Whatsupmum: HSE initiative

Whatsupmum

“Whatsupmum” is an interactive initiative developed by Healthcare Help Ltd for the HSE using apps and videos providing free advice to pregnant women and their families. Describing itself as “Your complete guide to pregnancy, birth, and parenthood”, Whatsupmum, is endorsed by National Clinical leads, obstetrician Michael Turner and Midwifery lead Shiela Sugrue, and is in the process of being rolled out nationally to be screened to expectant parents in all of the Country’s obstetric maternity units.

With this national push in mind, AIMSI committee took a look at Whatsupmum to see if it was truly a ‘complete guide to pregnancy, birth, and parenthood’ and if it was an initiative we could endorse to be shown to women across Ireland during their ante-natal care visits, given the obvious influence such an initiative would have.

Our key interests were:

Does Whatsupmum provide unbiased information?

Does Whatsupmum provide information on care options?

Does Whatsupmum support informed consent/refusual?

Does Whatsupmum support and follow evidence based care recommendations?

Does Whatsupmum provide benefits and risks to assist in informed decision making?

As a private company, is Whatsupmum influencing women through advertising on the behalf of the HSE?

The process:

The AIMSI committee watched the videos, making personal notes, and presented them to the committee. The following points are a collaboration of these key points.

Videos of particular interest were:

Antenatal Care

Preparing for Birth

AIMS Ireland’s Key points:

The “Preparing for Birth” video begins with 2 minutes of discussion on baby products expectant parents will need and stresses the importance of researching ahead of time various products in order to find the best product for each individual family’s circumstances. Surprisingly, the video does not expand this discussion to the importance of researching care options, tests and procedures, and preferences for labour, birth, and the care of the baby. Unfortunately, things did not improve from there, and the video felt more in keeping with “grooming” women than assisting in informed decision making as illustrated by the following examples

Antenatal Care options:

Midwife led and homebirth initiatives are listed briefly as care options, however, there is no discussion of each care option available and how they differ from obstetric led care options. There is no discussion of the benefits of midwife led care nor the risks of obstetric led care. The HSE’s Mid-U study provides excellent evidence on the benefits of midwife led care and yet there is no promotion of these services, reference to where they are available, nor explanation of how midwife led policy differs to obstetric led policy in the videos.

Medicalised Messages

AIMS Ireland found the videos to be patronising, cold, and reinforcing of a medicalised approach to childbirth which normalises obstetric led care, which is evidenced to be inappropriate for the majority of women. One obstetrician is interviewed in front of an incubator, another in front of a scanner, and the other wears a white coat sitting behind a desk with a stethoscope on it. All these images are strong symbolic references suggesting “I am the one in charge here” and “birth is a medical event requiring a doctor”.

AIMSI firmly believe that care providers are there to guide women but that women are the key decision makers and should be supported in informed choice in order to make the best possible decisions for themselves and their babies in their circumstances. Pregnancy and childbirth for the majority of women is a healthy, normal event and should follow a physiological care path. The obstetric medical care model is inappropriate and not recommended for the majority of women. These videos feel very clinical and sterile, fortifying the medical care model.

Pain Focused

In the “Preparing for Birth” video, Rotunda’s Sam Coulter Smith speaks about how painful the experience of birth will be. He says “having a baby is a painful experience” and uses the word “suffer” and “severe”.

While Sam Coulter Smith does discuss relaxation methods, mobility in labour, and TENS machine, he then says ‘there will be a point when you need to consider other methods of pain relief”.

This language is very suggestive and implies to women that birth is an experience that will require medical pain relief and that women cannot do without it. While many women choose to have medical pain relief options, many women do not. All women, regardless of their choices should be provided with support, information on risks/benefits, and alternatives to medical pain relief options. Women’s beliefs play a strong role in how she copes in labour. If a woman fears pain and is told that she is going to suffer and need pain relief, she is less likely to be relaxed and find alternative coping techniques.

When discussing the epidural, Sam Coulter Smith briefly discusses risks to mother with epidural but none for baby. He describes epidural as “very safe”.

Something many women don’t know, once an epidural is cited, it changes how her labour is managed by care providers. With an epidural, a woman’s risk status changes to high risk, even if she had no risk factors previously. The reason for this is that epidurals instantly introduce additional risks to a woman’s labour which were not present before. One study showed that the main reason for a change in risk status in labour (from low to high risk) was the use of an epidural. The epidural introduces other interventions, such as continuous monitoring by CTG, which has a false positive rate of 99% without reducing the rates for cerebral palsy but does increase a woman’s risk of caesarean section, mortality and morbidity.

Time Limits

The stages of labour were very clearly defined by time limits in the preparing for birth videos. The first stage defined as 2-12hrs, second stage 1/2hr to 2 hours and third stage is the shortest stage of labour lasting 1-2 minutes up to a 1/2hr.There is no discussion of the benefits and risks of physiological 3rd stage v managed third stage of labour or that labour will be different for every woman. Some women will have labours which are longer than these defined limits and others may be shorter, but both can be normal for that woman in that labour. Time limits are unhelpful and do not support normal birth practice. Many women will have interventions in labour for not progressing within a defined time limit despite the absence of medical indication. Length of labour in itself is not a complication yet many women birthing in Ireland will have Active Management of labour based on these time limits.

There is a fantastic section filmed in the MLU (although the video doesn’t state this) on mobility in labour, positions to alleviate pressure, showing birthpools and birth balls. This is the only segment of the video which touches on normal birth practice. This is immediately forgotten at 15:25 of the video when the stages of labour are recapped with a picture of a woman in a hospital gown, lying flat on her back, feet high in stirrups and a sheet draping her legs with lips puffing as if she is pushing or panting in late labour. This depiction of giving birth completely negates all that was beneficial in the previous section and once again pushes a non-evidenced medical care model.

Interventions in Labour

In the “Preparing for Birth” video Peter Boylan discusses common interventions in labour (induction, episiotomy, caesarean). He lists the main reasons for induction of labour as a woman going significantly over her dates and if a woman’s waters have SROM 24hrs previously, or for medical implications such as high blood pressure or pre-eclampsia.

The video does not define the length of a healthy normal pregnancy nor best practice recommendations for postdates induction where there is no medical indication to induce. The reason for this is most likely that there is no standardised induction policy in Ireland and instead each unit creates its own induction policy which may or may not be based on evidence.

Most pregnancies go to full term, which means that a woman will go into spontaneous labour some time between the 37 and 42 week mark. The vast majority of babies will arrive when they are ready – not on an estimated due date (EDD) but some time during this 5 week window – up to and including 42 weeks gestation. There is a slight increase in risk factors after 42 complete weeks but many women, with monitoring, have a healthy pregnancy without induction into the 43rd week.

Despite the evidence for waiting to 42 complete weeks, many obstetric led maternity hospitals in Ireland do not follow this best practice and may suggest induction prior to 42 weeks or even prior to a woman’s due date. So, when Dr Boylan speaks about a woman going “significantly over her dates”, this is greatly open to interpretation depending on her care provider and local policy.

The video states that another common reason for induction of labour is spontaneous rupture of membranes (SROM) without labour beginning and that in these cases women are induced after 24 hours. Women with SROM at or over 37 weeks should be offered the choice of induction of labour or expectant management (to wait for labour to begin on its own) as recommended in NICE clinical guidelines. A Cochrane review comparing planned (induced labour) vs expectant (waiting) management concluded that:“  Fewer infants went to neonatal intensive care under planned management although no differences were seen in neonatal infection rates. Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices”  (Dare MR, Middleton P, Crowther CA, Flenady V, Varatharaju B. Cochrane Database of Systematic Reviews 2006 )

Recent research has shown that induction of labour increases a first time mother’s risk of Caesarean Section 2 fold, as well as other interventions, yet there is no discussion of risks of induction in the video nor discussion around informed consent/refusal of induction.

Peter Boylan discusses episiotomy at length, stating that an episiotomy is performed “if there is going to be a large tear”, despite evidence suggesting that there is no way to predict this and that episiotomy does not reduce severe vaginal or perineal trauma and actually may increase the risk of anterior perineal trauma. In fact, episiotomy appears on the NICE “Do Not Do” list and several bodies have come out with statements supporting the reduction of episiotomy. Best practice recommendations are that episiotomy should be largely restricted practice and that episiotomy should never be used as routine. In 1996, WHO suggested that episiotomy rates should not exceed 10%.

AIMS Ireland was alarmed by Dr Boylan’s statement, particularly given the National Maternity Hospital rates for episiotomy with first time mothers is just shy of 40% and an overall rate of 22%.

In fact, out of 19 obstetric units in Ireland, 11 units have an episiotomy rate over 30% for first time mothers and only ONE obstetric unit (Wexford at 17%) has an episiotomy rate of under 24% for first time mothers. This is a huge issue of concern for the HSE and yet their promotional guide for women includes statements on episiotomy which does not follow evidence and is predictive of the professional beliefs that drive high rates.

The section on common interventions fails to include the most common interventions in Irish obstetric units: CTG, admissions trace, artificial rupture of membranes (ARM), membrane sweeps, syntocinon in the first, second and third stages of labour.

 

There is no discussion of risks for any of the interventions but focuses on why a care provider might do them. This is a huge concern with regards to informed consent/refusal and again reinforces a ‘grooming’ of women rather than supporting a system where women are involved in their care plans.

VBAC

Despite discussion of Caesarean Section and high rates across the Country for first and subsequent pregnancies, there is no discussion on opting for a VBAC and the benefits/risks of VBAC compared with repeat Caesarean Section.

The woman’s voice

These videos heavily represent the voice of the medical care provider, mainly obstetricians. While there are some segments with midwives, there is a distinct lack of discussion on midwife led services and normal birth practice.

The voice of the woman has been completely omitted from this initiative. There are no segments featuring women’s experiences of birth or their preferences on care options or birth preferences. It is as if the woman’s voice has no value and that women are simply passive on-lookers in their maternity care with no significant role to play.

Captive Audience

AIMS Ireland were very uncomfortable with the idea that these videos are to be rolled out nationally to be screened during ante-natal appointments to a captive target audience. We found the videos to be un-evidenced, void of informed decision, and to be suggestive towards the medical model approach using strong symbolism and imagery to reinforce these ideas. The videos are completely void of the woman’s voice and experience and fail to outline the benefits of midwife led care and normal birth.

It is unclear how the HSE has funded this initiative and the total running cost to provide this type of ongoing services – AIMSI remain concerned that there may be advertising involved in the screening of these videos.