Julie Smith is a Lecturer Practitioner at the John Radcliffe in Oxford who splits her time between teaching students on the midwifery degree course and practising as a midwife herself. She had for a long time been aware of a demand from women for what she calls a post-natal "de-briefing" opportunity.
"The majority of women are discharged from hospital within two days and by the midwife within ten days. The maternity service is very good at shortening discharge times but what happens is you get a woman who's had a caesarean leaving hospital after five days then going to her GP and asking, `Why did I have this surgery?' The GP can't answer and nor could the health visitor because they don't have access to a woman's birth records."
This, she explains, can leave a woman feeling frustrated and confused. And such feelings might develop into post-natal depression or, in an extreme case like that of Joy Perkins, to a lifetime of trauma which prevents the formation of a close relationship with the child.
When Julie Smith heard in early 1995 that the Royal Hampshire County Hospital in Winchester, who had pioneered Birth Afterthoughts to provide the type of follow-up service she had in mind, were running a study day in London she couldn't book her place fast enough. And within months she had set up Birth Afterthoughts at the John Radcliffe.
Each woman leaving the maternity unit at the hospital is now given a bookmark which says she may discuss her experiences of childbirth "whatever they may be", with someone from the Birth Afterthoughts team at a venue of her choice. There is no time limit after the birth. Once a woman has called the confidential answering machine to set up a meeting, her notes are taken from the archives so she can go through them with the midwife who visits her.
The Access to Medical Records Act of 1990 means that any woman can get a copy of her records by writing to the hospital where she was delivered. "But it is having someone go through them with you, explaining each detail, which is the important thing," Smith insists. "It is a very important part of the therapeutic process."
Joy Perkins says she cannot remember anything about Janice's birth. "At the time I was told that I'd had eclampsia, which meant nothing to me, and that I'd had a fit, which left me with the constant fear that I would have a fit again. I had no idea why I'd been drugged for two days. No one made any attempt to explain."
The result says Joy, was that she wanted nothing to do with her daughter. "I didn't love her and that feeling never really changed. If someone like Julie had been there when I came round from the drugs, things might have been very different."
Julie Smith visited Joy and Janice and spent an hour and a half with them. "Against all odds Julie found my notes," says Joy. "She explained every detail, and discussed the possible effect it's had on my relationship with Janice. It was an enormous turning point for us. Janice and I are now able to spend real quality time together. It's not soppy stuff, there is genuine love there at last. I'm 68 and a great grandmother but the disturbing thing is that if I had died at 45 like my own mother I would never have had this chance."
Sixty women have been seen by Julie Smith's team since July last year. Every one of them has filled in a questionnaire and all said the service had been of benefit. Eileen Cowley has a 15-month old son Tony who was born by caesarean after an 18 hour labour. But her reasons for approaching Julie Smith had nothing to do with the trauma surrounding her son's delivery, nor indeed her recovery from the surgery.
"In a hospital the size of the John Radcliffe I felt that the experience of childbirth had been depersonalised," says Eileen, "I needed someone to talk to and Birth Afterthoughts sent Lisa. She was genuinely interested in what I was saying and really cared. Now I know who was present at the delivery, what Tony's heart beat was just before he was born and the name of the midwife who brought him into this world. It's so easy to feel that they get you off the delivery table and chuck you out as soon as they can but Birth Afterthoughts appears to be a genuine attempt to make women feel they are not insignificant. I feel good knowing I have that point of contact should I ever need it again."
Julie Smith has been resourcing Birth Afterthoughts on pounds 5,000 of the hospital's project money. She was told that if the service proved successful it would be put into the business plan. "We've just written up the first 46 cases which will soon be published, and I'm using them as evidence of the money it is saving the health service," says Smith. "Statistics show that 17 per cent of the women had the potential for complaint but because they were heard and was able to validate their experiences then feed it back into the system there was no complaint. As a result there's value in Birth Afterthoughts as a risk management tool."
Since setting up Birth Afterthoughts at the John Radcliffe, Julie Smith has liaised with Birmingham's Hartlands Hospital. They now have a Birth Afterthoughts service. "They've also set up post natal stress support groups in Southampton. These don't offer the individual care of Birth Afterthoughts," says Smith, "but it's worth women ringing their local maternity unit to see if similar provision is being made in their area."
Catherine McCormick of the Royal College of Midwives thinks women should press their local midwives to start up a Birth Afterthoughts. "In the meantime any woman can write to the hospital where they were delivered and get a copy of their notes. She can then call her midwife or health visitor who would, if they were unable to help themselves, most certainly refer her to someone who could."
Alex Stoner, an English teacher, has a 16- month old son Isaac, and is pregnant with her second child. She was told Isaac was in the breech position shortly before his due date. "But I was determined to have him naturally," she says. "I ended up having a terrible time, culminating in the caesarean, and not really knowing why it had all happened."
Alex started to have insomnia three months after Isaac was born. She was told by her GP that she was suffering from Post Natal Depression and was given two types of drug in succession. "The thing was I didn't feel depressed. The insomnia was the only thing wrong. Then I was given these drugs which meant I had to stop breastfeeding. The whole thing simply added to the sense of disappointment and confusion I'd had since Isaac's birth."
Birth Afterthoughts was mentioned to Alex and she made an appointment to go and see Julie Smith. "It was the first time anyone had explained to me why certain decisions had been taken during the labour - decisions of which I'd been completely oblivious. It was marvellous therapy. It really helped me come to terms with that gulf between my expectations and what had actually happened. I've been sleeping a lot better since. If only someone could have done it for me in hospital after I'd had the caesarean."
Alex says she now has a missionary zeal when it comes to Birth Afterthoughts. "So many women I know feel deprived just because they can't see their notes, even if they've had a wonderful birth. When you're busy with the hard work of looking after a new-born you have to push everything else into the background. By the time you realise you'd really appreciate talking to someone about it all - not just a friend but a professional who can explain things and reassure you - the midwife's long gone. That's why Birth Afterthoughts is so good. I admit, my problem's not been completely solved, but that chat with Julie has at least opened the door to progress for me."
Julie Smith is calling for a revision of the statutory maternity care provision. The Health Service should, she says, make a midwife available to every woman for the duration of her reproductive life. But she acknowledges that day might be a long time coming. So for now she is concentrating on getting as many hospitals in Britain as possible to set up a Birth Afterthoughts. "It helps a woman to close a chapter of her life and move on."
! Birth Afterthoughts at the John Radcliffe in Oxford can be reached on 01865 220605Reuse content