I was scared. VERY. I am dreadfully phobic of enclosed spaces and didn’t know how I was going to cope with an MRI. For a while I considered putting it off but I realised that being a doula has given me a number of useful tools.
First, I reached out to a friend who was able to use her hypnobirthing skills to defuse my fear and keep me calm. Second, I was able to advocate for myself. I was lucky – I had a medical practitioner who noticed my fear, welcomed and utilised my companion, talked calmly and offered me further tools and reassurance. It was a team effort for which I was very grateful. Afterwards, I learned that companions are not normally ‘allowed’ into the room with the MRI machine. Yet this practitioner had seamlessly adapted to the circumstances, tailoring my care to my particular needs.
I can’t imagine anyone objecting to the way he handled things or criticizing him for not following guidelines. Most of us are intelligent enough to realise that different patients will require different approaches. In fact, medicine and healthcare in general hasn’t always been based on research, clinical trials and verifiable evidence. Until relatively recently in history, all the care we received from doctors was based on opinion, observation and experience. Even today, doctors often rely on their own experiences of treating patients and the opinions of their colleagues.
Pressure to follow evidence-based guidelines is increasing. In general, I think this is a Good Thing – it ensures consistency and encourages clinicians to follow the evidence, rather than allowing assumption, bias or prejudice to influence their care. But it seems that the focus solely on evidence – and increasingly only certain cherry-picked evidence at that – is allowing us to throw the baby out with the bathwater.
Let me explain. If you’re reading this blog, like me, you’re probably very interested in that little corner of healthcare called maternity services. We birthworkers inhabit a rather strange world in which the users of the service are not necessarily ill. They may not require ‘treatment’ like in other areas of the hospital but all of them require some kind of ‘care’.
So if ‘care’ doesn’t always have to be medical treatment, what does it encompass?
Here’s what I reckon. The ‘care’ part of maternity care should be relationship based. That means continuity of carer – getting to know someone who trusts and respects you and your choices. That relationship can be deepened and strengthened in various ways; spending time together, exploring options, sharing information and feelings. All this can be helped along with tools and comfort measures that may or may not have been researched and ‘proven’ by scientific research. Tools like hypnosis, aromatherapy, acupuncture, reflexology, singing or yoga can have profoundly positive effects on the experience of pregnancy and birth. They may not be ‘evidence-based’ (in terms of being universally accepted by the Western medicine paradigm) but there is overwhelming anecdotal evidence that they can help parents through the ‘maternity experience’. And in some cases, there is solid research evidence that these modalities can be extremely efficacious, improving outcomes under a number of measures. In fact, the Royal College of Midwives has found that nearly 90% of women use some kind of complementary therapy during pregnancy and considers some understanding of these therapies to be an essential part of a midwives education.
Time was that interventions using complementary therapies were widespread in NHS maternity care. Hinchingbrooke hospital in Huntingdon, for example, reduced their induction rate by 5% with the use of reflexology. Yet around the country projects like this are being cancelled, with lack of evidence being cited for the withdrawal of funding.
Yet how many of the guidelines that maternity services use are based on high quality evidence? Actually, less than 12% are based on Grade A evidence. That’s no one’s fault – it’s hard to ethically experiment on pregnant people and babies! But it does mean that looking down on complementary therapies or banning their use because they are ‘not evidence-based’ is not logical thinking – actually, there is some evidence that acupuncture, for example, can help nudge a woman into labour if the baby now needs to be born. It can also make someone feel nurtured, cared-for, safe and relaxed – a hormonal state that we know has a positive impact on the maternity journey. Crucially, there is no evidence of harm. Yet its use is criticised and even banned in some NHS trusts.
My clients are routinely offered treatments that are less evidence based than the ‘intervention’ I offer as a doula. Numerous trials have found positive effects of continuous support from a companion who is not a member of the hospital staff, but I do not see the NHS falling over themselves to promote the use of doulas! Yet when it comes to routine practices like continuous monitoring in labour, which has not been found in studies to improve outcomes, no one seems to be questioning its use. A recent study found that outcomes were not improved by using continuous electronic monitoring on women or people labouring naturally after having one previous cesearean. New guidance was published, but the Royal College of Obstetricians and Gynaecologists protested so much, that the guideline was changed back again. So a non-evidence based intervention is supported and promoted, while therapies like acupuncture, reflexology and aromatherapy are scoffed at and rejected, despite a large body of evidence to support their use and prove their safety.
It occurs to me that there are likely to be some inherent biases going on here. Biases that shine a light on the power structures within the medical system. If a tool, such as a complementary therapy, is used by a midwife, it is quickly criticised, banned or funding for it denied. Yet practices that doctors endorse are never questioned.
I am not criticising doctors for having their own opinions or their own styles and preferences. But I think I see toxic power structures at play here. The system is inherently patriarchal, firmly fixed in the Western, medical model; centering eurocentric ideas. The emphasis is on ‘treatment’ – identifying problems and fixing them. The ‘female knowledge’ that focuses on ‘caring’ for the woman or pregnant person is ignored or actively obliterated. I want to be clear here, that I am not against the ‘medical model’ of maternity care, nor do I think that all midwives and all female health professionals are free of bias. Both men and woman are products of, and can be conduits for, the patriarchal, paternalistic, white-centric system.
Whatever the reason, there is is a lack of consistency that can leave parents frozen in cognitive dissonance. When faced with different kinds of interventions, one kind has status and the other is belittled.
Deep, trusting relationships are surely enhanced by the use of relaxing complementary therapies. Pregnant people need ‘care’ as well as surveillance. They need relationship based care, inclusive of complementary therapies, that enhance oxytocin and build trust between service users and staff. Maternity care should have the mother’s emotional state at the heart of all its activities. It should be inclusive of all cultural backgrounds, integrating treatments and attitudes to care from as many sources as possible. Western medicine is wonderful, but it is not the only approach to health that humanity has access to. Surely it makes sense to be open to it all?
I have a lot of compassion for the CCGs – the groups of commissioners who have to make decisions about what is funded and what isn’t. It must be a mind numbing and heartrending job. But it’s surely a no-brainer to focus on health-maintenance and pathology-prevention – we’ll save a shed load of money in the both the short and long term. At the moment the focus in maternity services seems to be on intervening with technologies to prevent poor outcomes. I believe that if we put the same amount of energy, enthusiasm, training and money into health promotion in pregnancy, including continuity of carer, peer support (such as doulas) and complementary therapies to promote good mental and physical health, poor outcomes would be reduced massively. (And I’m including the psychological impact on the parents here – not just whether they all go home alive – because if that is the pinnacle of our aspirations rather than the bare minimum we should expect, I despair).
When it comes to funding, just like every other aspect of maternity care, we need to listen to the people actually using the service! I want to know whether the CCGs that are refusing to fund complementary therapies have actually asked us if we want access to these techniques, whether we find them helpful and why we found them helpful. Yet again, it’s people in suits, sitting round a table looking at spreadsheets making the decisions. But we can’t plan healthcare at arms length like this. Listen to the people – we won’t just tell you want we want – we’ll help you save money too!
Are complementary therapies being integrated into your local maternity services? Are you a midwife or doctor being supported by your CCG to fund training and implementation of these therapies? Or have you had this kind of funding cut? We would love to hear your experiences and opinions so please comment below.
Further reading, if you’re interested in the use of complementary therapies in maternity care