A video of us reading the guide can be found at the bottom of the article
This review has been written by Sarah Hawkins and Reign Lawrence. Our experience and twin journeys are very different from each other. We are quite different people, which Sarah considers Reign would probably put down to where our moons rise, planetary locations and whether, according to our birth charts, we are land or sea mammals. While Sarah plays off that she is spiritually bankrupt, prefixing many "woo" statements with "I'm not very woo" Sarah’s only point of reference to earth, wind, fire and water is from the movie, The Fifth Element.
With that said, people have drawn their own conclusions about us, accurate or not, as individuals.
Because Sarah doesn't post images or videos of other people’s babies or births, people assume that she doesn't support home birth of twins. Because Reign works exclusively with those either freely choosing, or being corralled into, freebirth there is an assumption that she sees no value in medical interventions.
Neither of these are true of us.
We are both outspoken and that has won neither one of us a huge fan base among our peers and their followers. These followers seem to expect an allegiance to the person they follow, who they have great faith in being the authority in what is often referred to as our “profession.”
We do not shrink away from criticising or trying to have meaningful discourse with our birth colleagues, indeed sharing of ideas is the only way we will exact change.
Unfortunately, the response is often defensive, dialogue is avoided and factual content is overlooked in preference for how people FEEL about what’s been said. There is confabulation, factless allegations and ad hominem attacks that can carry real life consequences.
Fortunately, for anyone currently pregnant we are much less interested in becoming big social media influencers, prioritising information and awareness of important, life-altering subjects over vapid posts in which we misinterpret research.
We both want the best for people in regard to pregnancy and birth and are willing to say what needs to be said. Occasionally, we disagree with each other and that is okay, in fact one might even consider it healthy. We have even interpreted some parts of Mrs Cronk's article differently. As such we will talk in general terms about things we agree on and name ourselves when the opinion is held by one or the other.
We have found, while interrogating this guide that some parts can only be responded to comically, this we hope comes across as good-natured and not in any way meant to be disrespecting the memory of Mary Cronk and all she has meant to people.
If you know our stories beyond what you think you know, if you knew the stories of families in the twin and multiple community, you might consider that respecting memories of all the babies who didn’t make it or who struggle in life because of poor information to be important enough that however we choose to address it, is rightfully ours.
The Review.
Mavis Kirkham, Emeritus Professor of Midwifery at Sheffield Hallam University, in her 2018 obituary to Mary Cronk, described her as someone who
“politely stood up for the women in her care, regularly challenging consultant obstetricians who required all “their patients” to have an episiotomy”. (The Guardian, 2019)
While we hold Mary Cronk in high regard for her advocacy of consensual care and her contributions to improving knowledge about breech vaginal birth, it concerns us that, even today, midwives refer to Mary Cronk's work and guidance. They were written almost twenty years ago and, whilst well-respected, the poor dear cannot be expected to keep abreast of the most up-to-date evidence from the grave.
She is also, in that prominent article, posthumously regarded as an “expert in twin births”
This review, will demonstrate that she was far from a twin expert when she was practising from between 1957 to 2018 and that the advice she was offering in 2007, and to which some contemporary NHS and independent midwives still refer is inaccurate and dangerous.
She first studied nursing at Glasgow Royal Infirmary, and in 1957 started training to be a midwife at Queen Charlotte's in London. A video of a birth at this hospital from the 1950s can be found and watched on Youtube here.
The tone of her 2007 "My Guidelines for Care of a Woman Expecting Twins" might be fitting if written in the 1950's and has some quite major inaccuracies and misunderstandings.
Under the heading, Antenatal care, Mrs. Cronk states that:
“Depending on the gestation when the diagnosis of the twin pregnancy is made, the following should be discussed with the woman, and her partner if appropriate”
It is unclear what content Mrs Cronk’s gestation-dependent discussions would include so it is so vague as to be unsuitable as a guide for other professionals. She doesn’t mention what different gestations mean in regard to information sharing.
Under the headings, Nutrition and Diet and then Excercise and Rest:
The paragraphs talk about optimising health with a balanced diet, vitamins, exercise and rest that should be made. This is good, common sense advice. Mrs Cronk would be pleased to know that while not always practicable, contemporary NICE guidelines do recommend that:
“those expecting twins be referred to a dietician, physiotherapist, perinatal mental health professional and even a lactation consultant who should have experience and knowledge relevant to twin and triplet pregnancies." (NICE, 2019)
Whilst the NICE guideline recommendations for a full and knowledgeable support team is seldom adhered to, towards the end of pregnancy this same guideline is weaponised with a dogged determination to get babies born when, where and how a clinician would prefer.
Mrs Cronk refers to giving information of
“appropriate groups, classes or support organisations.”
I wish sourcing and signposting was as easy as it sounds here and maybe in her day, it was.
Unfortunately, it is currently difficult to practise due diligence and ensure that the support services you recommend are safe, reliable, ethical and experienced.
Under the heading “The place of birth” Mrs Cronk advises to:
“explore with the woman her wishes and feelings on this subject and inform her of the options open to her in her geographic area.”
We are in complete and utter agreement with this.
She adds:
“Should the woman choose to give birth to her babies in hospital, I would inform her of her rights to decide who will be in attendance during her labour and at the births. I would tell her that the practitioners attending her can give her advice, but have no power to stop her eating or drinking, if she feels like doing so, nor have they any power to restrict her movements or insist on being present. In fact her rights are exactly the same as they would be at home”
We cannot help but point out that while perhaps at some point in the past this may have been possible, currently this is not the reality on large obstetric units. It is obvious this was written by a white, independent midwife who served private clients. The presence of bias in healthcare means that it is not always possible or safe for individuals to express their preferences, and they are seldom respected. (BMA, 2022)
The National Maternity and Perinatal Audit NHS Maternity, Care for Women with Multiple Births and Their Babies provides data from births between 1 April 2015 and 31 March 2017 and found that around 24% of twin mums have their labours induced. (NMPA Multiple Births Report 2020.)
It would be reasonable to consider like Caesarean rates the induction rate is higher than when the audit was conducted. With that said the likelihood of these women being permitted to freely eat and drink on a labour ward is low. From our experience, as soon as the induction process is commenced a woman is strongly discouraged from consuming anything more than sips of water.
There is a well-documented culture of clinical professionals using coercive powers to have someone do exactly what they want them to do.
Huge racial disparities mean that the greater the melanin content of your skin the less you will be heard and respected. We think with this awareness, being frank and honest with the client will help them discern for themselves the extent to which they feel comfortable and able to assert their wants and wishes. This is evident year after year in The MBRRACE Report
Mary says:
“Depending on the gestation I discuss with the woman the advantages of having an ultrasound scan to determine chorionicity”
Chorionicity is determined by looking for the presence of what is called a Lambda sign (λ) in dichorionic multiples and the T sign in monochorionic multiples.
Timing of ultrasound scans can be
important because in monochorionic twins the amniotic membrane can often be missed prior to 12 weeks and in rare cases (15%) chorionicity is harder to discern by 20 weeks. Videos of diagnosing twins can be found Here
and more information on the FMF website Here
She goes on:
“Should she agree, with that information gained, I discuss the increased risks of a twin over a singleton pregnancy. I point out that while most twins are fine there are increased risks, and that the risks are greater if the twins are monozygotic (identical).”
We suspect she erroneously uses the word "monozygotic" when "monochorionic" is the intended term. Mothers rarely know the zygosity of their twins as it is difficult to determine without uncommon, non-invasive prenatal testing and it is not something a midwife is likely to enquire about as it does not usually inform pregnancy or labour care. Chorionicity (whether the babies have one or more placentae) however, provides useful information to twin mums that could help them make informed decisions about required antenatal monitoring, appropriate place of birth, safety, expected labour interventions and neonatal treatment.
Twins and multiples can be from one egg (zygote) or more than one egg. Twins from one zygote are called monozygotic and twins from two zygotes are called dizygotic. Monozygotic twins can share a chorion from which the placenta is formed or they can each have their own. However, dizygotic twins will never share a chorion.
Zygosity is the twins genetics, chorionicity is the twin pregnancy presentation.
Mary’s implied hypothesis is that in terms of zygosity, monozygotic twins (one egg that splits in two) are more vulnerable to chromosomal abnormalities than dizygotic. However, this is not true. It is often claimed by clinicians that there is a greater risk of chromosomal abnormality in monozygotic twins but there is, in fact, no known twin-specific monozygotic genetic abnormality.
Furthermore, when looking for evidence of such we found that a recent study shows:
“MCDA twins were found to have a significantly lower incidence of chromosomal abnormalities compared with DCDA twins (0.9% vs. 0.2%, p = 0.004). The study also Recognises, 25–30% of monozygotic twins are DCDA twins”
That is DCDA twins are 4 times more likely to have chromosomal abnormalities than MCDA.
It is therefore logical, based on the numbers shown here, applying them to the groups adjusting the 25% of DCDA twins who are Monozygotic, adding them to the MCDA group, reflecting overall zygosity. It is likely that dizygotic twins would be even more likely to have chromosomal abnormalities because dizygotic twins can never be monochorionic.
Rain Man, Good Will Hunting, Stephen Hawking, Mathematicians and statisticians we are not but even if we consider 4 times more, basic maths tells us that this is more than double the likelihood.
Please have a look at the study because it is a fairly large study which it doesn't allow for conformation bias and accounts for various propositions.
We considered the proposition of miscarriage was not relevant because this review is about Midwifery and maternity care and the cohort are all twins who were born alive.
If you are able to work out accurately the adjusted number please let us know and we will update this. (J Hum Genet. 2022)
We had difficulty interpreting this part of Mary’s guidance, spending an entire afternoon in robust debate. We couldn’t imagine that antenatal discussions, that didn't refer to the fact that there were two babies, would be conducted. We therefore interpreted Mary Cronk to be using the “variation of normal” (singleton) cliché as her logic, stating that chorionisity (number of placentas) alone ought to be the deciding factor in whether or not there is any value in discussing the twin aspect of the pregnancy. This presumes that there are no other complicating factors associated with twins when there are.
In the next paragraph, our beloved champion of feminine autonomy, who has heroically defended women’s rights, allows her mask to slip, stating:
“a woman really needs domestic support as she is big and ungainly, and easily tired. She may find an abdominal supportive garment helpful or support tights may help as there is an increased risk of varicose veins”
Even Reign, who sympathises with the esoteric, found Mary’s belief in the supernatural too much to bear. Professing psychic abilities, she claims to be able to discern:
“how much the woman wants to know at each consultation”
Seemingly concerned with overburdening the mother’s pretty little head with anything beyond ensuring:
“that there are relatives, friends, available to help with other children, shopping, cooking, housework etc in the latter part of the pregnancy, and in the first month or so after the births.”
Mary tries desperately:
“to ensure that she understands that the labour could be preterm”
We can only sympathise with how difficult it must have been for Mary to convey such a wildly sophisticated concept to anyone who has 2 X chromosomes!
However, Mary is absolutely right to advise the mother:
“that she is at increased risk of pregnancy-induced hypertension.”
Conversely, encouraging mothers to:
“monitor…babies' growth based on the feel of her clothing.” even in 2007 is a little alarming.
It is true to say that sudden changes in the size or shape of the abdomen can be a sign of something that requires immediate attention but this needs to be hastily responded to by a fetal medicine doctor with the science and technology to assess, and if necessary, treat. Calling a community or independent midwife, who lacks the necessary equipment, knowledge and expertise, to come and assess can lead to false reassurance.
Mary goes on:
“I plan to see her at frequent intervals, but make sure she feels able to access me, or my locum, if she has any concerns.”
We were impressed by the continuity of care promoted here. However, today this is unrealistic unless you have an independent midwife.
In the Place of Birth section she has this to say:
“In my experience women who are encouraged to monitor growth and how they feel, are very good at recognizing deviations from normal.”
Suggesting that a woman needs encouragement to have an awareness of her own pregnancy and to “take some responsibility for their health,” is conceited, patronising and infantilising.
Mary warns that:
“This does not relieve the professional attendant from vigilant care.”
Assuming that the “professional attendant” is the midwife, what is this “vigilant care” and what is the pay off to a woman of having it?
Indulge us for a moment to speak from our own experiences of maternity services today, as twin mothers, service users and birth workers.
“Vigilant care” in 2024 looks like this: There are not enough midwives within the NHS to implement continuity of care, the vast majority of midwives do not possess the competence to support twin pregnancy, maternity services are so overstretched that if a birthing person presents to a community midwife or maternity triage we know, given the most recent MBRRACE reports, that often, they are not listened to.
They will be forced to engage in huge amounts of performative clinical enquiry with the aim of the NHS Trust avoiding litigation. Often they will be coerced into doing something against their will or sent home with false reassurance.
They will have their intelligence insulted by midwives and clinicians who doubt their ability to comprehend medical terminology or complex data. If we chuck in a few protected characteristics, all the worse for the mothers and babies. Even independent midwives, able to manage their own caseloads and relatively free from the rigidity of the obstetric ward, lack in knowledge and competency of twins, especially if they are taking this flimsy guide as read, which some do.
When a mother clearly states she has concerns these are not responded to, when scans show up an issue sonographers are not competent enough or don’t have the time to interpret what’s going on and counsel the family. (we will be sharing an article and podcast that talks about this specifically in the near future)
You might be shocked to learn that midwives are searching google for information on how to support twin births. It's because there is no expectation for midwives to be competent in twin and multiple birth, the NMC allows for a student midwife to count twin birth as two singleton births in order to gain the required number of “births attended” to qualify. (NMC, 2024)
Endlessly reiterating, she states:
“There should be a full discussion of the labour, what the attendants will want to do, and what the woman and her partner feel that they will want”.
The way that the desires of the attendants feature as prominently as those of the family is outrageous and the fact that she phrases it as the parents “feel that they will want” could indicate doubt as to the validity of their choices, without the clinicians trust in cold, hard data and relying upon squishy, mutable feelings.
When discussing labour and birth options Mary recommends:
“A tentative plan for labour should be made and updated as necessary. This should include discussion of various birth positions.
If the woman is having midwife-only care the following list, which is not exclusive, are reasons to seek appropriate medical input:-
Lack of observed growth
Hydramnios
Any abnormal urinalysis
Any signs or symptoms of labour prior to 36 weeks
Abnormal results of full blood count
Any signs or symptoms of PIH”
If a woman is engaging with maternity services or independent midwives they clearly want to benefit from good quality monitoring and there must be no wishy-washy, subjective interpretation of results. There is not a midwife in existence, who can diagnose “hydramnios” in a twin pregnancy. Because there are conditions in which one twin has polyhydramnios and the other has oligohydramnios, a midwife cannot fully explore hydramnios using her tools, of measurement and palpation, alone. We suggest instead that full discussions around birth gestation ought to be conducted in order that parents have a good understanding of all eventualities pertaining to birth weight, gestational age and infant feeding. We disagree that 36 weeks’ gestation should be the primary threshold at which a mother and her midwife should seek obstetric input.
Mrs Cronk has not qualified why she suggests 36 weeks as an important marker. The NHS now deems 37 weeks to be “early term” and it is the gestation at which an independent midwife can obtain the adequate insurance to attend a homebirth. I wonder if these legal, financial and insurance issues were a consideration Mary made when choosing this timeframe.
We now move on to “The Labour”. Mary asserts that:
“Most twin labours progress well. The woman should be supported in the way that is most appropriate for her and that has been planned.”
We agree.
And:
“If a hospital labour has been chosen, I feel that it is good practice to do a 20 minute or so CTG trace of the fetal hearts in early labour,”
A 20 minute cardiotocograph (CTG) trace is not likely to give you a great deal of information and again, it is subjective. Computerised CTG (cCTG) is not recommended in labour and the reliance is on someone to interpret the results, therefore again not objective. If Sarah, having been at many twin births, had any faith in CTG being of any benefit in twin labour she would be singing its praises. When the topic of CTG or cCTG comes up with clients, Sarah encourages exploring what the mother believes she will gain from it. Are they wrongly assuming it can accurately diagnose chronic hypoxia? Or do they yearn for an all too common situation in which the trace of a twin is lost, ward staff hit the panic button and mother is dashed to theatre for an emergency caesarean? Because this is a bit of a fallacy. For varying reasons midwives would sooner put their backs out trying to relocate the heartbeat for upwards of an hour over pissing off the on-call obstetrician.
She goes on:
“taking great care to ensure that one is actually recording two heart beats and not just hearing the same heart in two different places. This is an easy mistake to make with a CTG monitor if the twins are monozygotic, as the heart rates can be very similar. Even if a CTC monitor is used there should also be auscultation by two practitioners using two Pinards stethoscopes simultaneously. They will be listening in different places and this can corroborate the opinion that there are two fetal hearts”
We are glad that Mary suggests that one “corroborate” that there ARE two heartbeats. However, many midwives who venerate Mary hold the misguided belief that twins have the same heartbeat. It is often stated by midwives, and we are currently supporting a mother whose second twin was stillborn and the midwife believed this very notion.
MIDWIVES PLEASE STOP BELIEVING THAT TWINS HAVE THE SAME HEARTBEAT.
In a hospital situation there are more reliable ways to monitor heartbeats in much less time and we suggest you skip this, do not pass go, collect £200.00 and opt for an ultrasound scan. It’s much quicker and more reliable in giving the information clinicians are hoping to deduce from a CTG. One could contend that if she is referring to a monochorionic set of twins, they might be less likely to have similar heartbeats but that is too much biology for now. Two substantially different heart rate readings in a singleton on different occasions or between twins at the same appointment necessitates further investigation, particularly if they share a placenta. We expect any healthcare professional monitoring heart rates during pregnancy to take into account various factors, including the fact that they are dealing with two or more independent hearts.
End of Part One
We hope you’ve enjoyed this review, please share it with your colleagues in the birth world as it is incredibly important that we go forward and improve, for the good of women, birthing people and their babies.
We suspect and there may be people who will take issue with this who will want to let us know immediately.
This is free education, learning and information we have created for you because we care. As such we will not be engaging with any negative comments.
We will not be encouraging anyone to defend or fight our battles but because we are a community with a high number of baby losses, compassion and understanding is requested.
To that end if you have found this interesting and a beneficial resource please leave a positive comment so that the families know that there are people taking notice of balanced discourse even if it is delivered in a casual and conversational way.
Disclaimer: We are not clinical, (by choice) and often know more than clinicians. However to be "clinical" or not seems to be something people consider to be important enough that it becomes the foundations for whether they think information to be credible. If this is how you feel, we encourage you to read this and if we are wrong reach out and we will happily learn and grow with information you have. We urge you to expand your knowledge and critically discern for yourself using various resources.
To Be Continued
Expect Part 2 in the near future.
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