Denise and her blog

This week is World Reflexology Week!

Reflexology in pregnancy can offer a range of potential benefits for expectant mothers, including:

• Relief from pregnancy discomfort
• Stress reduction
• Preparation for labour
• Improved sleep

During my time at the University of Greenwich, I discovered that by using foot reflex zones linked to the reproductive tract and pituitary gland (based on my research), I could identify different stages of the menstrual cycle in non-pregnant women with a 65-70% success rate.
I've since taught midwives worldwide how to perform this assessment through my courses.

Complementary Therapies and The M25 

I frequently drive along the M25 motorway around London, particularly the stretch from southeast London to Heathrow.  As I drive, I’m struck by the analogy between drivers on these busy roads and midwives venturing into the field of complementary therapies (CTs).

Having been practising, teaching, researching and publishing on CTs for over 40 years, I consider myself an experienced “driver” of this aspect of midwifery care. I was in the right place at the right time to pioneer the subject as a midwifery specialism in the early 1980s. I’m well qualified in several therapies and practise safely; I recognize difficulties and can deal with them, or recognise when to withdraw temporarily. I understand where I can cut corners and when I need to `drive by the book' and I’m fully informed about the rules and regulations relating to practice, both in CTs and in midwifery.

But what about those midwives who are only just starting out on their CTs journey? In observing other road users on the M25, I can see that midwives are similar to many drivers – the plodders, the safety conscious, the sceptics and the mavericks.  

There are the “lorry drivers” who proceed slowly in the inside lane, struggling up the inclines and rarely able to overtake others, but eventually reaching their journey's end. This is similar to midwives who press on competently with their existing practice, but who are fearful of moving out of the `slow' lane to drive new initiatives. There is nothing wrong in this: we need midwives to deliver fundamental services in the same way as lorry drivers deliver goods around the country. Midwives who are “plodders” wanting to introduce CTs into practice, may take a long time to make it a reality, but are safe, reliable, conscientious practitioners. They’ve thought through all the issues, sought answers to numerous questions and eventually achieved their aims of enhancing care for women with CTs.  

Next come the safety conscious midwives, like mature, experienced drivers whose reactions may be slower but who painstakingly observe all the rules of the road. Their practice of CTs is based on adequate and appropriate preparation and adherence to the laws, regulations and guidelines dictating safe practice. These are by far the most professional when it comes to using CTs in midwifery practice, with a focus on both theoretical and practical training and an acknowledgement of prescribed boundaries, especially within the NHS. 

Conversely, there are those maverick lorry drivers who rampage along the motorway, tailgating other vehicles and – increasingly – breaking the law by moving into the outside lane in their time-restricted rush to get where they’re going. Similarly, drivers of fast sports or status cars - the typical exhibitionist “boy racers” - believe they can charge along with little regard for others, blaring their horns or flashing their lights to make their presence felt so that everyone else is forced to make way for them. This is a case of appearances being deceptive, of course, because these drivers may be no better (and are sometimes considerably worse) than the more cautious ones. They antagonise fellow road users and are a danger to themselves and others. 

Midwives who advocate the `racing car approach' to implementing CTs, often with a misplaced ideal of being the first or the best, are far more likely to make mistakes and cause safety issues that could result in a managerial knee-jerk response of abandoning the CTs services. There is more to it than looking good on the surface whilst vociferously forging ahead with ideas and ideals at the expense of colleagues who work more slowly but with more attention to detail. Implementing CTs into midwifery care will be far more effectively achieved by respectful, professional and reasoned dealings with colleagues than by riding roughshod over sceptics or those who are already working in their own professional `fast lanes' in different ways.

Likewise, the `white van syndrome' is also inappropriate. We have all had experience of the drivers of transit vans, often tradesmen, attempting to force us into slower lanes so they can get ahead. Increasingly too, there are those who disregard the rules: I’ve seen impatient white van drivers barging their way across several lanes to exit the motorway at the last possible minute. Many are so familiar with their route that they become complacent with the task of driving, preferring instead to monopolize and control the road and its users. 

Complacency is definitely an issue for midwives, especially those who have been using CTs for some time. They may think they are competent because they have refined their practical and manual skills, but this does not make their practice contemporary, nor is it necessarily safe or evidence based. As regular readers of my blogs will know, this is a group of midwives which concerns me greatly. Failing to keep up to date, arrogantly believing that they’re “experienced” and know what they’re doing, can only lead to safety incidents, some of which have come under national scrutiny in recent years. There is no place for those wanting to use CTs to demonstrate either complacency in their work or superiority over colleagues. There is always something to learn from others, most of all the need for good teamwork. Those who think they know it all will eventually make mistakes which may be fatal to themselves, their colleagues and even the people in their care.

There is also the novice motorway driver. In order to venture onto the motorways a full driving licence is required and drivers should preferably have some experience of driving on non-motorway roads. In the same way, midwives moving into the field of CTs must be qualified and experienced clinical midwives in order to add to their basic practice. It is daunting taking those first journeys into a new area, especially when others may appear competent and confident. Sympathetic drivers already on the motorway may slow down to enable newer ones to join the road, and this should also be the case when introducing CTs into midwifery care. Often those who are new to the road take time to learn and understand what they’re doing - and may sometimes remind more experienced `drivers' of some of the rules they have recently learned. 

The road itself often presents dangers and problems. The surface may be icy, blocked by debris or altered by new roadworks, and drivers need to negotiate their way around carefully. Possession of well-developed driving skills, knowing the rules and regulations and remaining alert to changes all contribute to achieving a safe journey. Midwives using CTs must be appropriately skilled, cognisant of relevant local, national and international rules and must take account of new developments in practice and policies in healthcare. 

There is one section of the M25 between the junctions of the M3 motorway and the M4/ Heathrow turn-off where mandatory variable speed limits are imposed at peak hours to regulate traffic flow. These can be likened to clinical guidelines on CTs in midwifery, which are used to protect the public (and practitioners) and avoid individuals becoming too independently autonomous at the expense of safety. It is occasionally necessary to slow down the pace of change in order to consolidate what has happened so far and prevent enthusiasts from racing forward inappropriately. Once the restrictions have passed it is perfectly acceptable to regain speed and press on.

So where do you fit in with all this? Are you continuing to be the plodding “lorry driver” or the newly licensed novice lacking in confidence? Do you want to be seen as a sports car or white van driver? Do you recognize the ups and downs of the road? Are you familiar with the rules and regulations? Will you reach your destination or fail at the first set of “roadworks”? Whatever category you fit into it is ultimately essential to appreciate that we all have a part to play in the greater journey we are taking together - with care, attention and integrity we will all achieve a safe and satisfying outcome and complementary therapies will hopefully become integral to midwifery care.

This blog post is adapted from a 2000 article I wrote for the Complementary Therapies in Clinical Practice journal. Unfortunately, things do not seem to have progressed very far in some respects. Whilst CTs are far more prevalent in maternity care and midwifery practice, we still have midwives who want to be sports car drivers and rush ahead without planning, or lorry drivers who break the rules. There are still midwifery managers who do not acknowledge the need for proper training and expect staff to teach others immediately after learning CTs themselves, despite the recognition that all other aspects of midwifery require consolidation and experience before passing on the mantle to others. And we still have midwives who fail to update because they believe themselves to be experienced, yet conveniently forget the NMC requirement to remain updated in all aspects of their work. 

Today is Expectancy’s 20th Birthday! 🎉

For two decades, we’ve proudly remained the only company worldwide dedicated to providing professional academic courses that teach midwives and birth workers how to integrate complementary therapies into their care.

From designing our unique programmes to launching the signature Licensed Consultancy, it’s been an incredible journey preparing midwives to build their own businesses in maternity complementary therapies.

Thank you all for your unwavering support—here’s to another twenty years! 🌟

Pass The Baton - Where Is The Next Generation Of Leaders In The Specialism Of Midwifery Complementary Therapy?

Whilst in Tokyo recently, I was invited to contribute to an aromatherapy forum discussion on changes in the profession. One question focused on how - indeed, whether - the aromatherapy world is preparing the next generation of authorities for the profession as it moves towards the 2030s. Those who have made a name in aromatherapy, such as Robert Tisserand, Gabriel Mojay and Kurt Schnaubelt - and my host was kind enough to include me in this group - are reaching an age when we will all soon be retiring and leaving day-to-day involvement in the discipline. Yet there is no name that shouts out to us about who might be one of the next generation of aromatherapy leaders.

This led me to thinking about the midwifery specialism of complementary therapies (CTs) and to whom I should hand over the baton when I retire (not that I intend to, yet!). Many midwives are interested in CTs but are not fully qualified in any therapy. It is important to acknowledge that the field of “complementary therapies” is not just about aromatherapy (the most commonly used therapy in pregnancy and maternity care) but requires training and a comprehensive academic knowledge of several other therapies. Whilst interest in a subject is a great starting point, developing an area of expertise requires dedication, a lengthy time commitment and a single-mindedness that is similarly applied to achieving a PhD. However, having a postgraduate qualification in a subject does not, in itself, make an expert in the overall subject matter. Within midwifery, becoming a specialism leader requires a combination of advanced clinical practice and academic involvement including teaching, research and publication. 

However, most midwives have not been in positions to enable them to gain wide clinical experience of using CTs in their practice. Yes, there are many several midwives who have introduced an aromatherapy or postdates pregnancy service and sustained their involvement in CTs, but most have other roles within the organisation and are unable to focus solely on CTs. Almost all of these midwives are not qualified teachers (as is required by the therapy regulatory bodies), nor have they engaged in the higher-level teaching of colleagues (and I don’t mean “cascade training” here).  There are a few senior academics in the UK and Australia who have engaged in research around midwifery CTs, but who do not necessarily have the direct clinical experience of working with CTs in pregnancy and birth. Additionally, whilst most of these have published their research, which provides a valuable contribution to the subject area, very few, if any, have added to the textbooks available on the subject. 

That “complementary therapies” is an established specialism within midwifery is still under debate, despite my having spent forty years developing it. Many still see CTs as an add-on to physiological birth care, but do not appreciate that there are many more facets to the specialism that should be incorporated into midwifery education, at least as a post-registration activity. I have long campaigned for pre-registration education to include a general introduction to the subject, but lack of educators with adequate knowledge and understanding of this vast subject area means that inclusion in the programme is patchy at best. Acquiring a working knowledge of CTs in midwifery is NOT just about learning some massage and throwing a few aromatherapy oils about. It requires an understanding of safety and safe practice, and an ability to apply the principles of the therapies to their use within midwifery practice and their self-administration by expectant and birthing parents.  

So which midwives are interested in developing the requisite skills, knowledge and attitudes to become the new leaders in midwifery CTs? Where are they – and importantly, how can we prepare them to continue CTs as a midwifery specialism and to develop it further? I have a few colleagues whom I would trust to take over my own work – but that is not the only issue here. We need new leaders who can sustain the subject of complementary therapies as a significant field within maternity care.

Our Woman In Tokyo

I've been coming to Tokyo since 2001, incredible to think that's almost a quarter of a century. Apart from the pandemic years, I've made the long journey at least I once, If not twice a year, and occasionally even three times .

Safe Care Cannot - And Should Not - Be Done On The Cheap

This slogan refers to the Royal College of Midwives' campaign calling for better salaries for midwives, implying that better funding for recruitment and retention leads to safer care for mothers and babies.

However, this same principle also applies to the introduction of new practices, including complementary therapies. Any new initiative requires a financial and educational commitment to ensure safety.  I find it inconceivable that midwives want to introduce complementary therapies to facilitate physiological birth - yet they want to do so as cheaply and quickly as possible with no investment in training or professional development.

I was recently contacted by a birth centre manager interested in training 20 midwives in aromatherapy, acupressure, moxibustion for breech and reflexology - and wanted me to do this in a single study day! This is not an uncommon request, which is triggered by a laudable interest in and enthusiasm for complementary therapies, and a lack of understanding of what each therapy involves or how difficult they can be to learn the knowledge and skills effectively. This particular request involved four different therapies and professional disciplines requiring a minimum of ten days' training to prepare midwives to use the therapies effectively and safely.

Midwifery budget holders want to be seen to be introducing new initiatives to reduce intervention yet fail to recognise the need for comprehensive training of both the midwives who will practise the therapies and the managers who will monitor standards of practice. They have little appreciation of how complementary therapies need to fit into NHS care and the various laws and regulations relating to their use. 

Further, there is concern amongst complementary therapy educators and regulators about other professionals "cherry picking" aspects of therapies to add to their own professional disciplines. We would be horrified to think a therapist would want to study a few days of midwifery and then go out to practise - or even worse, to teach it to others, yet midwives and their managers sanction this very same concept when it comes to complementary therapies.

SAFETY in midwifery requires comprehensive theoretical as well as practical education so that midwives can apply the principles of each therapy to its practice in maternity care. It requires an understanding of how to minimise risk and how to practise cost effectively and equitably as well as safely and effectively and in line with available evidence.

Other experienced midwifery educators will attest to the general decline in students' desire to understand their practice (becoming a knowledgeable doer) and an increase in just becoming a "doer" without that underpinning knowledge. In today's fast paced world students want to "achieve" their certificates as quickly and cheaply as possible, especially as pre-registration students are generally "customers". 

However, when it comes to complementary therapies as a post-registration option, it is even more essential to be knowledgeable enough, not only to be able to justify their actions but also to counter the sceptics. Perhaps even more crucially, since midwifery complementary therapies have come under national scrutiny by the CQC and Ockenden review teams in some units, adequate education of an appropriately academic calibre is paramount to SAFE practice. 

In twenty years of Expectancy, I have always stuck to my absolute belief that safety, professional accountability and evidence-based practice are fundamental to the use of complementary therapies by midwives. This has often been at the expense of my business, but I steadfastly refuse to compromise my own principles to offer courses that do not adequately prepare midwives to practise complementary therapies SAFELY. I am always happy to offer a single introductory awareness study day to interested midwives and students - but the profession must understand that this, in no way, prepares midwives to practise the therapies. So - to quote the RCM - Safe care cannot - and should not - be done on the cheap, either in terms of cost or education.

Guest Blog : Annual Networking Day

I recently had the privilege of attending the Expectancy Annual Networking Day in London, for the “endorsed by Expectancy” midwives working in private practice .

The event was set up to network, share experiences and to explore successes and hurdles encountered with the daily running of their midwifery businesses. Some midwives are already in business and some are bravely starting up their own — I am sure this opportunity served as a valuable insight into setting off on the rewarding yet sometimes intimidating path of going it alone. Denise was there to offer sound business advice and encouragement, she must be very proud of her midwives — and rightly so! 

It was lovely to hear people talk about their reasons for having gone it alone, how they came to that decision, and how things are going for them now. It’s been a difficult time in the UK of late, but I really admired their determination to press on, adapt to changes and grow their businesses.

It was clear from the pulse in the room that the discussions were hugely beneficial for the fledgling midwifery entrepreneurs in attendance. The opportunity to explore business issues together and share information and advice was inspiring for all involved. Not to forget the camaraderie which was so vibrant and motivating. 

We all left feeling positive, full of inspiration and determined to keep flourishing. I salute these lovely and enthusiastic midwives — you are wonderful ambassadors of the Expectancy community! 

Why I Love Reflex Zone Therapy 

Having trained in aromatherapy and massage, I decided, for some unknown reason, to train in reflexology in 1989. Like many others, I naively thought reflexology was just foot massage – but I was in for a big shock. The course I started was not actually reflexology in the standard sense, but a very specific form of clinical reflex zone therapy, a German style devised by a former midwife. In the UK, the British School of Reflex Zone Therapy was headed up by a very formidable South African lady, also a former midwife, who knew her stuff and ruled us with a rod of iron – but how blessed we were to be taught by her.

Training at the end of 1989, my son was only nine months old at the time and I was still breastfeeding him. During the first weekend of the course, I realised I was producing much more milk than before I started the training. When I asked the tutor why this had happened, she explained that we had been practising the day before on the parts of the feet that reflect the endocrine system and that the student I was working with had slightly over-stimulated the reflex zones on my feet relating to the pituitary gland. These was my ah-ah moment and my lifelong fascination with reflex zone therapy was born.

Many midwives have heard me tell this story before, but this was only the beginning. I went on to develop and refine my skills and experience in reflex zone therapy and over the next fourteen years I treated almost 6000 pregnant women with a variety of symptoms and antenatal and postnatal issues. For a while, having experienced shocking pregnancy sickness myself, I specialised in treating women with nausea and vomiting and developed new theories about the causes of the issue and new reflex techniques to treat the problem. Sometimes, using something I call the “advanced technique” – a rather forceful toe-twisting manoeuvre - I could treat a woman in just ten minutes, reducing the severity of her symptoms almost immediately.  I learned ways to treat other symptoms such as backache, sciatica and pelvic girdle pain or carpal tunnel syndrome, with short dynamic, focused treatments, a necessity when my clinic at that time was NHS-based and a teaching clinic for my students at the University of Greenwich.

The focus of my work was less on relaxation therapy and more on resolving specific problems, although most women reported feeling much more relaxed even when the hands-on treatment was only fifteen or twenty minutes. Whether this was directly due to the manual treatment or the fact that women had an opportunity to talk to me and to have their symptoms validated, is debatable and was probably a combination of both. Everyone working with complementary therapies understand the power of holistic therapies and the importance of reducing stress hormones to enable an increase in feel-good hormones including endorphins and oxytocin, both so fundamental to progress in pregnancy and birth.

I was in an invaluable position, being a university lecturer, to undertake research on reflex zone therapy and other complementary therapies and to spend time writing for publication. Although my book, Reflexology for Pregnancy and Birth was published in 2010, the gist of it is still valid today, apart from the research component which is, of course, now quite old. As the years went by, I actually made some changes to parts of the map used in reflex zone therapy (which is different from those used in other forms of reflexology) and did some research into using the reflex points on the feet to predict stages of the menstrual cycle. I am over 70% successful in being able to detect whether a woman is in the first pre-ovulatory or later post-ovulatory stage of the cycle, to identify which is the active ovary of the month and to predict when the next menstrual period will commence, certainly to within a day or two.

This led on to becoming absolutely fascinated by what the feet can tell us. I have a friend in South Africa, Chris Stormer, who is a worldwide authority on reading the feet, who first introduced me to this element of the therapy (although her style is very different from mine). Chris takes a more spiritual approach to foot reading, almost an esoteric approach, whereas I am firmly focused on the anatomical and physiological aspects of detection from the feet. Many reflexologists are taught that they should not “diagnose” but this is largely to avoid those who are not conventional healthcare practitioners from making assumptions about what they see or feel on the feet. In my opinion, it is difficult to avoid making some form of diagnosis about wellbeing of the client, otherwise we would not be able to individualise the treatment to her specific needs. I have detected various medical issues via the feet and was once asked by an obstetrician if I would try to find a diagnosis because the medical staff had been unable to do so. I can often tell you which teeth need filling, whether you have had an appendicectomy or hysterectomy, or whether to advise someone to get their breasts checked for lumps.

This is what makes reflex zone therapy so amazing. It is not just a relaxation therapy, but a very powerful clinical tool, both to aid diagnosis and treatment. In midwifery, I have used RZT techniques to treat gastrointestinal, musculoskeletal and reproductive system issues. In pregnancy, RZT can be used to treat almost all physiological symptoms and to prevent some complications from becoming more severe. Later, it is invaluable for aiding the onset and progress of labour, easing contraction pain and dealing with retained placenta. Postnatally, it helps recovery from birth, eases complications from epidural or Caesarean labours and encourages lactation.

Later, when I set up Expectancy, now in its 20^th year, I started to teach reflex zone therapy to other midwives. Initially, I offered a short course of three days but soon realised not only was this not enough to gain practice and understanding of such a dynamic and complex therapy, it was also too much for midwives to receive repeated treatments from fellow students on three consecutive days. I changes the course to two 2-day blocks which was less stressful for the students’ physiology, but still didn’t give enough time to learn the theory and engage in the practice to feel entirely confident in using RZT in clinical practice. The course was finally expanded to a six-day course, one weekend per month, which gives time to practise in between study blocks and provides midwives with some fascinating insights into the power of reflex zone therapy.

Although I am experienced in practising and teaching several different therapies in midwifery practice, reflex zone therapy remains my favourite. I have practised, studied, researched and taught it now for 35 years and still love it – although the impact on my somewhat ageing hands is beginning to tell (repetitive strain). Although I could probably not now practise regularly on real clients, if I had to give up teaching it I would be very disappointed. I am still learning about German reflex zone therapy and other forms of reflexology and hope to be able to do so for many years to come.  

Annual Networking Day

Saturday 13th July saw the annual networking day for our Licensed Consultants – midwives who’ve completed their studies and are already in business as well as those just finalising their plans to start up a private maternity complementary therapies practice. We got together for a relaxed day of chatting about our businesses and meeting new midwives. We started with networking bingo where everyone had to talk to each other to find out interesting facts such as “I love rice pudding” or “I’ve changed jobs in the last year” , We went on to explore our successes and challenges from the past year as well as planning our goals for the coming year. We also enjoyed a lovely lunch from the local falafel shop.

My Favourite Aromatherapy Oils

My absolute favourite essential oil is lime – to me it smells like the old-fashioned Opal Fruit sweets (not Starburst!), you can even taste it in your mouth because the smell and taste senses are closely linked. Lime is a gentle oil and can be effective for sickness in pregnancy but also goes well with many other oils to balance some of the heavy aromas of oils such as black pepper or ylang ylang. Should be avoided by anyone allergic to citrus fruit such as oranges.

Ylang ylang is another firm favourite, which is surprising as it is quite a heavy floral aroma and something I don’t usually like. The oil comes from the flowers of an Indonesian tree. Ylang ylang is incredibly relaxing and can be sedative so useful for relaxation and aiding sleep. It is also claimed to be aphrodisiac, presumably because it is so relaxing.  It blends well with lighter oils such as lime, grapefruit and even cypress. In practice, my only precaution is to avoid it when working with women with postnatal depression – it is so deeply relaxing that it seems to push negative emotions deeper inside, whereas these women may benefit from more uplifting oils.

Spearmint is also a firm favourite. It has a lighter aroma than peppermint but is equally as effective for nausea and vomiting in pregnancy and during labour. Spearmint is a very uplifting oil and enhances the mood. It is a good oil to use for pain relief in labour and can be helpful for headaches (with the proviso that they are not a symptom of pre-eclampsia) and for respiratory congestion, coughs and colds.

My least favourite oil is geranium – indeed, after many years of using it when teaching,  I am now allergic to it, developing headaches and nausea and increasingly experiencing throat irritation when inhaling it. This is an important issue to take on board when using essential oils and I always discourage midwives learning aromatherapy from using oils which they dislike. This is due to certain smell receptors in the nose being aggravated by one or more chemicals in the oil – and repeated use will exacerbate this effect until eventually an allergy can occur. Having said that, many women like geranium and it is a useful oil for relaxation and aiding labour progress.

The Conveyor Belt Of Childbirth

OK, so now we have a new US research paper concluding that epidural in labour reduces maternal morbidity by 35% (Kearns at all, BMJ 2024). Of course, it's a team of anaesthetic and obstetric doctors which has completed the study, which gives it the political power to affect policy and to lead organisations such as NICE potentially to recommend epidural in labour as the optimal method of pain relief. If this happens, epidural will become even more of a routine than at present, with even more risk of needing other interventions in labour, likely leading to Caesarean section.

Intervention in birth is at an all-time high, to the extent that it affects service users, service planners and service costs. Women are either petrified that they will be coerced into unwanted and unwarranted induction or Caesarean, or conversely, they have lost all confidence in the ability of their bodies to give birth naturally. Midwives are fast losing their knowledge, skills and understanding of birth as a physiological process, and have certainly lost their confidence to enable women to labour spontaneously. Service managers and budget holders have completely lost sight of the fact that physiological birth is cheaper, more fulfilling for parents and staff and far less likely to lead to ultra-expensive litigation.

Having trained as a midwife in the middle 70s,. I've seen the battle for "normal" childbirth go round and round. In the 1980s we had the Maternity Care in Action reports, in the 90s it was Changing Childbirth and more recently we've had Better Births. Despite these initiatives, we are further away than ever from physiological childbirth and midwifery seems almost to be a dying profession. The incredibly vocal anti-natural childbirth lobby has inveigled itself into the debate too and is using the sad loss of many babies to add weight to the argument that medical management of birth is essential, a move guaranteed to increase unnecessary intervention.

Midwifery is no longer the autonomous ,champion of birth that it was 50 - or even 20 - years ago. Midwives in the NHS are bowed down by petty rules and regulations, too much paperwork and not enough time to care for parents. Childbirth is a conveyor belt of monumental proportions, In which all parties - parents, midwives, doctors, managers - are supposed to know their places in the system and behave accordingly to avoid breakdowns that might interfere with the complex mechanism of the maternity services. The more checks and balances we put in, the better that mechanism will run - supposedly - but at what cost?

Woe betide any maverick who challenges the system. They are subjected to coercion and emotional blackmail if they are service users, or to extreme bullying and unnecessary managerial processes if they are staff. This means that everyone either puts up and shuts up or leaves the system. Parents choose to employ independent midwives or Douglas or even to freebirth, while midwives and doctors leave their professions completely or risk alienating themselves by daring to work in private practice. 

I am not alone in despairing for the maternity services, for expectant and birthing parents and for the midwifery profession. I recently saw a post from another Facebook page, In which someone with a well-paid but unfulfilling job was considering training as a midwife and was asking midwives whether it was a good idea. Without exception, all the respondents said "don't do it" - a very sad indictment indeed for the profession. Yet if the current midwifery profession doesn't encourage new blood, the only thing that will change is the loss of midwifery as we know it and the further pathological approach to birth.

Best Foot Forward: Teaching Reflexology In Hong Kong 

I was so excited to be back in Hong Kong last week for the first time since before the pandemic. Travelling Business Class on BA, I was able to benefit from the new “pods” which provide an individual little area with a flat screen for films and, more importantly, a flat bed, so much more comfortable than the previous arrangement which required stepping over the next passenger’s feet to get out to the washroom during the night. I arrived on the Saturday afternoon, well refreshed, and was met by my lovely colleague Elce, head of the school of midwifery at the Prince of Wales Hospital. All week, I was so well looked after and treated as an honoured guest, being presented with a School of Midwifery teddy bear at the end of my stay – he had to be rather ignominiously shoved into an already full suitcase as I was leaving straight for the airport to come home.

In 2019, I had taught aromatherapy but this time I was asked to teach two 2-day introduction to reflexology courses for almost 60 midwives. This proved logistically challenging as the close supervision required to ensure students can accurately locate and palpate reflex points on the feet means that I usually only have about 12 in a group in the UK (and the course is six days, not just two). We also had some ongoing discussion before I left the UK about a suitable bed / couch on which I could demonstrate and how to position the midwives so they could comfortably work on their partners’ feet. For the first course, we had everyone working on mats on the floor although this was not particularly comfortable, so we arranged the second course with everyone working on chairs, which was much better. The midwives were fascinated by reflex zone therapy and learned a mini relaxation and some first aid points for treating women with backache, carpal tunnel syndrome, constipation, heartburn and, of course, pain relief in labour.

Midwifery practice in Hong Kong is very similar to UK midwifery, unlike in mainland China which is even more medicalised than the UK. Currently, the Beijing government is challenging midwifery numbers, claiming that there are too many midwives in Hong Kong. This is despite midwifery managers and educators stating that there is a shortage of midwives. The government has counted all those on the midwifery register but not accounted for those who have returned to nursing (midwifery is a post-registration qualification) or those who are not working at all at present. My colleague had a busy week of meetings to discuss this issue as it is likely to impact on student midwife numbers.

Back home, I had one day to recover and then it’s back to work with a vengeance as we come to the end of the current academic year and assignment marking and prepare for the new intake of midwives starting in September. Before that, I have my second trip of the year to teach aromatherapy in Tokyo and then I am back in Hong Kong in October to speak at the Normal Birth conference. Happy days!

Safe Use Of Natural Remedies In Pregnancy: Guidelines For Maternity Professionals

The use of natural remedies is at an all-time high, especially in pregnancy. Women are advised not to take drugs unnecessarily, yet many do not appreciate the potential risks of inappropriate self-administration of herbal and other remedies. Natural remedies (NRs) have, of course, been used for centuries and were traditionally a significant part of midwifery care until around the 17^th century when the emerging medical and pharmaceutical professions took control of healthcare. We know that, today, around 80% of expectant parents resort to complementary therapies and particularly to self-medication with NRs, perhaps as a means of recapturing some of that control of pregnancy and birth that has been lost in the mists of time. Herbal medicines, including many traditional and folk remedies, act in exactly the same way as drugs (and can interfere with them). They are not regulated in the same way as drugs and are relatively easy to access in health stores.   

Midwives, doulas and doctors may be asked for information or advise on herbal remedies such as raspberry leaf tea for birth preparation, clary sage and other aromatherapy oils for use in labour or to avoid an induction or, occasionally on homeopathic medicines such as arnica for perineal bruising. However, this is not a subject that is taught within pre-registration training for midwives and obstetricians, despite the increasing use by the public. Whilst herbal medicine is a self-regulated profession in its own right with graduate level training of at least three years, the issue for birth professionals is not those women who consult medical herbal practitioners but those who wish to use remedies and oils at home, sometimes without adequate knowledge to use them safely.

Many people, including conventionally trained healthcare professionals, believe that because these remedies are “natural” they are also safe – but this is not the case. Anything that has the power to do good also has the potential to do harm if not used appropriately. No remedy is suitable for every expectant, labouring or newly-birthed woman – and many are not suitable at all.

So how can maternity professionals advise expectant parents? Here are some guidelines to help you:

• All NRs should be treated with the same respect as that given to pharmaceutical drugs.

• No remedy should be used routinely for prolonged periods of time and NEVER as a replacement for proven medical treatment, especially in the event of an emergency.
• Women should be advised to avoid ALL NRs before and during pregnancy, labour and breastfeeding unless under the supervision of an appropriately qualified, insured professional.
• Women should be asked at their first antenatal appointment to reveal if they are using any NRs and their answers recorded in the maternity notes.
• Women should be advised to seek professional advice on NRs and not to rely on information obtained from the Internet, social and other media or friends and family.
• Women should be informed that not all NRs are approved, regulated or evidence based. NRs obtained from the Internet may be falsely labelled, contaminated with chemical impurities or contain banned or toxic ingredients.
• Women should be informed about the possible risks of taking pharmacologically active herbal remedies or using aromatherapy essential oils, including adverse effects such as allergies and interactions with other NRs, prescribed medications or foods.
• Advise women against combining several different NRs / complementary therapies: take only one remedy at a time, particularly at term when women may seek to expedite labour.

• Aromatherapy essential oils should not be applied to the skin neat; they should not be taken orally, rectally or used in or around the vaginal opening; keep away from eyes. Avoid using oils in the birthing pool.

• Pregnant maternity professionals and birthing companions should avoid exposure to (inhalation of)  essential oils intended to promote uterine contractions during labour eg clary sage, jasmine.
• NRs should be avoided / discontinued in the event of any medical, obstetric or fetal pathology, either pre-existing, gestationally-induced or occurring incidentally during pregnancy, labour or postnatally.
• Maternity professionals should consider the possibility that deviations from normal progress in pregnancy or labour may be linked to undisclosed use of NRs.
• Women admitted to the antenatal ward have, by definition, pathological complications requiring medical attention; they must be asked directly if they are self-administering NRs.
• Women should be advised to discontinue all pharmacologically active NRs (herbal and traditional medicines) at least two weeks prior to elective surgery or dental extraction to reduce the risk of excessive bleeding.

Why is it that “money” is a dirty word in the NHS?

Recently, I was teaching aromatherapy and acupressure to midwives at a large London hospital. In the course evaluation, I was accused of being too commercial because I was providing information on my textbooks (offered for sale as a learning resource) and on other courses they could take with Expectancy (in response to direct questions from a few midwives). This was not only distressing but blatantly unfair as I am always conscious of not being overly “sales-y”. This was a group that had been funded by the NHS trust to attend the course – and who were also able to attend it in their work time – so there was no obligation to appreciate the financial element of having the course.

Why is it that “money” is a dirty word in the NHS? Did the midwives think the course was provided free of charge? Did they not recognise that the training not only cost the fees that were paid to Expectancy by the trust but also that the clinical hours “lost” to training had to be replaced with other midwives? Further, did they think I was providing it from a misplaced sense of altruism? Midwives do not seem to understand that everything costs money – and that they are paid for the services they provide in the form of a salary. Just because no money physically changes hands at the point of providing the service does not mean our “customers” (expectant parents) are not paying for it. Healthcare costs the UK over £180 billion a year and is funded largely through taxes - so working people pay for the NHS, including care for those who do not pay tax. However, ask any midwife how much it costs for a spontaneous vaginal birth, a Caesarean, a urine specimen pot or an epidural and no one can tell you – a factor that contributes to huge wastage since employees do not have to take personal responsibility for equipment, medicines and other tools used in client care, unlike in the private sector.

Midwives who choose to go into private practice, whether as independent midwives providing full birth services or in a self-employed capacity offering services such as pregnancy complementary therapies, antenatal classes or tongue-tie division, are often castigated by colleagues because they dare to charge their clients. Yet there are services provided in the private sector that are not available on the NHS – and which some expectant and birthing parents choose to access and to pay for.  Similarly, increasing numbers of midwives are choosing to work outside the NHS – perhaps because they want a better work-life balance or are committed to offering services less accessible in the NHS. This is, as I have said before, about choices.

Prospective clients know that there will be a charge, should they choose to access private services – and it is not a problem for them. If they don’t want to pay it, they don’t become clients. If they become clients, they are happy to pay. Midwives who choose to work for themselves usually find it really difficult to price their services and to ask clients for the money – but they need to tackle this issue if they are going to be successful. If a midwife goes to the hairdresser, she expects to pay the going rate – so why is it so difficult to ask to be paid for the services offered? Obstetricians who work in private practice have no such qualms – although in fairness, they usually have an administrator who actually invoices their clients, effectively removing doctors from actually asking for the money. It would, however, be well worth any midwife considering private practice to have a chat with an obstetrician about this aspect before they set up their business.

Charging a realistic price for services can make the difference for a self-employed midwife between success and failure. Being aware of exactly what it is they are charging for is the first step on this difficult road. Prices are based on costs of training, setting up the business, costs of the actual service equipment and other aspects that have to be factored in – insurances, unpaid holidays of sick leave, legal and accountancy services and much more. On my business training days, we discuss “money” a lot and try to work out realistic pricing strategies so that clients feel they are receiving value for money without being fleeced, and midwives feel appropriately remunerated to fund their lifestyle without the guilt of over-charging. It’s a fine balance, but one that has to be confronted. If you’re considering starting your own business – come and find out how to “get over ” the charging-for-services  hurdle!

It’s Aromatherapy Awareness Week!

I strongly believe in the power of holistic care for expectant parents and maternity service professionals.

As a midwife, staying updated with the latest advancements in aromatherapy and other complementary therapies is essential.

We recommend updating your aromatherapy knowledge every two years to ensure you provide the best care possible.

Tips for practitioners:

🌸 Start with basic essential oils like lavender and sweet orange for relaxation.

🌸 Integrate aromatherapy into birth care to create a calming environment.

🌸 Stay informed about the latest research on aromatherapy benefits and risks.

Learn new knowledge and skills on our Expectancy Certificate in Midwifery Aromatherapy.

Making The Move To Starting Your Own Maternity-Related Business

So … you have decided to set up your own business … but where do you start? It’s vital to research what you want to do and how you want to do it. Don’t be tempted to rush ahead with enthusiasm as this may cause you to make mistakes (which can be costly – professionally, financially, or even legally) or you may find you have to “unpick” something you initiated too early. I have mentored many midwives who become so excited about branching out on their own that they forge ahead with ideas that are only partly thought-through, often with disastrous consequences (I’ve also done it myself in the early days!). Make sure you are deciding on private practice for the right reasons – are you moving towards something better or running away from an untenable situation? 

Once you’ve decided that you really do want to set up your own practice - and having looked honestly at your reasons for doing so - you now need to start by making some concrete plans. Decide on the specific services you wish to provide and consider how you would like to provide them. Take time to think about things, leaving it for a while and going back with fresh eyes once you have had time to consolidate your ideas. Try to identify exactly what you wish to offer – if you don’t know, then neither will your potential clients understand what you are offering. It’s also counter-productive to include too many different elements at the start of your new venture and you need to be flexible enough so that other services can be added later.

When I set up Expectancy, I made the mistake of trying to be all things to all my potential customers. I wanted to offer clinical services to pregnant women, as well as professional courses. Not only did I want to provide education for midwives, but also for doulas, antenatal teachers and therapists. This meant that I was trying to spread myself and my colleagues (and my limited advertising budget) across at least four different markets. Indeed, my adverts were completely unclear because we had tried to have a “one size fits all” leaflet – which just did not work. Everyone was confused – including the team. It was only later that I made the decision to focus solely on offering professional courses preparing the students to provide their own clinical services that it started to make sense. When I finally decided to concentrate entirely on marketing courses and business services for midwives there was a consequent substantial growth in income. If I’d taken time and explored specifically what I wanted to do, I may have achieved success more quickly and more productively. You can’t start everything at once, and your business will develop as you grow.

Discuss your thoughts and plans with your family, your colleagues and, if possible, talk about your ideas with potential users of your services. Is there a market in your area for what you want to offer, and will women pay for it? You will need to be aware of what’s available to women via your local NHS services. For example, if you’ve decided to offer postnatal care and lactation services, be sure that you know how much - or how little – of this is provided by the local maternity services. Similarly, it would be difficult, both in business and professional terms, to offer a service for women who want to avoid induction of labour by accessing complementary therapies if your local maternity unit had already implemented a postdates pregnancy clinic. Perhaps you could start earlier than 40 weeks’ gestation and offer a pre-birth preparation package instead? Research the competition and look at ways in which you may be able to offer something different or better. Which service providers in your area are successful, or more successful than others? Do they have a particular focus on how they market (sell) their services? Are there other midwives or doulas in your area already offering what you are considering?

Taken from Denise’s book The Business of Maternity Care, a guide for midwives and doulas setting up in private practice (Tiran 2019)

What Is A Practising Midwife?

Why is it that many midwives believe - incorrectly - that those who are not working in NHS clinical midwifery are not practising midwives? 

 I recently saw a Facebook question asking who had left midwifery and wanting to know what they were doing now. Almost half of respondents actually stated that they had "left" midwifery - yet they were still registered for NHS bank work or had roles that required a midwifery (or nursing) registration, such as safeguarding. There were one or two ex-midwives now working as doulas (in which case they are required to lapse their midwifery registration), but the majority were practising midwives by virtue of still being on the NMC register, even if they were not employed by the NHS.

This disrespect for midwives not working in NHS clinical practice extends across the whole profession. At the recent RCM annual conference, I overheard a midwife joking about a colleague having "gone over to the dark side" ie, into midwifery teaching. When I left the university sector, where I had worked as a midwifery lecturer, to set up Expectancy, I had colleagues wishing me well "on my retirement" - despite the fact I was about to embark on a journey on which I would work harder than ever before. There was even one who implied that I could not possibly be as good a lecturer now I was about to go freelance as I had been the previous week when I had been employed.

Even at the highest levels, there are often comments made about the number of midwives who have "left" the profession. And yes, midwives are leaving the NHS in droves, but they have not all rescinded their midwifery licence to practise. Some move into independent midwifery, whilst others set up their own businesses providing maternity complementary therapies, antenatal education, lactation support or tongue-tied division. Leaving the NHS to work in a self-employed capacity is seen as traitorous by many, and the notion of actually charging for their services is the ultimate treachery. This is despite the fact that these same midwives do not work for nothing in the NHS - they receive a salary.

When I teach business studies to the midwives who join Expectancy to start their own businesses, we spend some time discussing their personal attitudes to becoming self-employed and to physically charging for the work they do. There are some who never quite overcome what I call "the NHS mentality" - and who consequently only achieve a "hobby business" that they enjoy and that gives them some pin money for a few extras in their lives. But there is a growing number of midwives who embrace this new challenge wholeheartedly and who become successful as "endorsed by Expectancy" business owners.

The nature of maternity care is changing and pregnant women are increasingly prepared to pay for what they want. We talk a lot in midwifery about giving women choices - but what about the midwives? Don't they deserve to be able to make choices about the way they work? A qualification in midwifery prepares you to practise midwifery anywhere in the world (subject to local national requirements) and in any setting in which pregnant, birthing or new parents require our support. This includes teaching and private practice. The NHS doesn't own you and charging for your professional midwifery services is not the heinous crime some would infer.

Let's learn to respect ALL our midwifery colleagues wherever and however they choose to work. The term "practising midwife" refers to anyone with a midwifery qualification who - in the UK - is currently registered with the Nursing and Midwifery Council.

The Power of Reflexology: Predicting Stages of the Menstrual Cycle

Reflexology is a popular relaxation therapy and often used as a therapeutic technique to ease physiological discomforts of pregnancy and the postnatal period. “Reflexology” is not a single complementary therapy, but a generic term for a wide variety of different modalities. The principle of all types of reflex therapy is that one small area of the body (usually the feet) represents a “map” of the whole, with all parts of the body reflected in that defined area. Almost all styles of reflex therapy focus primarily on using the two feet to represent the “map” or chart of the whole, with every part of the body identifiable on one or both feet, although the precise location of different organs varies considerably between different styles of reflex therapy. The application of manual pressure to specific points aims to induce a sense of relaxation, relieve pain, reduce stress and, with some modalities, to treat specific clinical conditions. By working on these precise points on the feet, impulses are thought to be directed to the various organs, having a physiological effect on that distal part of the body to which the foot point relates.

Most forms of reflexology currently used in the UK, USA and southern Europe are based on modified versions of early 20^th century charts. In the 1950’s, a German midwife, Hanne Marquardt, refined reflexology into a dynamic clinical tool for treating various clinical conditions. The Marquardt style of reflex zone therapy (more recently renamed as “reflexotherapy”) is notably different from generic reflexology, with a different “map” of the feet, different terminology, different therapeutic techniques and different pressures. It is commonly used by midwives in Germany, Switzerland, Austria and Scandinavia. RZT is the basis of my personal style of practice which I have taught to many midwives around the world and Expectancy is the only UK organisation offering RZT courses specifically for midwives.  

RZT can be useful from the preconception period to the end of the postnatal period. Regular reflexology treatments allow women to take time for themselves; the accumulative physical and emotional effects assist in preparing them for the birth through a proven reduction in stress levels which automatically increases oxytocin levels. When physical discomforts occur during pregnancy, specific techniques can be used to reduce symptoms such as sickness, backache and sciatica, carpal tunnel syndrome, constipation and oedema. Receiving regular RZT in the final weeks of pregnancy may contribute to spontaneous labour onset, reduced duration of the first stage and greater parental satisfaction.  During labour, it can reduce anxiety, pain and duration of the first stage. 

Many reflexologists claim to be able to “read” the feet and there is growing evidence to suggest a correlation between reflexology points and physiology as well as actual, impending or previous pathology. From my work whilst at the University of Greenwich, I found I was able to identify stages of the menstrual cycle in non-pregnant women, using the foot reflex zones for the reproductive tract and the pituitary gland (a different location from most styles of reflexology, defined by my own research). It is possible to identify in non-pregnant woman with average 28-day menstrual cycles whether they are in the follicular or luteal stage of their cycles, which ovary is active and then to predict the date of onset of the next menstrual period. My results showed a 65-70% success rate and I have since taught midwives on my courses how to do this assessment.  I also adapted the technique to enable an estimation of the onset of labour based on palpation of the two reflex zones for the pituitary gland. Accumulated experience over many years suggests that the pituitary reflex point on the right foot is tender throughout pregnancy, inferring that it is consistent with ongoing anterior pituitary activity. However, the pituitary point on the left foot becomes increasingly tender as term approaches, potentially reflecting the changes in hormonal activity as pregnancy hormones decline and labour hormones increase in readiness for the birth. When the pituitary zone on the woman’s left foot is more tender than (or at least equal to) that on the right, this suggests that labour is imminent, albeit based on a subjective assessment by the woman on the severity of tenderness. The pituitary gland reflex zones are fundamental to midwifery practice of RZT and the primary points to be stimulated for facilitating labour onset. In addition to using this point for postdates pregnancy or to avoid early term induction. It is also useful for encouraging progress in the latent phase of labour, as well as for stalled first stage, retained placenta and, postnatally for lactation, all of which rely on the production of oxytocin. 

If you would like to learn how to use RZT in midwifery, including estimating stages of the menstrual cycle and onset of labour, contactinfo@expectancy.co.uk for details of our Certificate in Midwifery Reflex Zone Therapy commencing 28^th September 2024.

Aromatherapy in Fife

I can hardly believe that April is almost over. Time has flown by so quickly!

One of my highlights was leading the aromatherapy and acupressure course for postdate pregnancy in Fife, Scotland.

It was wonderful visiting the midwives who are eager to embrace the nurturing aspects of midwifery and to establish a service for women seeking alternatives to induction for being overdue. They are committed to promoting natural birthing processes and reducing medical interventions at the unit.

Twelve enthusiastic midwives are now dedicated to this new initiative!

A special thanks to Louise Hepburn and the group for their warm hospitality. 

What has happened to childbirth?

When I teach our postdate pregnancy courses, midwives tell me that term labour is considered to be “overdue” if it has not started spontaneously by 41 weeks and five days gestation or – if you’re lucky – by 42 weeks.

Why are obstetricians – and increasingly, many midwives - so frightened of physiological birth that they feel the need to manage it as a pathological medical condition?  

Why is there such an obstetric dependence on measuring time limits or other numerical markers? Induction rates and other interventions have sky-rocketed, with some units having a 60% induction rate.

There is so much reliance on watching the clock that we are producing midwives who have rarely witnessed an entirely physiological birth. I talk more about the “Institutional Ticking Clock’ in my  blog post.

You can read it here - https://pulse.ly/ukzr1isgag (Photo: Mateus Campos-felipe via Unsplash)

Denise looks back

On my first trip to teach obstetricians in Hong Kong in 2001, I visited a typical Chinese medicine clinic, which was a fascinating experience.

Acupuncture was sometimes used as the primary treatment for a condition, sometimes with herbs or massage, and sometimes the patient was referred to the "bone-setter", who appeared to be a sort of Chinese osteopath.

However, on this trip, my medical peers, trained in the West, had mixed feelings, especially witnessing the informal atmosphere of the clinic and unconventional methods of prescribing herbs.

Yet, years later, I've seen Traditional Chinese Medicine (TCM) evolve into a blend of tradition and modernity in clinics across Hong Kong, China, and Taiwan - bustling, professional, and as popular as ever.

With nearly 66,000 hospitals and 19,000 clinics dedicated to Chinese medicine in China by 2019, and an increasing amount of research evidence, it's clear: TCM's impact is profound and growing.