Professor Stuart Hampton-Reeves, Head of the Graduate Research School, and Alison Naylor went to meet with Professor Soo Downe to talk about her research and recent international collaborations in the area of normal childbirth.
There is a lot of research on the pathology of childbirth (as there is in health in general) but very little on how things go well. I have become really interested in how the normal physiology of labour and birth can be promoted. The main genesis of this research was a study conducted by a group of research midwives in 5 different hospitals in the Trent region, which was published in 2001. We looked at births that were called “normal” in the notes, and at what actually happened to those women during those births. We found that, conservatively, only about 25% of women overall actually had normal births without technical interventions. The response rate to the survey was nearly 100%, and we had over 1000 participants. The hospitals covered the whole range of maternity care provision available at the time, so we were fairly sure that the findings could be generalised across the country.
This research generated a lot of professional and political interest, as there are important health consequences for mother and baby consequent on how childbirth takes place. The work led directly to the foundation of the Royal College of Midwives Campaign for Normal Birth (for which I was the foundational chair). That was really about promoting the concept of, and skills in, normal birth among midwives. The Campaign has been taken up internationally, partly because there is international concern about rising rates of Caesarean Section.
For example in China, in some hospitals the caesarean section rate is 80%, and across Europe it ranges from 13% approximately in Demark to 35% Italy. This variation cannot be justified by case mix, and it has important clinical and psychosocial consequences, for the mother, baby, and family.
I had a degree before I came into midwifery (in literature and linguistics) so I came with an enquiring mind. In the middle of my degree, I spent some time in Bophuthatswana, South Africa, when apartheid was still active. I happened to end up on a mission station where there were white nuns who were acting as midwives to black African women in the homelands. It was at that point that I thought, if we get birth right we get the world right. I knew then that midwifery was my vocation. Although I then practised clinically for about 15 years after I qualified as a midwife, I started undertaking research alongside that clinical practice, as I felt strongly that maternity care was not supporting women effectively in achieving the optimum birth for them, their babies, and their future health and wellbeing.
Absolutely – definitely. That’s right. I am not a neutral scientist. I have a definite agenda.
I get invited across the world to talk about normal birth, because this is also an agenda that resonates internationally: for example, this year, I have been invited to talk about normal birth and the importance of midwifery, or planning/running related research studies with colleagues, in the US (Hawaii, California and Michigan), The Sudan, China, Sweden, Switzerland, and Malta. There is not country in the world where this does not matter!. Locally, we have also been working to maximise normal childbirth, most recently in supporting the development of the new birth centre that has been set up in Blackburn, which is probably the biggest birth centre in the country at the moment.
We’ve been awarded €400,000 from the EU for a project called Childbirth Concerns, Consequences & Challenges, which is looking at what could make child birth better across Europe. There are 21 countries engaged in this and over 50 people, mostly in Europe but also in South Africa, China, Israel and Australia. We are also being funded by the Department of Health NIHR to do a randomised control trial, teaching women to hypnotise themselves when they are pregnant so that they can use that in labour to help them with labour pain. We are about half way through that project at the moment.
We also have funding (from Wellbeing of Women) for a midwife, Jo Holleran, who is based in the East Lancashire Hospitals’ Trust. She is undertaking an ethnography of computerisation on a specific labour ward, and the consequent social dynamics between the midwife, the mother/partner, and obstetric and anaesthetic colleagues, to see how this supports or hinders optimal childbirth. Internationally, I am doing some work with Professor Hannah Dahlen in Australia looking at how woman in labour use different spaces and places, and I am co-supervising a PhD student with Professor Marie Berg at the University of Gothenburg, as part of an Action Research study that is examining the social interactions that occur when women first enter a hospital in labour.
I run a masters module, titled ‘normal birth, evidence and debate’, which is based on our research programme. It is usually local midwives who attend the face-to-face sessions, but we also have students from across the UK, and (by distance learning) international students. The primary focus of learning for that module is around story telling. As well as direct teaching on theory and evidence, each midwife has to tell a critical story of a birth they were involved in. As they tell it in front of the rest of group we write it on the board and at each point the rest of students or myself can ask questions like:
“OK, how did you feel here?”; “how do you think the obstetrician/partner felt?”; “what is the evidence for this procedure or approach”; “what kind of theoretical framework might explain this”. As these various layers are unpacked, the students re-engage with emotions and values as well as with evidence and theory. The student evaluations suggest that they go away with a much more comprehensive understanding of why people behave the way that they do, particularly around normalising or not normalising childbirth. It is a reflexive module which helps them to think through the consequences of how things are. Some students have also reported that they believe the module has equipped them to argue the case for changing the service for the better where they work.
All the undergraduate teaching I do is based on elements of our research programme. Apart from our normal birth research findings, which is the basis of a session that I teach to all the undergraduate students, and of the masters module described above, we have also developed and published a new methodological approach to metasynthesis of qualitative evidence, so I teach a session on systematic review and meta-synthesis to the masters and PhD students. I also introduce the undergraduates to the science of knowledge – why we know what we know, why positivism is currently supervalued, and how to get beyond ‘normal science’ thinking.
I’m a polyglot! The great thing about being a clinical academic is you don’t necessarily have to have a specific methodological allegiance. For example, we have just written a book on phenomenology, but we are also conducting randomised trials, ethnographies, surveys, and basic interview and focus group studies. I believe in integrating all of these particular ways of looking at the world. I suppose at heart I am an interpretivist: I think that you can accommodate all these various ways of seeing to get at a good enough version of the truth through different lenses. This view is borne out in the composition of our research team: across mine and Fiona Dykes’ group (the midwifery research cluster) there are currently 2 midwives (Fiona and I) a historian, two psychologists, a physiologist, a biochemist, a complimentary therapist, and a social scientist.
We held the first one here at UCLan in 2001 and since then we’ve held it biennially at Grange-over- Sands, because we wanted to bring people right out of academia, right out of cities and have an event which was almost suspended in time. The conference provides an opportunity for junior and senior researchers (midwives and others) from across the world to talk together. It is very informal. We mix art and science – so we have drama and we have music, but we also have really high level science as well. By request from overseas midwives and others involved in midwifery practice and research, we now hold it internationally on alternate years, so in 2010 it was held in Vancouver; this year it is in Hang Zhou in China; in 2014 it will be in Brazil.
We are increasingly aware that just saying, ‘routine intervention childbirth is economically a problem and women don’t like it, and it causes some morbidity’ is not enough. We have begun to look at something much more profound. There is increasing evidence that there is an association between the mode of birth and autoimmune diseases such as Type 1 Diabetes in the under 5’s, multiple sclerosis, bronchiolitis, asthma and eczema. We don't yet know why this might be. Our hypothesis is that child birth affects the epigenetics of DNA and that is passed down through generations. So there could potentially be damage caused by different ways of doing child birth and different interventions in child birth that not only might affect the infant of that mother but might then be passed down to that infant’s child. If our research supports our hypothesis, we think that health policy makers will sit up and take a bit more notice. However, I also acknowledge that we may find that our hypothesis is disproved, or even that intervention in childbirth has long-term benefits for some mothers and babies, and, if this is the case, I will be very happy to promote these interventions for the specific groups that need them.