Who safeguards mothers?

I’ve been researching and writing about group B streptococcus (GBS) and early-onset GBS disease all summer (see my updated book here!), and this has entailed having lots of conversations – both verbal and written – with women who have made different decisions in this area.

I’ve talked with women who had a risk factor and wanted antibiotics, women who were concerned about the side effects of antibiotics and wanted to wait and see, and women who sought private screening for GBS because they wanted to know their carriage status despite routine screening not being recommended by the RCOG (2012).

This only scratches the surface, of course, and there are many other viewpoints as well.

The women I want to consider in this article are those who did not choose to be screened for GBS, but who were coincidentally found to have GBS after having a swab or urine test for another reason.

Some of these women decide they do not wish to have antibiotics themselves or their baby, and I have become concerned, because these are the women who seem to be least able to get their needs met at the moment.

Group B Strep Explained; the updated second edition of a popular book which helps parents, professionals and others to understand the issues and the evidence relating to the screening and prophylactic measures offered in the hope of preventing early-onset group B strep (EOGBS) disease.

GBS decisions in labour

Although routine screening is not endorsed in the UK, the RCOG (2012) recommend that intravenous antibiotics should be offered to any woman known to carry GBS once she goes into labour (RCOG 2012*).

* Please note: when I first wrote this article, I referred to the current guidance. While this particular aspect of the guidance remains the same, the guidance has been updated and other aspects of it have changed. Please see my book or our information hub for the latest evidence.

National guidance reflects the finding that, while antibiotic prophylaxis has “reduced the incidence of EOGBS disease, it has not been shown to reduce all causes of mortality or GBS-related mortality” (RCOG 2012: 2).

The RCOG also expresses concerns about the disadvantages of routine screening and antibiotics, which “include anaphylaxis, increased medicalisation of labour and the neonatal period, and possible infection with antibiotic-resistant organisms, particularly when broad-spectrum antibiotics such as amoxicillin are used for prophylaxis” (2012: 2).

Ultimately, though, we live in a culture which prioritises action over thought and in which many professionals fear that they may get into legal or professional trouble if they do not do as much as possible.

What happens in reality?

Where women in this situation decline antibiotics, the support they receive is variable according to where and with whom they are planning to give birth.

But my advice to those who encounter problems is fairly straightforward. Speak to your midwife or doctor, I suggest, but if you have any problem, then ask to see a Consultant Midwife, if one is available, or a midwifery manager.

The midwives in these roles usually have an excellent understanding of their responsibilities and woman’s rights and are likely to have encountered similar situations in the past.

I can’t offer any guarantees because individual midwives do practise and interpret their roles differently, but as I can’t be there with every woman who encounters this situation, I feel confident in recommending this course of action, supplemented with the phone numbers of consumer support organisations.

Antibiotics and babies

But what happens in situations where a woman successfully navigates herself through declining antibiotics in labour, only to encounter a paediatrician or neonatologist who feels that antibiotics should be given to her healthy, asymptomatic baby?

This is not uncommon amongst women who decline antibiotics in this situation, and it often leads to incredibly distressing conversations at a time when women are feeling tired, sore, vulnerable and more in need of kindness, understanding and support than ever.

It’s not that this is an outrageous choice to make, either.

The risk of GBS disease in a healthy, term baby is low, and although the overall mortality rate in babies who experience GBS disease sounds scary, I have heard too many people quoting this without then being clear that the mortality rate for healthy, term babies who develop GBS disease is around ten times lower than the mortality rate for preterm babies (Centers for Disease Control and Prevention 2010).

I don’t want to underplay the potential consequences of GBS disease or the experience of affected families, but antibiotics are also not without consequences and bacteria are a normal and important part of being born and being human.

All of the current treatments for GBS, whether antibiotics or alternatives, are not only under-researched; they are specifically designed to remove all bacteria, good or bad, and not just GBS.

It is not unreasonable to be concerned about giving prophylactic antibiotics to a healthy newborn baby.

But too many women, and some of them the same women who were really well supported by a midwife when they decided to decline antibiotics for themselves in labour, are spending their first hours as a new mother battling with staff in an attempt to have their wishes for their baby respected.

What can I tell them?

I can explain to them that, while no-one can force a woman to make a particular decision while she is pregnant, once her baby is born it has rights of its own and neonatologists have a duty of care to the baby. I can explain how this changes things; that doctors can access a degree of legal power if they feel that treatment is in the child’s best interests. But who is there to advocate for the mother?

Who is ‘with mother’?

I posed this question to a handful of friends who were at the time Supervisors of Midwives (SoMs). We had some interesting conversations about how the role of a SoM isn’t always clear-cut. Sadly, it has now been eroded altogether.

Many women and families in the situation I have described are more likely to meet a safeguarding midwife (or nurse), but while some of those in a safeguarding role have been very supportive to women in this situation, this is by no means guaranteed. As with the neonatologist, the primary concern of the midwife in this role is to advocate for the baby.

To whom can these women turn for help, advocacy and support in making a decision that, in almost every case that I have encountered, is based on concern about protecting the long-term health of their baby?

They may be being cared for by lovely (if overstretched) postnatal ward midwives, but these midwives are hardly able to leave the ward in order to stand by the side of a woman wanting to go against the advice of a neonatologist.

I am not challenging the value of safeguarding, or the need for advocacy for babies, but surely there ought to be somebody on staff whose role it is to stand by and advocate for women not just until they give birth but throughout the childbearing year?

References

Centers for Disease Control and Prevention (2010). Prevention of perinatal group B streptococcal disease: revised guidelines from CDC, 2010. Morbidity and Mortality Weekly Report 59(RR-10):1-36.

Royal College of Obstetricians and Gynaecologists (2012). Prevention of early onset neonatal group B streptococcal disease. Green top guideline No 36. RCOG: London

Wickham S (2018). Group B Strep Explained. Now updated!