not support a positive experience. Women ideally want some continuity too, with the midwife able to transfer with them, and good care and attention on arrival, not judgement - of them or of the professional who provided their care to that point. > > Other studies such as Overgaard's in Denmark and the Canadian studies and the Australian study have used similar methodology to ensure these kind of issues are taken into account. > > It seems at times that people in quite senior roles feel entitled to speak on an issue without reading the research in detail, to check the methods and what is covered, so then draw misleading conclusions such as 'it is all very well to say it is cost effective but what about the cost of transfers' and convey them to others with an air of authority. > > > > > > > On 14/11/2018, 13:24, "A forum for discussion on midwifery and reproductive health research. on behalf of MacVane Phipps Fiona" < [log in to unmask] on behalf of [log in to unmask]> wrote: > > Keep up the good work, Laura! I agree with previous comments but where is the 40% transfer rate coming from? I think it is important to also talk about education, education for midwives, for women and for doctors about physiological birth. A lecture from a vet always goes down well. Imagine you are breeding horses, what conditions would a veterinarian say would be optimal for a safe birth? Vets usually say, a known, warm, safe, quiet, dark environment. No intrusions, let the mother do it herself (no tugging, pulling etc.) but know how to help if and when it becomes necessary, . The physiology of birth works for all mammals (and human babies don't have those long awkward legs with sharp elbows)! If physiology is respected and women and midwives both understand this and have developed a trusting relationship then transfers will go down. > > -----Original Message----- > From: A forum for discussion on midwifery and reproductive health research. <[log in to unmask]> On Behalf Of Billie Hunter > Sent: 14 November 2018 09:50 > To: [log in to unmask] > Subject: Re: Debates on the ‘uselessness’ and costs of having MLU and homebirth in ongoing Italian Congress > > Great answers Soo and Laura! It's so important to turn these arguments on their head and point out the flaws in the 'logic'! > Good luck with the presentation Laura & congratulations on the important work you are doing in Italy Very best Billie > > Billie Hunter, RCM Professor of Midwifery & Director, WHO Collaborating Centre for Midwifery Development, School of Healthcare Sciences, Cardiff University. > > Sent from my iPhone - apologies for any typos > >> On 14 Nov 2018, at 09:38, Soo Downe <[log in to unmask]> wrote: >> >> I would say: >> >> 1. all women in hospital have had to transfer from home to hospital, >> often in strong labour, but no-one seems to worry about this - if we wanted minimum transfers in labour, we would have 100% home birth, with women only being transferred when they really needed the hospital 2. there are units with much lower transfer rates, still with safe outcomes, so if we want to reduce transfers lets look at these units, and use their guidelines - lets not work on the basis of units where the guidelines are so restrictive, without any benefit to mothers and babies. >> 3. If there really is a need for 40% transfer (which is unlikely) this >> still means that 60% of women are able to have their baby as they want >> to in a BC. This is much higher than the % of healthy women who manage >> to have the kind of birth they originally wanted in hospital - so what >> is the problem? Indeed, if we want to maximise the chance for women to >> have physiological births, even with a 40% transfer rate, BCs beat >> hospitals every time >> >> All the best >> >> Soo >> >> >> -----Original Message----- >> From: A forum for discussion on midwifery and reproductive health >> research. <[log in to unmask]> On Behalf Of Laura >> Iannuzzi >> Sent: 14 November 2018 09:07 >> To: [log in to unmask] >> Subject: Debates on the ‘uselessness’ and costs of having MLU and >> homebirth in ongoing Italian Congress >> >> Dear all >> I am attending the pre congress courses of the BIRTH Congress in >> Venice and I ll be speaking this afternoon of our experience in the >> Margherita birth centre in The Italian context The doctor who was >> chairing the course this morning in his presentation posed the >> question of what is the benefit of having MLUs if women in large part >> need to be transferred (he mentioned the 40% transfer rate for >> nulliparous in the birthplace study) and access to obstetric led unit >> with consequent trauma for women and costs for the system and ‘risks’ >> related to emergency (homebirth was not even considered to be an >> option being ‘risky’ - and he used US based literature ) So he was >> posing question on the issue of transfers >> >> I am trying to slightly change my presentation trying to address this >> question (that express a very common cultural standpoint in some >> context, that encourages midwife led care in labour ward but not >> midwife led care in midwife led units or home) >> >> For sure in my mind are coming reflection such as ; >> - yes it might be quite a challenge the theme of transfer for both >> women/ family and midwives >> - what is provided is not only intrapartum care >> - the more you protect physiology the less u need to transfer >> - the theme of women’s choice >> - the fact that transfers are mainly not due to emergency reason but >> more ‘tranquil’ situation such as slow progress of labour >> - what about the costs of unnecessary interventions ? Are we sure that >> they are lower than the costs of transfers >> - health is more than a intact Perineum and so on >> >> >> But as even if thoughly posed this is an interesting are of debate, I d like to know if possibile from you what would you argue, what points would you make to answer ? >> This could be of massive help >> Thanks! >> Laura >> >> Laura Iannuzzi >> PhD, MSc, PgCert, BMId, RM >> Lead midwife physiological pregnancy path and Margherita birth centre >> Careggi university hospital Italy >> >> >> >> Inviato da iPhone >> ###################################################################### >> ## >> >> To unsubscribe from the MIDWIFERY-RESEARCH list, click the following link: >> https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww >> .jiscmail.ac.uk%2Fcgi-bin%2Fwebadmin%3FSUBED1%3DMIDWIFERY-RESEARCH%26A >> %3D1&data=02%7C01%7Cf.e.macvanephipps%40SALFORD.AC.UK%7Cc89a9852ba >> 7d4f1e6a0c08d64a16acc6%7C65b52940f4b641bd833d3033ecbcf6e1%7C0%7C0%7C63 >> 6777858587576324&sdata=ibSiBEnfbkeeb3zvinXUCBOEFubIAgU0wXSL%2Fmxju >> sU%3D&reserved=0 >> [University of Central Lancashire] >> Please consider the environment before printing >> >> ###################################################################### >> ## >> >> To unsubscribe from the MIDWIFERY-RESEARCH list, click the following link: >> https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww >> .jiscmail.ac.uk%2Fcgi-bin%2Fwebadmin%3FSUBED1%3DMIDWIFERY-RESEARCH%26A >> %3D1&data=02%7C01%7Cf.e.macvanephipps%40SALFORD.AC.UK%7Cc89a9852ba >> 7d4f1e6a0c08d64a16acc6%7C65b52940f4b641bd833d3033ecbcf6e1%7C0%7C0%7C63 >> 6777858587576324&sdata=ibSiBEnfbkeeb3zvinXUCBOEFubIAgU0wXSL%2Fmxju >> sU%3D&reserved=0 > > ######################################################################## > > To unsubscribe from the MIDWIFERY-RESEARCH list, click the following link: > https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.jiscmail.ac.uk%2Fcgi-bin%2Fwebadmin%3FSUBED1%3DMIDWIFERY-RESEARCH%26A%3D1&data=02%7C01%7Cf.e.macvanephipps%40SALFORD.AC.UK%7Cc89a9852ba7d4f1e6a0c08d64a16acc6%7C65b52940f4b641bd833d3033ecbcf6e1%7C0%7C0%7C636777858587576324&sdata=ibSiBEnfbkeeb3zvinXUCBOEFubIAgU0wXSL%2FmxjusU%3D&reserved=0 > > ######################################################################## > > To unsubscribe from the MIDWIFERY-RESEARCH list, click the following link: > https://www.jiscmail.ac.uk/cgi-bin/webadmin?SUBED1=MIDWIFERY-RESEARCH&A=1 > > > > ######################################################################## > > To unsubscribe from the MIDWIFERY-RESEARCH list, click the following link: > https://www.jiscmail.ac.uk/cgi-bin/webadmin?SUBED1=MIDWIFERY-RESEARCH&A=1 ######################################################################## To unsubscribe from the MIDWIFERY-RESEARCH list, click the following link: https://www.jiscmail.ac.uk/cgi-bin/webadmin?SUBED1=MIDWIFERY-RESEARCH&A=1 ------------------------------ Disclaimer: This e-mail and any files transmitted with it are confidential. 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