The MBRRACE report is incredible. Confidential Enquiries have reduced maternal deaths from 90/100,000 to 10/100,000 since the 1950s, which is a huge achievement.
MBRRACE is also put together by prestigious, multidisciplinary teams.
So it might seem strange that I'm putting up a post finding fault with it.
But midwives have a duty to assess recommendations as part as advocacy for women. It’s why midwifery degrees cover how to critique guidelines and research.
It can feel really frightening going against the grain. But midwives time and again have changed practice for the better. (Click here for Mary Cronk's wonderful account of refusing to do routine episiotomies).
There are 2 main questionable areas of the MBRRACE report I've noticed so far:
1. The Flu Vaccine Recommendation:
Pregnant women are more at risk of getting flu, and of complications.
MBRRACE states: 'Increasing immunisation rates in pregnancy against seasonal influenza must remain a public health priority'.
This sounds like very good advice.
But we don't know for sure how effective the vaccine is.
Sara Wickham, in particular, has mentioned on her wonderful blog that there isn't evidence to say all the flu-related maternal deaths were preventable. This is because a recent Cochrane report found protection from the vaccine was only mild; there was ‘no appreciable effect on hospital admissions or working days lost.’
MBRRACE argues the deaths were preventable, as it would have been better for these women to at least try the vaccine.
There are some specialists that argue the Cochrane data was too ‘finely cut’ to show any overall message, and quote trials which show the vaccine is very effective.
It seems there’s a lack of information from the research.
2. The 'Think Sepsis' Obs Recommendation
Like with flu, pregnant women are more at risk of sepsis. We think this is because their immune system is a bit suppressed during pregnancy, so the baby doesn't get treated like an invader.
MBRRACE says ‘Think Sepsis’ at an early stage when presented with an unwell pregnant or recently pregnant woman, take all appropriate observations and act on them.’
But this is controversial just because it’s sometimes very hard to tell when a woman is unwell.
We might screen women needlessly…and then end up with false positives.
Sepsis comes with lots of different symptoms. Women can have the typical ones like a fever, shivering (rigors) or nausea and vomiting.
But they can also have headaches, painful urination, and light-headedness.
Should we do a set of obs on every woman who has any those symptoms?
We’d end up doing obs for pretty much everyone, as headaches can be caused by crying babies, passing urine can be painful because of stitches, and light-headedness can be caused by tiredness.
Doing obs on every woman means eventually we'll get a dodgy result. So we'll end up sending at least some healthy women into hospital for a check….and we medicalise, which can do more harm than good.
I'm totally biased, but wouldn't a better conclusion be: midwives and others need more time and more continuity with women?
It’s a lot easier to tell if someone’s sick if you're not meeting them for the first time.
It could be argued that a one midwife, one woman system of care would help prevent a lot of these flu/sepsis deaths. Better communication between professionals and women, and continuity of care would help nearly every case.
Currently, this is hard to achieve as time = money.
For now, we just have to try our best to give a balanced opinion about the flu, and Think Sepsis.
Heavy stuff! But important.
See part one: Before Their Time
See part two: 5 Lessons I Learnt
Amazing as always Elliex
Thanks Elena! x
So wish women could have continuity of care always each pregnancy 🙁 a personal experience this weekend with a close friend and I’ve been left feeling really upset and frustrated for her!
I watch some crass to unwind the latest one is called Jerserylicious it’s terrible but I can zone out to it
Oh no, I’m sorry to hear that about your friend, continuity would be fabulous. Wow, just had a look on youtube, that’s some very big hair on the Jerseylicious girls! Glad you’ve found something to chill to:)
I am not a student midwife (yet!) but interestingly would like to see more awareness regarding strep, particularly relating to homebirths. That’s just from my experience which could of gone very wrong (thankfully it didn’t!). I suppose that is down to funding though.
I’m afraid I like to unwind to rather indepth stuff that requires my concentration, like Silent Witness or Broadchurch.
He Melanie, I totally agree with you about the unwinding type TV! Interesting thoughts on Group B Strep, it sounds like a tricky time for you there. It’s a hard thing for midwives I think because of the number of clients you need to treat to prevent one case…Hmm, perhaps we need a post on that. Thanks for your insight x
I’ve recently completed placement in a private hospital, the standard of midwifery care is very high and they strive to normalise things as much as possible for women. I really noticed that continuity of care shared between the women and their obstetrician too (obstetricians in this hospital did most of any VEs deemed necessary, and were also present to assist with the birth during 2nd stage/baby’s head was on view. Even though they weren’t there for most of the time, the continuity was obvious and I really saw that difference between them and us as shift midwives doing our job. I wish that there was more opportunity for women to access continuity of care in the midwifery model, I can really see that lack here in Australia.
I’m not even sure what to suggest to address the lack either – funding certainly, but what policy changes need to be implemented to enable such a thing? I’m also especially interested in this so that women can also have continuity with midwives in partnership with an obstetrician where their pregnancy involves higher risk factors – and I wish such a thing were more possible without private health insurance.
I’m really interested in more information on post-dates induction – they were most of the births I saw on my 2 weeks in the labour ward recently. Which meant I also saw the cascade of intervention take place which was very educational, and I could see the evidence in practice being used. But now I’m interested in the other side of the story, especially since inductions seem to invariably lead to epidurals, instrumental births or even caesarean section.
Fascinating points 🙂 I think it could take a big political change to get the policy addressed, and money besides. Do you think the majority of women would appreciate midwifery led caseloading care in Australia?
What do Australian midwives think of the New Zealand model of caseloading care? Just over the Tasman, a completely different style of midwifery is going on by the sound of things!
Postdates induction is also a very interesting subject. Have you read Sara Wickham’s wonderful article ‘Ten Things I Wish Women Knew About Induction’? : http://www.sarawickham.com/wp-content/uploads/2014/10/AIMS-Ten-things.pdf
Really interesting post.
post natal visits are becoming few and far between now, and as you say mums feel u well and tired quite often just as a result of long labours, painful perineums etc.
I am a parent ed. Midwife and would love to see more visits for mums in the early days ( I remeber how valuable I found them as a new mum) but if anything things seem to be getting worse… I run through signs that might mean problems for new mums, and make sure they know its fine to contact midwives or g.p’s for more advice…I justs wish with all my heart we could do more, though.
‘I just wish with all my heart we could do more, though’ This for me sums up why maternity care from midwives and people like yourself in the UK is so brilliant. Such a committed team of people under such pressure. Thanks for taking the time to comment Jane.