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Nurturing Birth Book Review: The AIMS Guide to Resolution After Birth

Book review by Natalie Stringer

Image of the book "The AIMS Guide to Resolution After Birth"

The AIMS Guide to Resolution After Birth, by Shane Ridley, is available from the AIMS shop as a printed book or on Kindle, for £8: https://www.aims.org.uk/shop

“An absolute must-have resource.”

This book from the Association for Improvements in the Maternity Services (AIMS) is an absolute must have resource guide. It will point you in the right direction to find answers and peace following a challenging birth where you have experienced traumatic events.

All information provided in this book is completely up to date being published in 2020, therefore all signposting to relevant websites are accurate and still in practice.

There are so many different, confusing avenues you may need to explore when wanting to raise a concern or make a formal complaint after birthing a baby. This book very easily allows you to recognise and guide you towards the best route for your individual circumstance. It is UK specific and highlights the different organisations in England, Scotland, Northern Ireland and Wales, so you can contact the relevant people in your country. There are some time limits when making a formal complaint within the NHS Maternity system, and these are highlighted in the book. Therefore having this guide to hand to dip in and out of when you feel comfortable, will help you piece together what you need in a time frame that suits you, but does not exceed the cut off point.

There are template letters provided in the book that you can work with to raise a concern or make a formal complaint. Numerous support organisations and charities are listed throughout the book, enabling you to seek out who can help guide you through this process, if necessary.

The book also provides a great insight into how to prepare for a subsequent birth and who to liaise with, as this will help ensure certain traumatic events do not reoccur again. Guidance on how to write your ‘birthing decisions’ is a great resource and will give you the foundations to make this birth better and more in-line with your own personal needs. It provides different options for you to choose the best support for you throughout your next pregnancy, labour and birth. This will help ensure you can feel more emotionally and physically in control of your decisions and your autonomy.

Exploring how you feel about your difficult birth experience and/or the care you received is discussed in Chapter 3 of this book. I know this will be so comforting for many mothers and birthing people who decide to put pen to paper and allow their experience to be validated. This may just be a starting point that encourages you to recognise that you do indeed wish to raise a concern or make a complaint. For others it may provide enough emotional release and your resolution may end there.

The language used in the book can be a little difficult to digest in some places. Although written thoroughly and very clearly, some areas can be a little heavy on abbreviations and putting a sentence together in places may need re-reading a few times to help it sink in or understand which organisation or charity has been written about.

Ultimately, many readers will be looking to find much needed answers and therefore it can be used as a reference book. So it may be a case of finding the relevant chapter(s) for their individual needs rather than reading the book from cover to cover. The contents pages at the beginning make it easy to navigate through whilst missing out sections that are not relevant to you. However, I believe every birth worker should read every page of this book and refer to it often, not only to recommend to their clients who need to seek resolution after birth but also to locate relevant information very quickly.

As part of ‘The AIMS Guide To’ series of books I believe this one will help many, many birthing people find their inner strength and courage to explore not only what happened during and following the birth of their babies, but also find the light to indeed seek resolution.

The main success of this book is giving parents the permission to find a way to raise their concerns or make formal complaints about their birth experiences. Together, if more people feel listened to, respected and supported when choosing to revisit their difficult experiences in order to find answers, they will be paving the way for a better maternity system for birthing people now and for the next generation.

Book review writted by Nurturing Birth Doula Natalie Stringer.

Natalie can be found at www.equilibrium-birthing.com or on the Nurturing Birth Directory: https://nurturingbirthdirectory.com/doulas/united-kingdom/kent/sevenoaks/natalie-stringer/

The man who birthed his babies

Nurturing Birth doula and writer Emma Ashworth interviews Yuval Topper, trans man from Yorkshire and birth father of three to find out more about his experiences, and how doulas can better support trans men during pregnancy and birth.

Emma: Tell me about yourself, where you’re from.

Yuval: I am married to Matan, I’m from Israel but I live in the UK and I’m a trans man with three children who I gave birth to.

I had my oldest son (Lyrie) and my daughter (Aria) in Israel – my son in hospital and my daughter at home, although I had planned a home birth for them both. It’s not easy to have a home birth in Israel, and most midwives will not come once you reach 42 weeks, so at just over 41 weeks I was getting quite nervous. I decided to take castor oil which did seem to trigger labour – but also may have been why my Lyrie passed thick meconium when my waters broke, so we transferred to hospital.

Emma: How did Lyrie’s birth go?

Yuval: I really hadn’t wanted to go to hospital. I had gone to a different hospital at about 26 weeks with reduced movements. The experience in the hospital wasn’t too bad, and my baby was looking healthy, but then shortly afterwards a national newspaper contacted me, wanting to write about my ‘story’.  Matan and I decided that we really didn’t want to talk to them – and they ran the story anyway – the first trans man to be pregnant in Israel. It was not positive coverage. The hospital denied that it came from them of course, but it really made me wary of contact with unknown medical staff.

Lyrie’s birth was quite traumatic. As is common in Israel I was made to have interventions that I didn’t want, such as an episiotomy and ventouse. I was also mis-gendered a lot. In Hebrew everything has a gender. In English I might be mis-gendered when someone talks about me, ie using she/her rather than he/him, but in the Hebrew language this can happen when someone speaks to you directly, and this happened a lot during his birth.

I really wanted to be completely naked while I was in labour, but the staff kept covering me which felt really irritating and against my body’s instincts. I did wonder whether they felt uncomfortable seeing my non-conforming body which is why they kept trying to cover me.

After Lyrie was born and I was moved to the postnatal ward, I had a frustrating conversation with a midwife or nurse who kept telling me how unusual the situation was, and she’d never come across it before, but she was fine with it. She was clearly out of her comfort zone and continuing to repeat that she was “fine with it” showed that she maybe wasn’t! Next day another staff member came round to see me and asked whether I was going to “stay a woman” now!

Emma: That sounds really exhausting

Yuval: Yes, I was feeling that I had to justify my existence rather than focus on my baby. But it didn’t end there. Although they gave Lyrie a registration number in the hospital, I had lots of problems when it came to register his birth. They would not allow registration from a man, and that forced me to re-register myself as a woman, register Lyrie and then register as a man again. The process is complex and for a while it was unclear whether they would re-register me as a man, which would have left me with unmatched identification such as my passport and driving licence.

Emma: What happened with Aria’s birth?

I again planned a home birth with Aria, and this time had a very positive birth at home. However when it came to registering her I had even more problems! The Registrar refused point blank to register her and actually told me that Lyrie’s was a “one time offer”! We did manage to register her in the end but it took so much time and effort, and for no benefit to anyone at all. It was transphobia, pure and simple.

Emma: So then you moved to the UK?

Yuval: Yes, and I became pregnant with our third child, Liam. At around 12 weeks of pregnancy I was phoned by the hospital and asked to come in for a scan – they had found a problem on my blood tests. My husband was away and my friend was unable to come with me – I was really nervous about attending an unknown hospital in a new country. Did they even know I am trans? How would they treat me?

In the end I went with a midwife that I had met once before, who I knew was trans friendly, and that she would support me to advocate for whatever I needed – but as it turned out I could not have been better cared for.

When I went to the appointment I received the devastating news that Liam had died at around 10 weeks of pregnancy. Despite the shock of the news I felt extremely well cared for by the obstetrician at the hospital. She made sure to ask me my pronouns, not assuming that I would prefer he/him (which I do) as some trans people prefer they/them or something else. I was otherwise treated just like anyone else – no one tried to ask me whether I was now going to stay as a woman! They were kind and supportive and recognised that I had just lost my baby, and my gender changed nothing about that.

Emma: When you were pregnant with your fourth baby, how did this influence your care decisions?

Yuval: When I was pregnant with Teagan – or Tig as we call him – a medical condition meant that I needed to have frequent scans and tests. My body had become Kell+ sensitised. This is a very rare condition which is very similar to being RhD Positive, but there is no equivalent with Kell+ to the anti-D treatment. I am Kell- and my husband is Kell+, so each baby has a 50/50 chance of being one or the other. As with RhD, this doesn’t matter for the first baby, but if any baby has a different blood type to the birth parent, and if this blood mixes, this can cause problems for subsequent babies. It seems likely that Aria’s blood, which is Kell+, mixed with mine during her birth. This means that my body became sensitised to it and my immune system is then able to attack the blood cells of any Kell+ baby.

We discovered through the NIPT test that Tig was almost certainly Kell-, which was a huge relief, but we could not know for sure. This did lead to a very stressful pregnancy, and I decided that I needed the support of a midwife that I knew, so we hired Hannah, the independent midwife who had been with me when I learned that I was miscarrying Liam. Having Hannah was a huge help, although I was also receiving excellent support from the NHS as well. In the end I birthed Tig at home together with Hannah and my friend Mari, and these photographs are the ones that Matan and I decided to share, and which have gone viral!

Even though the care in the UK was far more trans-friendly than I experienced in Israel there were still serious issues. For instance, the lab rejected my blood tests a number of times as my medical record has me recorded as male, and the lab tests were for pregnancy related conditions. This caused delays and could have impacted on mine or Tig’s health. I was also frustrated that, like in Israel, I had to have my name recorded on Tig’s birth certificate as “mother” – but here I also had to add in my occupation. So Tig’s birth certificate says “Mother… occupation – Full time dad”!

Emma: I love that! I do hope that the NHS will be able to update its systems to better support trans and non-binary people with all aspects of health care. It’s great that that you got the support from the staff. I’m wondering what, as doulas, we could do to better support trans or non binary clients?

Yuval: I think my biggest request would be to not make assumptions! For instance, many people assume that trans people don’t like their bodies. This is really not the case for many people! Many of us are very happy with our bodies. Different people do have different feelings about their body parts though – especially the genitals and the chest. Some people really struggle with the names of genitals and prefer to use different names. Others are happy to use the regular names. Where appropriate and relevant, just ask. However, consider whether you need to know – don’t just ask just because you’re curious. Also listen carefully for the words that the person you are supporting uses, and use the same words. For instance, if they mention chestfeeding, use the word “chestfeeding” rather than “breastfeeding”.

Please don’t assume what our pronouns will be, but ask what we prefer to use.

It can be really helpful to have the discussion about what kind of advocacy would be useful to us when we are in labour, or in hospital if we’re planning a caesarean. Please check whether, for instance, we’d want you to correct people using the wrong pronouns or words to describe the body that we have already said we would prefer to not use.

Ask if there are any other aspects of care that the doula should know and ensure that the medical staff know, if relevant. For instance, some trans men may be even more likely than women to object to having their breast/chest exposed or touched – especially those trans men who have not had top surgery (breast removal surgery).

Otherwise, trans people have the same needs in pregnancy and birth as anyone else, so once the differences have been discussed, please just support us as you would everyone else. Like birthing women, we want to have births which are right for us and personalised support where we are each asked what we need as an individual.

Yuval lives with his husband Matan and three children in Yorkshire, UK. To follow him on Facebook, click here: https://www.facebook.com/yuvaltopperez

If you are looking for doula support, please visit the Nurturing Birth Doula Directory.

Three photos of Yuval - 1, Yuval in the birth pool leaning over the pool with Matan behind him. 2, Yuval holding a newborn Tig in his arms and smiling at him while still in the pool. 3, Yuval cuddling Tig who is wearing a rainbow hat.

Nurturing Birth would like to thank Tara Leach for permitting us to use her birth photography images in this article.
‘Your Child’s First Adventure’. ‘Tara Leach is a Manchester-based birth photographer.  She is interested in documenting all births and all adventures. To get in touch either see her on Facebook or email [email protected]

Montgomery & birth rights: what doulas should know

By Emma Ashworth

Photo of Emma Ashworth, white woman with shoulder length brown hair wearing a floral dress.

What is Montgomery and how does it relate to birth rights?

‘Montgomery’ is critical to understanding our birth rights. It refers to a legal case, formally known as ‘Montgomery V Lanarkshire’, where Montgomery is Mrs Nadine Montgomery, and Lanarkshire is the Lanarkshire Health Board in Scotland. The case was brought after Mrs Montgomery’s son was severely injured during his birth. During pregnancy, Mrs Montgomery was very concerned about her forthcoming birth because she felt that her baby was too big for her to birth vaginally. She had diabetes, was very small herself, and the baby appeared to be large. However, her obstetrician did not offer her a caesarean birth as an option to consider.

During the birth, Mrs Montgomery’s son experienced a very severe shoulder dystocia. After a variety of interventions he was born by caesarean, and now lives with cerebral palsy and a damaged shoulder.

The injuries that occurred during his birth are rare, and, statistically speaking, were unlikely to occur even with the risk factors that Mrs Montgomery had. However, the legal case came about not because of the complications themselves, nor how they were handled, but because the obstetrician made the decision to not share the information about the possible outcomes of a vaginal birth and a caesarean with Mrs Montgomery, thus stopping her from being able to make an informed decision herself over what was right for her. Ultimately, the case came down to whether or not information was shared to support informed decision making – and, the case found, it was not.

What did it change about consent and birth?

Before the Montgomery case, what doctors shared with pregnant women depended, basically, on what other health care providers were sharing. They could decide to limit what information they shared with women as long as other doctors were doing the same. This was known as the ‘Bolam Test’, and it states, “If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent”. This applied to all areas of medicine, and led to many outdated principles still occurring (eg immediate cord clamping) because, from the practitioner’s point of view, if they did what most other doctors did, they had more protection against being sued.

With Montgomery, all this changed. Rather than just relying on what most other people did, practitioners are now obliged to share information on ‘all material risks’, meaning any risk (of an intervention or NOT intervening) that might be important to that pregnant woman or person, irrespective of what was normally done by their colleagues. If followed, this gives the pregnant person information they need to be able to make an informed decision about their own care.

Why do doulas need to know about it?

Sadly, no single legal ruling can resolve all of the problems that we have within the maternity system. Montgomery has given us a hugely valuable legal framework to support informed decision making.  It means that the pregnant woman or person must be offered information to ensure that they are able to make an informed decision about their care. If your client isn’t experiencing this, you can suggest that they raise this as an issue with their health care provider, and remind them that they alone can make decisions about their body.

Unfortunately, there are downsides to this ruling in practice, if not within the aims of the law. The ruling states that providers should ensure that they take “reasonable care” to ensure that “patients” are aware of “material risks”.

The text reads, ‘The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.’

What this should mean is that individualised care is offered, with doctors and midwives ensuring that women are given information that is relevant to them, personally, depending on their personal needs and wishes. What is happening in reality is that doctors and midwives misunderstand this to mean that they have to tell women of every possible horrific outcome that might happen if they decide to decline an intervention, or birth outside the hospital. They seem to be forgetting that their obligation is to offer a balanced picture of all of the material consequences of interventions and non-intervention (when was the last time that you heard all the potential risks of an induction, for example?), and they also seem to be forgetting that women are not obliged to listen to any of this!

Pregnant women are still autonomous beings, and they alone can decide what they want to hear. Our clients do not have to attend meetings with doctors or midwives who they don’t feel are supportive of their rights or decisions if they don’t want to. They don’t have to listen to a stream of possible horrific outcomes if they don’t want to. If they want the information, they can choose to ask for another midwife or doctor, and they can point out that being told only one part of the picture is coercion, not informed consent, and is going against the Montgomery ruling just as much as not being offered information is.

Further reading

The online content of Nurturing Birth’s Expansive Doula Course has a video on consent which includes information on Montgomery.  This presentation is also available to Nurturing Birth graduates who purchase the online modules after completing their Intensive Doula Course. 

AIMS has published a helpful article on the Montgomery ruling by a solicitor who looks at the ways it can be used in medical negligence cases within maternity: https://www.aims.org.uk/journal/item/montgomery

The MDU (Medical Defence Union) has a web page on Montgomery which clearly explains the legal situation: https://www.themdu.com/guidance-and-advice/guides/montgomery-and-informed-consent

Birthrights is continuing its work on consent, following the Montgomery ruling, by offering workshops to midwives and doctors on this topic, and they are part of a team launching an app for women to use in labour: https://www.birthrights.org.uk/campaigns-research/montgomery-and-consent/

Emma Ashworth is a Nurturing Birth doula, a trustee of AIMS and she is currently the AIMS Journal Editor. She has a special interest in consent and has written extensively on women’s rights in birth including on Montgomery and birth rights. Her book, “The AIMS Guide to Your Rights in Pregnancy and Birth” is available from AIMS. You can find Emma at her Nurturing Birth Directory listing here.

Birth and consent: the basics!

By Emma Ashworth

Photo of Emma Ashworth, white woman with shoulder length brown hair wearing a floral dress.

Your baby… Your body… Your decisions!

When we’re pregnant we are offered so many tests and checks, we’re poked and prodded and our bellies are listened to. We’re even told to “leave our dignity at the door”.

But did you know that you have the absolute right to decide what happens to your body? Did you know that it’s only you who gets to decide whether you have any of the tests, checks or interventions that are offered in pregnancy and while giving birth? Did you know that they are an option, even if they’re not presented to you in that way?

If you’re told that you “have to” do something or you’re “not allowed” to do something, remember that they can’t allow you any more than you can allow them. If you are told what to do, try to change it in your head from, “do this” to “I’m suggesting that you do this and you’re welcome to ask me more about it if you wish, before making your own decision.”

Making your decisions about tests in pregnancy

You have the right to ask as many questions as you want to before you make a decision, and often this is necessary as some of the decisions we need to make are complicated, and need serious thought about the pros and cons. In many cases, it isn’t solely about taking the test, it’s about what the consequences may be, of how your care may change, if you take it and you’re diagnosed with whatever they are testing for.

So let’s look at some of the questions that you might want to consider asking your midwife or doctor, to help you to get the information you need to be able to make an informed decision.

  1. What are the benefits and risks of the test itself?
  2. If I am diagnosed, what will the treatment options be?
  3. What changes to care would be recommended, if any, and why?

A commonly used acronym that can also help is “BRAIN”:

B – Benefits
R – Risks
A – Alternatives
I – What does your Intuition say?
N – What happens if you do Nothing?

You have the right to have as much time as you need to make your decision, even if this means another appointment to talk it through again. Usually you can go away to think about it and come back when you’re ready, if you choose to.

Making your decisions about labour

A common decision that many pregnant women and people have to make is whether or not to accept the offer of an induction at the end of pregnancy. Inductions are not a risk-free process, and this should be explained to you before you decide whether or not to accept one. Unfortunately, as induction has become more common, there is often little time allocated to explaining the risks and benefits, and yet without knowing all of this information the health care providers are not fulfilling their legal duty to obtain informed consent for the intervention. In fact, they are obliged to ensure that you have this information, and it must be unbiased, and where possible, evidence-based. If the advice that they are giving is not based on evidence, but their own opinion or something else, this must be made clear.

If you feel that you don’t have the information that you need to make your decision, you have the right to spend the necessary time with your doctor or midwife until you do. This might not be possible in one appointment but you should be given an additional appointment for as detailed a discussion as you wish. When you make your decision, it must be respected.

Making decisions while in labour

While you are in labour, it is sometimes harder to make decisions and for this reason it can be very valuable to think through in advance what you would or wouldn’t want to accept. One important decision is how you feel about vaginal exams. They are not compulsory. Nobody can put their fingers in your vagina without your consent, at any time, ever, and this doesn’t change during birth. Other common interventions include monitoring your baby’s heartbeat, and you might want to find out about options for pain relief and what the pros and cons are of each type on offer at your chosen place of birth.

During your labour, whether you’ve investigated something thoroughly or something completely new comes up, you still have the right to make your own decision about whether or not to accept it. If you want more information to make that decision you can ask for it.

How can a doula help with your birth rights?

While it’s helpful to know that you can ask for more information, not all midwives and doctors are helpful, and sometimes they can feel challenged, and become defensive or dismissive. The situation can sometimes feel confrontational, and that can be very upsetting for many people.

Doulas can be excellent mediators. They can take away the confrontation and instead support positive communication, helping you to ask the questions you need, and suggesting questions that you may not have thought of. Although doulas can’t give medical advice, they can signpost you to information that you may not have been given. They can remind you that you have rights, and encourage you to recognise your own empowerment.

A doula can help you to plan your birth and they will have knowledge about the options that you might want to consider in advance which you may not otherwise think of. So many people come out of birth saying, “I wish I’d known XYZ”. Having a doula means that you know more – and knowledge is power.

During your birth, doulas can help you to stay grounded and strong. If you feel that you are being pushed into something that you don’t want, they can be another voice to remind the staff that they need to listen to you. They can help you to remember what you wanted, and support you in that decision, or, if you change your mind, your new decision. Crucially, they can help to facilitate communication if there’s an emergency, helping you to understand what’s going on even if the staff feel too busy to take the time to talk to you properly.

Sadly, many women who have experienced birth trauma say that the trauma came from feeling out of control of what happened to their bodies. By knowing that we are the ones who can make decisions for ourselves, we know that we can insist on that information before we agree to anything happening to us, and that itself can lead to a much higher chance of a positive birth, no matter how it ends up. And, if we want support with that, our doula will be there for us.

In February I’ll be looking at the Montgomery ruling, and why we all need to know about it

Emma Ashworth is a Nurturing Birth doula, a trustee of AIMS and she is currently the AIMS Journal Editor. She has a special interest in consent and has written extensively on women’s rights in birth. Her book, “The AIMS Guide to Your Rights in Pregnancy and Birth” is available from AIMS. You can find Emma at her Nurturing Birth Directory listing here…

Video interview with Polly Hand, chiropractor

Sophie chats to chiropractor and Nurturing Birth doula, Polly Hand, about her work with pregnant women, babies and families, especially when it comes to breech or malpositioned babies. She discusses how she uses the Webster Technique amongst others to help babies move into an optimal position.

Polly works with pregnant women and people to help their babies to get into an optimal position for birth, post birth to help recovery, as well as with newborn babies themselves who need chiropractic adjustments.

This video is an essential watch for anyone who would like to know more about optimal foetal positioning, how chiropractors can help in pregnancy, and also after birth.

For more information about Polly visit her website or follow on Instagram

Click here to watch Sophie’s interview with Aine Homer about baby reflux or click here to watch Sophie chatting with Hannah Wallace of Wear My Baby about baby wearing and the benefits for families.

If you are looking for a respected, quality doula then do visit the Nurturing Birth Directory

Video interview with Liz Stanford, The Calm Birth School

Sophie caught up with Liz Stanford who recently took over The Calm Birth School from Suzy Ashworth. They chat about Hypnobirthing, the science behind it, the mind body connection and how empowering it is for women who are approaching their birth. They also talk about how the term hypnobirthing can be off-putting for some and dispel some of the myths around it. Liz shares her experiences of using hypnobirthing for the birth of her three children.

To find out more about Liz and the Calm Birth School visit their website, Facebook Page, Instagram

Click here to watch Sophie’s interview with Alex Heath, Hypnotherapist about Birth Trauma recovery.