Where do we go from here? What does it mean to bring this style of care effectively into health networks and health systems? How do we change the culture of birth among women, care providers, institutions, and health systems? Let's turn to some parting words of inspiration and experience from Dr. Down to conclude our module. One of the critical elements of providing optimum maternity care is to make sure that all the care providers that are working with women are working together in respectful mutual collaboration and we know this quote here, "Getting beyond the gargantuan struggle". This is a quote that came from some work we did on collaboration numbers of years ago in one of our local hospitals. It was a quote from one of our obstetricians saying we have to get beyond the gargantuan struggle between us all to be able to deliver optimum maternity care. I want to reflect back really on this textbook or this book of Irvine Loudon. Irvine Loudon was a medical sociologist who looked at death in childbirth in Europe between 1800 and 1950. The reason I'm going back to this as an old text is because I think the quote he came up with is fascinating and highly relevant still. He said, and I'm going to read this even though I wouldn't normally because you can see it. I'm going to read it because I think it's quite powerful. "I found, and it was not a finding I expected that wherever there was a system." I've highlighted some of these words. "A system of maternal care based on trained, licensed, regulated," and my underline, "Respected midwives, especially in close and cordial cooperation with doctors and hospitals, the quality of maternity care was at its highest and maternal mortality was at its lowest. I cannot think of an exception to this rule." I think obviously he was talking about a time when maternal mortality was much higher in Europe, but we know that the maternal mortality in many countries around the world is probably as high now as it was in Europe in 100 years or so ago. We also know that in some countries, not least the US maternal mortality is going up and the gap between marginalized women and wealthy women is widening in many countries, including in the UK and the USA. These statements, I think, are very powerful and very important and we need to bear them in mind because they matter to the women and babies and partners we're looking after. I want to give you a couple of examples from the UK. This particular one was a result of projects across a whole hospital where they were, among other things, they decided they were going to congratulate each other if they did good things. If you saw a health care provider, or reporter, or whoever, domestic person, whatever, doing something good, then the idea was you wouldn't just go, "No, you're doing great things, you are." But you would say, "You've done a really good job there, and this is why you've done a good job." This particular e-mail was an e-mail sent through a midwife. The midwife is called Louise to a Consultant Obstetrician. I'll let you read what Louise wrote there. Lets just be quiet and let you read it. Caroline was a senior midwife who was on duty with Louise at the time. As I said this e-mail is going to the obstetrician. Here's the woman herself, who has given permission to have her picture used. You can see she's in an old NHS birth with all kinds of sticky stuff there, she's got an old IVAC in the background. She's on the anti-nausea in the pool. Basically she said it was the best experience of her life, because all of the people concerned, the infection control people, the obstetricians, the midwife, whoever, the porters or say, everybody got together to make this experience as physiological as it could be and as positive as it could be for her. Here's another example. This is Nicola. This is about Nicola with her baby. In Nicola's case she had bought with a midwife case holding team. The team was set up particularly for women who'd had previous traumatic birth, and Nicola had had with her first baby a very bad third and fourth degree tear and lots of peroneal repair following that birth. When it came to the current birth, the one you can see here with her current baby or the baby current at the time of the story, she was in the hospital and she was in the second stage and she just couldn't push the baby out. In the end, the midwife looking after her brought one of the obstetricians in. Nicola, we don't have time for me to tell the whole story, but basically what Nicola says is, Liz Martindale who was the Obstetrician, sat on the bed and said to me," What do you want to do?" Nicola said," No one had ever asked me that before." The consequence of this was that Nicola said, "Look, I really can't cope if I lay flat on my back. I can't lay from my back again like last time." What the Obstetrician did, and this is a mockup of actually happened. This is the actual Obstetrician you can see in this picture, Liz Martindale down in the blue kneeling on the floor, and then the person in purple is the actual midwife, Anita Fleming, and the two in the middle are midwives in a Care system who are enacting the woman. As Nicola tells a story she said, "What Liz Martindale does did is she lied on the floor underneath me and she put the forceps on the baby's head and she turned the baby, and then he took the forceps off and then I pushed him out." She said she had no tears or she had one small tear which needed just one state. Then, she said, and when she tells the story, she tells it like this, she said, "She did something for me that day that I will remember for the rest of my life," She says. She couldn't change what happened before, but she put the puzzle back together basically. The point is here that Nicola and Anita and the others in the team worked together respectfully without saying, "No, it can't be done, but always saying, how can we do it? Not No, but how can we to make this as good as it possibly could be for that particular woman in fact, they've done it for others subsequently?" One of our studies, led by Joe Thompson looked at women who had traumatic births and then positive births, and the words they used. The words that women use for their first traumatic birth were words like torture, rape, they actually used these words, "Torture, rape, abuse, hell." When they were asked about their positive birth, they use these words, "Joy, euphoria, fantastic, positive, amazing and loving, credible." The trouble is if we measure satisfaction, we miss all that stuff there is at the top of satisfaction, all the both and stuff, the top of Maslow's hierarchy stuff that matters so much to women, that these women in their positive births were expressing, you can see the quote from Holly. It was a positive pain. It was fantastic. These things are very important in terms of how we take maternity carefully. We have to recognize the space above the bottom of Maslow's hierarchy that matters to women. This is another quote from the same study and I particularly like it because you can see that, I still get it. These are women who are being interviewed some years after the event. They were saying they still get that feeling of amazing joy and euphoria, which tied them into the motherhood, the wrap-up I was talking about earlier, that matters to women from their pregnancy all the way through to the motherhood. The birth experience resonates into the future in terms of their capacity to mother effectively and to feel good about their mothering and the parenting in fact, for fathers this is also true, and other partners, so partners, fathers, mothers, everybody, if a good birth happens. I'm not good with Aami Cesarean because sometimes that's what's required. Whatever a woman needs and wants to her birth has to be done as well as it possibly can be, cesarean, induction, forceps, whatever, so that these positive relation, this positive phenomena can vibrate forward into the future for them all. Just really to finish with a couple of quotes, this is equivalent Dalai Lama, which I think is very important in terms of the care that we provide. This one, "We may be aware that we've done lots of things in the past." When I first trained, which was in the 1980s, 90s, we did Routine episiotomies on all first-time mothers. We clearly would not do that, at least I hope. No one does that anymore. We can't change that, though we have responsibility to change the future one breath at a time. This is what we need to take going forward to make a difference to the world. Thank you.
