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Puberty, birth control and cramps I grew up in Trinidad, in the Caribbean in a very Christian household, and attended religious primary and secondary schools. Sexual and reproductive health was discussed in a functional way in biology class. While we were taught about birth control methods (condoms, IUDs, etc), we were expected to follow the abstinence only path. The shame and stigma around premarital sex meant that a lot of incorrect information was passed from girl to girl. I was one of the lucky ones – my parents provided books, encyclopaedias and, no idea why or how we had them, medical encyclopaedias. From these books I learned about puberty and sexual differentiation With all this book knowledge I felt that I was well prepared for anything puberty threw my way. My first period was met with delight that I was finally a ‘woman’. My second was met with agonising cramps and being told, “stop being a baby, that’s life”. I learned the tricks – sleep on your side to prevent leaking (tampons were not allowed), get a hot water bottle, Buscopan tablets, always having a spare pad, count the days meticulously to avoid being embarrassed. We were taught that cramps were just a way of life and you had to just get on with it. In an all-girl school, period cramps were not considered a good excuse for PE or any physical activity. My period suddenly stopped In my second year of university (my first degree) I took on a very stressful course load and quickly became overwhelmed by the volume of work needing to be submitted every week. The stresses of university life made itself known by my period stopping. By the third month, I realised that something was definitely wrong, and I approached my mother with my concern. As soon as I’d articulated my concern my mother paled and gasped “ARE YOU PREGNANT?!” I was at a loss for words because, while I was in a relationship, it had not progressed to that point and I hadn’t even considered that my mother would think that. I immediately replied “Of course not.” This led to my first gynaecological visit, where my mother’s gynaecologist tried to insist I was pregnant and refused to accept that I wasn’t sexually active at 20. After a negative pregnancy test and a normal examination, they concluded that it was university stress, prescribed me a progesterone pill to restart my period and medication to regulate it. No further investigations were done, and without the knowledge to advocate for myself, I trusted in my doctor that he was right. My boyfriend at the time saw the medication as a gift – I could now safely have sex if I wanted to. I saw it as liberating for different reasons. I could skip a period, I knew exactly when my period would be so I could plan social activities and not be caught out, my periods were now pain-free and very light. I wished I had discovered this pill years before! As a doctor, I thought I knew what to expect with an IUD Six years later, with that relationship ended and me in another country pursuing my medical degree, I was still taking this pill to avoid periods even though I was single. However, with a varying schedule I kept missing my timing for the pill and, during my Obstetrics and Gynaecology rotation, on learning more about the copper Intrauterine device (IUD) I felt that this was a fool-proof method. Having attended clinics, been taught about the insertion of the IUD and having inserted some for patients myself, I felt confident that this was the method for me. How to insert an IUD: A properly sized speculum is inserted and adjusted to bring the cervix into view. A uterine sound is used for measuring to ensure high fundal placement of the copper IUD. The IUD is then placed. If, like me, your uterus is retroflexed, a tenaculum (device with 2 prongs) is used to grasp the cervix and straighten the uterus to avoid perforation. The above information was rattled off many times by doctors and nurses we observed as medical students, and we rattled it off to patients when we were allowed to assist. The other side of the curtain I went into that room thinking I knew everything. I had all the knowledge and experience from books and my teachers. This was going to be quick and easy. I was going to get this done, and re-join my peers for the rest of the day in clinic. The patient experience is definitely weird when you know that tomorrow you are going to come in and be face to face with the nurse who is currently all up in your insides. You try to make conversation and feel less awkward about the discomfort involved in a speculum insertion, you try to follow the instructions to “relax and take deep breaths.” But nothing prepared me for the white-hot searing pain that came after the words, “now you’re going to feel a little pinch.” I screamed. And immediately felt ashamed for it. Because, this is normal, right? This is what many woman go through. Why couldn’t I just grit my teeth and bare it? Why did I have to be so weak? Through clenched teeth I endured the rest of the insertion, got off the table and dressed and stumbled out to the waiting room before collapsing on a chair. My head was spinning, my insides writhed in agony and I couldn’t form words. I was sitting there in my white coat and scrubs and being stared at by all these women in the clinic. My clothes screamed that I was on the other side of this divide, and the curious stares drove me to leave. I stood up and walked out of the clinic and went to the café next door. I quickly realised what a mistake I’d made as I fainted and was luckily caught by a café patron and placed on a chair. A kind lady brought me a drink and sat with me while I waited for the ringing in my head to stop and my vision to return to normal. When I could stand without assistance, I got a taxi home where I got into bed and cried myself to sleep. Normalisation of female pain In the weeks and years that followed that experience, and now as a practicing doctor, I find myself asking, “why do we allow female pain?” Too often female pain is dismissed as ‘normal’ and from an early age we tell girls to accept menstrual cramps. It takes years for an endometriosis diagnosis to be made, all while the girl/woman is going through pain that can be so debilitating that they cannot go to school or work. In medical school and in practice, a lot of stress is placed on testicular pain and definitive treatment as soon as possible to save a testis. Meanwhile, possible ovarian pain/torsion is made to wait. Normalisation and diminishing female pain starts from a young age, and leads to the internalisation and acceptance of this by women. Painful periods, intercourse or just pelvic pain are often dismissed or trivialised as ‘a low pain threshold’, ‘making it up’, ‘excuses’, ‘all in your head’. Women learn to apologise for their pain. I have lost count of the number of women I have seen in the A&E who start off with “I’m sorry to bother you doc, but…”. We need to understand the female anatomy better Medical textbooks abound with descriptions of male anatomy. Journals are filled with erectile dysfunction treatment. For women, the same isn’t true. Prominent obstetric and gynaecological textbooks ignore detailed female anatomy. Illustrations such as this image of the female clitoral anatomy aren’t common in medical textbooks. If, as medical professionals, we don’t know the nerve supply to an area, how can we truly say, “this won’t hurt?” In order to truly understand female pain, we need a better understanding of female anatomy and to stop thinking that if they’re not complaining, it doesn’t hurt. Improving patient knowledge also goes a long way in being able to properly communicate their pain. When a large proportion of women use the word vagina to mean the vulva, it’s difficult to effectively communicate where the pain is. Validating the patient’s experience I don’t have an easy solution, but here’s how I’m combatting it: One of the things I found that made a difference to patients (children to adults) was saying, “I believe you.” Pain is something I can experience, but I cannot see. If someone is telling me they have pain, my job isn’t to judge or dismiss it, it is to try to help to relieve that pain. Starting off a consultation validating your patient’s feelings and pain isn’t hard to do, and makes a world of difference. As medical professionals, we can make the difference for other women and help to champion better responses to female pain. Further reading Is pain a patient safety issue? (Patient Safety Learning, November 2020) ‘Women are being dismissed, disbelieved and shut out’ (Stephanie O'Donohue, November 2020) Gender bias: A threat to women’s health (August 2020) Should mismanaged pain be considered an adverse event? (March 2015) Improving hysteroscopy safety (Patient Safety Learning, November 2020)

The benefits of Continuity of Carer (CoC) within antenatal and postnatal care, and the implications for patient safety are well reported. As a midwife, to know the person from booking to postnatal means I am aware when their mental health may be deteriorating, or when they may be experiencing relationship difficulties. It also makes me feel more confident to challenge situations, including potential safeguarding concerns or welfare issues. If a person trusts in their relationship with their midwife, they are more likely to confide that they are struggling, and we'll be better placed to support their health needs. Supporting people within their wider context Community midwifery is not just caring for a person’s physical needs. It’s knowing their family, their housing situation, their past social history, understanding their vulnerabilities and hearing them when they tell us that something isn’t right – whether that be in relation to their pregnancy, their relationship or their mood. This is incredibly difficult to achieve without CoC and is frustrating for both midwives and pregnant people. Midwives want to offer excellent care and pregnant people deserve excellent care. I recently visited a family who were struggling financially. Although I was aware of their financial predicaments, I had no idea the extent of the issue. I went one afternoon for an antenatal visit. The atmosphere was very tense, and I had heard raised voices upon approaching the house. When I entered the house, their child was crying and shouting, and the parents were distressed. Because of the strength of the relationship we had developed during the pregnancy, I felt able to challenge the couple about what was happening and what I was experiencing with regard to the tension between them. I was informed they had no food and had to get through the weekend with nothing to eat. The mother had been too scared to tell anyone in case her children were taken away from her. This opened up a conversation about their welfare generally and we were able to work together, with other support services, to meet the immediate crisis and attempt to start dealing with the ongoing issues. Monitoring mental health Another person disclosed at booking some historical mental health issues. She had been fine for a few years and had not required treatment recently. During an appointment a few months later, I felt I wasn’t experiencing her like I usually did. It wasn’t anything obvious just a ‘sense’ that she was holding something back. I gently probed her, and she informed me she had been struggling with anxiety in relation to hypervigilance regarding the baby’s movements. We spent some time working on strategies to manage this anxiety and, aware of the clock ticking during a short antenatal appointment, I arranged to see her for a double appointment at my next clinic and referred her to the mental health midwife for ongoing support. In times of loss Something we rarely talk about as midwives is loss. Caring for a family from booking, to finding out the baby had died, to birth and beyond, taught me a lot about the power of CoC. Being present when the couple met their baby and supporting them for as long as they needed postnatally was an enormous privilege. Although challenging because of the depth of grief, knowing I could make a small difference to their experience, because I knew them and they trusted me, meant we were able to discuss very difficult decisions over a cup of tea whilst the other children ran around us bringing a level of normality to a very awful situation. Relationships matter I have received some amazing feedback from families regarding CoC. Recently a woman said that the strength of our relationship was important to her because she trusted my judgement and ability to advocate for her. She said her experience of CoC had made something that was terrifying to her “not so scary”. Thank you cards I have received always comment on the strength of the relationship. Over and above any other element of care a person has received during the pregnancy continuum, the relationship and the patient feeling like I ‘know’ them is what they reflect on when we are saying goodbye (which is the hardest part of this model of care!). As a midwife I get amazing job satisfaction from taking a family from booking to birth to discharge. The privilege of being present during such a life altering time in a family’s life whether it be a first baby or tenth baby, leaves a mark. Every family I look after leaves a footprint. If you'd like to share your thoughts on the Midwifery Continuity of Carer model, you can join the conversation here.