27. Oxford Sabbatical
After struggling in Montreal with trying to produce in two years a family doctor who could provide all services, including birth, it was time for me to take a sabbatical. I decided to go to Oxford from 1980 to ’81, where full maternity care including the delivery was provided based on uniquely cooperative relationships between general/family practitioners and midwives. I wanted to see if and how full maternity care could be safely done.
I was given great freedom in Oxford. I was connected clinically with both the midwifery group and the obstetric group of consultants. Sometimes I worked with the midwives in their clinics, which took place in the offices of the general practitioners, with whom they were affiliated. The GPs provided backup for issues beyond the scope of midwifery, but it was a rare GP who actually attended births. If they attended births, it was as a second attendant, as they believed that the actual birth was better in the hands of the midwives. I also attended a number of midwifery home births in Oxford, acting mostly as an observer, though at times I participated as needed. In that role I dressed in civilian clothing.
On the obstetrical side of my sabbatical experience, I was used as a junior consultant. I took duty in the hospital, attending complicated births at the request of the hospital-based midwives. I dressed in greens with a white lab coat over and wore white wellington boots, as did all the surgeons. The midwives would page me from the on-call room to do a forceps delivery or to be part of a Caesarean section or to discuss induction or augmentation of labour. In these cases, I worked more as a technician, as the midwives had already decided what was needed. Mostly, I just did what the midwives asked. When the midwives called me and I entered the room of the labouring mother, she knew that the whole scene had changed. She was no longer a woman trying to birth her baby; here was a man in wellingtons who was going to intervene, moving her into a more passive role. Her expression would change to either relief or sadness.
Overall, this dual clinical experience could be viewed as a participant observer role. Sometimes I worked with and was seen as part of the midwife team. At other times, in a completely separate role, I was on the obstetrical side of the equation. In this way, I came to appreciate the roles of all the players and how they interconnected.
One of the unique aspects of the Oxford maternity system was that particular GPs and their practices either did or did not do maternity care, especially the birth itself. If they did not attend births, a complex system of hospital-based care was put in place. One group of midwives did the prenatal care, another group of midwives did the care for the birth and yet another did the postpartum care. The obstetrical consultants, in each phase of care, supported the midwives.
In contrast, if the community-based GP practice did provide full maternity care, the midwives associated with the GP practice provided full continuity. They did all three of the components. As part of my Oxford sabbatical, I studied the consequences of these two systems of care. Although some thought of my research as GP versus consultant care, it was really about fragmented care versus full continuity care. In short, full continuity care had better results across a broad series of outcomes.
Because of the Oxford experience, I saw that GP maternity care could be done safely and well in a Montreal context. Based on my own positive experiences working with Ethiopian midwives and with Montreal midwives pre-legalization, when we worked to develop quality regulated midwifery, and because of my former role as a neonatologist, I knew that birth by family doctors could be done safely. As well, I thought that I ought to be able to competently attend births myself. The next step was to develop a safe model of full maternity care for our centre in Montreal. That would wait for my return from sabbatical.
But Oxford provided much more than helping me to develop a model to apply in Montreal. I received research support and mentoring from two key figures. One was Iain Chalmers (later Sir Iain), an obstetrician who was head of the National Perinatal Epidemiology Unit (NPEU) at the Radcliffe Infirmary, a unit doing critical research on all procedures and approaches in maternity care. There I met statistician Diana Elbourne, who worked closely with me on several published studies.5 Iain and many others on staff taught me more methodology and helped me with my analyses and approach.
Sir Alexander (Alec) Turnbull, head of obstetrics and gynecology at the university department and the John Radcliffe Hospital, also worked with me and facilitated my research. Even as Dr. Turnbull was dying from cancer of the esophagus, he remained involved with my work and helped resolve a very serious academic breach when one of my research assistants stole my data and project, changed her thesis and took all my work and data as her own.
My Oxford sabbatical was partially funded by the Nuffield Trust. As a Nuffield fellow, I was privileged to attend many academic functions. The role opened doors and allowed me access to Green College, one of many Oxford colleges, where I was exposed to the Oxford academic community. Eating at high table with all types of physicians and getting to play squash with some was another benefit.
All the work I did at Oxford became the springboard for almost all the maternity research I subsequently undertook. Without the Oxford training and support, it is unclear if my research focus on maternity care would even have developed.
One of the high points of my time in Oxford was meeting natural childbirth activist Sheila Kitzinger, who generously engaged me in her activism. Sheila lived near Oxford in the town of Standlake, in a house that was renovated for the second time in 1492, as Columbus was setting out to “discover” America. Her fireplace was so large that you could walk into it. She was a cultural anthropologist whose contributions included a book on childbirth almost every year for at least ten years. These books on education and the power of women to give birth have been used by millions of pregnant women and birth caregivers. She thought that childbirth had become medicalized and was determined to empower women to contest the medical establishment and push it to provide evidence-based care. She saw midwifery as the central force in the needed changes. She became my teacher in the ways of birth advocacy and changing the maternity care system, a system that exercises pervasive control over women and childbirth to the present.
Sheila was a very tall woman, whose loud and good-humoured voice made her presence felt wherever she was. She believed that pain in labour was real, but women in labour could nevertheless overcome pain by thinking of birth as inherently sexual. In fact, she and others witnessed a number of women having orgasms in the later part of birth. Her talks on the subject encouraged many women to allow themselves to experience orgasm in birth.
During my sabbatical, Sheila often took me to meetings of the National Childbirth Trust, a birth advocacy group, which she frequently led. To that end, Sheila and I were sitting on the commuter train from Oxford to London, talking as usual about how to improve many aspects of birth. This morning the cars of the train were completely filled with men, with some standing, most in three-piece pinstriped suits, holding their briefcases. They were on their way to the financial heart of London. On this occasion, I cannot remember what triggered her, but she began describing in great and colourful detail, with primal sounds and gesticulations, oblivious to the men around her, orgasm in birth. The men around us moved away. Some began to move to the adjacent car. By the time we got to London, the two of us were alone.
Every time I worked with Sheila, from Oxford to Mexico City, to various cities in North America, it was always a pleasurable experience. Her topics were ever-changing, but she never stopped trying to make birth a positive and growth-enhancing experience. Sheila Kitzinger, a giant in maternity care, died on April 11, 2015. She was an inspiration to generations of women and maternity caregivers. We all miss her and continue to honour her legacy.
I was not the only one who benefitted from the Oxford experience. Because Bonnie was in the middle of making her infamous film Not a Love Story, about violent pornography, she had to go back and forth between Oxford and Montreal. I was thus the main parent in Oxford. Seth and Naomi were enrolled in a state-funded Church of England school in North Oxford.
Naomi’s experience at the Oxford state school was terrible. It started with a French teacher who told her that he did not want his students exposed to Quebec French, so he exiled her to study hall when he was teaching French. Naomi spoke better French than he did. In the end, after trying to resolve the issue with the headmaster and the threatened French teacher, we pulled her out of the school and enrolled her in an unusual school in a nearby town. It was a town where the European Economic Community (EEC) was working on a hush-hush nuclear project. The EEC was obligated to educate the children of the staff in their own language: French, English, Spanish, German, et cetera. I don’t remember exactly how it happened, but Naomi entered the French stream. She loved it.
Seth, in the same state school in North Oxford, had an extraordinary experience. Until then, Seth had been an average student, but in Oxford his English teacher was Philip Pullman, who inspired Seth. It was a major academic breakthrough. We attribute a large part of Seth’s subsequent academic success to this teacher, who later became the famous author of The Golden Compass and other books.