This IS a thread about a thread

(99 Posts)
Mintyy Wed 16-Jan-13 19:00:34

but I am doing it because I don't want to upset the op of the other thread, and I don't want to hijack what she has started.

But can we please de-bunk the myth that anyone can have a lovely birth as long as they are PREPARED and have the right mental attitude! It is extremely damaging psychologically for women to feel that they have failed (if they had interventions/caesarian/still birth) because they were not properly tutored or well-read enough in childbirth.

The healthiest, most physically and mentally perfect women can have things go mildly wrong or catstrophically wrong in childbirth. All the birthing classes in the world cannot fix that.

Am v angry!

shagmundfreud Sat 26-Jan-13 17:44:38

"I still wonder what you think separates women into these different groups with different outcomes. If you think it's just clinical indications and it's not influenced by informal criteria on the part of health care professionals doing a sort of risk analysis, then I'm not surprised we disagree."

I think some mothers ARE more likely to request a home birth and are more likely to be steered towards a home birth by birth professionals. Older mothers are more likely to request a home birth, as are educated women.

But the point is that the study matched women up according to age, parity, social class and risk factors at the start of labour.

Perhaps it is the case that some low risk women were steered towards the labour ward rather than into an MLU - not on the basis of any evidence based protocol - but because of a 'hunch' on the part of the midwife or because of the midwife's own prejudice or ignorance, but that doesn't fit with what I know of the midwives I work with. They are very keen that mothers who want to go to an MLU have the opportunity to realise their preferred setting for birth, and it's quite unusual for midwives to do what YOUR midwife did and lead mothers to believe they don't have a choice, or make suggestions that are not based on good clinical evidence.

In any case - it's a bit of a long shot isn't it? Thinking that midwives are regularly steering low risk women into OU's without any basis in protocol and that this accounts for such massive differences in birth outcomes between settings, in study after study on place of birth? And you have absolutely NO evidence or research which backs up your view.

"I feel lucky to be living in a place and time where all of these different types of delivery were possible."

I watch programmes on birth in the USA and other countries and also feel very, very grateful that we have the choices we do in the UK.

But it's still the case even in the UK that there is under provision of midwifery led units (MLU's) in much of the country and many women don't have a choice as to where to have their baby. It's also the case that lots of women aren't really aware of the clinical evidence on the safety and benefit of birth outside of medical settings, and I think this is something we need to work on.

peanutdream Sat 26-Jan-13 17:33:17

This is a really important thread even if people agree/disagree . there is lots of food for thought.

i think the care you get is paramount, not necessarily in affecting outcomes (although it makes sense that to some extent, it would) but in how you feel about it in the end.

It is also really interesting that where you plan to have your baby appears to affect the outcome in some ways that could make a difference to some women, and that is surely important information to have. So just wanted to say thanks, particularly Shagmundfreud for providing info and dreamingbohemian for questioning it grin

I have had babies in the delivery suite, the midwife-led unit, the operating theatre, and the special room for mothers delivering a baby that has already died in utero. Each was right for the situation, and in each I was empowered as much as possible and helped by amazing staff. I feel lucky to be living in a place and time where all of these different types of delivery were possible.

I can see why you might get that from my choice of words but honestly no, I did not feel coerced. I really wanted a homebirth until I talked to the professionals and they gave me their opinion, which made me see things differently and in the end I agreed.

I still wonder what you think separates women into these different groups with different outcomes. If you think it's just clinical indications and it's not influenced by informal criteria on the part of health care professionals doing a sort of risk analysis, then I'm not surprised we disagree. I think that once you accept women are being steered on one path or another based on variables that aren't reflected in the data, the evidence seems less deterministic.

shagmundfreud Sat 26-Jan-13 16:57:41

"Birth choices, decisions and outcomes are always going to be an opinion filled and emotive issue"

Yes - which is why there's always a place for a few facts in these debates. wink

They have their place alongside emotions and opinions.

shagmundfreud Sat 26-Jan-13 16:55:51

"it's about empowering women who didn't end up with their ideal birth situation that they weren't at fault at all for this"

Yes - and one of the MOST empowering things is to be told that sometimes the way birth is managed by health professionals is the thing which is responsible for things not turning out as hoped.

In other words - it's not you, your body or your baby which is at fault. It's the way you were looked after which might have made things harder, more painful or more frightening than they needed to be.

And to give information about ways of reducing the likelihood of having a repeat experience next time round.

What could be more empowering than that?

(or alternatively we could all just sit here and say nobody has control over anything and it's all just fate, despite there being so much evidence pointing to the fact that how you are cared for in labour sometimes making a HUGE difference. Is it just me, or is that the most disempowering and frightening thing to tell a pregnant women? hmm)

shagmundfreud Sat 26-Jan-13 16:51:12

"I think both of them said the fact it was my first was a factor. I did not feel coerced"

"I very much wanted a homebirth or MLU but my midwife said no, ^I had to go to the OU^"

"I was considered low-risk yet still was made to go to hospital unit"

I'm sorry my friend, but to me that sounds like coercion.

"it's not a good idea to generalise or predict based on it."

Midwives have a responsibility to give mothers information that will help them make a decision about where they will have their baby.

One piece of information they should give them is that based on multiple large scale studies, low risk women who opt for out of hospital births and MLU's appear to have significantly lower likelihood of interventions than similar mothers giving birth in OU's. And apart from in the case of first time mums giving birth at home, have as good outcomes for babies.

Is all. Would you be OK with women being told this?

I'm quite with you in not predicting in the case of individuals what sort of birth they will have. We can't do this and nobody is suggesting it's a good idea.

LaVolcan Sat 26-Jan-13 16:51:05

What determines whether women go to the OU or MLU?

One reason would be that there isn't an MLU within reasonable distance. Another would be that the pregnant woman (especially for the first time) goes along to her GP who says 'I will book you in for XX hospital' and doesn't know that there are alternatives.

SoYo Sat 26-Jan-13 16:49:34

Shagmund do you not think that maybe this thread isn't the place for your views. You obviously have very strong opinions and there's lots of papers and evidence out there that can be viewed in different ways, but this isn't a thread about arguing the toss, it's about empowering women who didn't end up with their ideal birth situation that they weren't at fault at all for this and to ensure they are not made to feel like failures. I don't see how you coming in here trying to force your views and opinions and making people feel like different decisions would have changed their outcome is helping anyone. It might be time to just appreciate that we as a collective obviously have different opinions to you and that your knowledge and opinions would be better served elsewhere.

Birth choices, decisions and outcomes are always going to be an opinion filled and emotive issue but surely we're better placed with supporting each other rather than trying to force people to sharing your opinions. There are plenty of mumsnetters and threads that would love to hear your knowledge and views and share similar ideals.

I completely agree with the original post. By the time I had my third and fourth, my birth plan was basically 'get the babies out alive, with me surviving the process'. Anything else I decided as I went along, as circumstances evolved.

LaVolcan Sat 26-Jan-13 16:46:19

Were you not aware that you are 'allowed' to have your baby anywhere you choose?

Not quite so shagmund - they can turn you down for an MLU if they decide you don't fit their criteria. But apart from that yes, there are still a lot of women being told that they have 'got' to do this that or the other, not being told that they are being offered advice but that ultimately it's up to them to say yes or no.

x-post

But what determines whether those women go to the OU or the MLU? Do you not think that what drives them to one or the other also has some bearing on outcomes?

I mean, why do you think women go to the OU versus the MLU? Do you think it's purely the woman's choice? My whole point is that low-risk women can still be influenced to go to the OU because of possible risks that are not necessarily reflected in their low-risk status.

Yes, there may be fewer CS in the MLU cohort. But what do you think is dividing women into the OU/MLU cohorts, if they are all low-risk?

But that's a dangerous generalisation isn't it, that statement? Because for first-time mothers, homebirth is not more safe. The study makes that very clear. This is my point, I'm not saying there isn't evidence, but it's not a good idea to generalise or predict based on it.

I did see a consultant as well, he agreed that I was not high-risk but preferred to have me in the OU. I think both of them said the fact it was my first was a factor. I did not feel coerced, they were just saying what they felt was best for me, and having considering everything I went along with that advice (I was also not super-close to a hospital, which concerned me). And they were right as in the end I had a CS and the surgeon said that for physiological reasons DS never would have come out naturally.

I agree evidence is important but too often evidence slides into speculation (so that evidence on location gradually evolves into speculation about confidence). It's that jump that I think can be unhelpful, as it neglects the role of luck in all of this.

shagmundfreud Sat 26-Jan-13 16:33:02

"I'm not saying psychological factors don't matter at all. I just think at the end of the day it's really quite difficult to predict or even explain afterward why things went well or not."

It depends whether you're talking about groups or individuals. In the case of groups, it's not that difficult to be honest.

I would be happy to put a year's salary on saying that over the course of a year, low risk women who pitch up in spontaneous labour at my local MLU will have lower rates of emergency c/s than similar low risk women who pitch up on the labour ward in spontaneous labour.

I honestly don't think any bookie would give me reasonable odds on it going on the last 10 years figures.

Every single study done on birth outcomes in the past 4 decades has found that women who book to give birth in MLU's and at home have lower rates of complicated labours than similar women who opt for OU's.

shagmundfreud Sat 26-Jan-13 16:25:39

"There are some women who actually ask for intervention; induction of labour, instrumental deliveries, caesarean section, who would have been entered into the study and deemed low risk."

Emergency c/s, forceps, ventouse deliveries are only ever done in NHS hospitals where there is a clinical indication that they're needed. They would not ever be done on a low risk mother on request when there was no clinical indication. Some low risk mothers request planned c/s. They would not have been included in the study.

The place of birth study only included women who were deemed low risk at the start of labour.

It did not include women who had planned c/s or planned inductions.

"I just think these kinds of studies can't capture the complexity of childbirth in a way that lends itself to making strong predictions."

Joint statement by the RCOG and RCM:

"There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman's likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.1-3"

OK - 'ample evidence'. You may think the evidence is weak. Experts in this field clearly don't.

"I very much wanted a homebirth or MLU but my midwife said no, I had to go to the OU. But she also insisted that she still considered me low-risk. I think it was a 'better safe than sorry' situation."

Were you not aware that you are 'allowed' to have your baby anywhere you choose? hmm Your midwife was guilty of coercion and if she'd been overheard telling you that you 'had' to go to hospital then she would have been pulled up on it by her line manager. That is not ethical behaviour. My midwife and I knew I was carrying a very large baby and wanted a home birth. She contacted a consultant midwife at a large teaching hospital and asked for advice. Then she sat down with me and went through all the possible risks and benefits of labouring at home with a large baby. She made it clear that whatever I decided it was my decision to make, and that her responsibility was to make sure I understood what the issues were. TBH I'm quite shocked that midwives are STILL telling women they 'have' to go to hospital, particularly if they're low risk. It really does go against all accepted guidelines on good practice.

Are you still not aware that midwives and doctors are supposed to be giving evidence based recommendations and advice?

"that so you should do X instead of Y"

I don't tell women where they SHOULD give birth. That's for them to decide, based on their feelings and beliefs about birth, and on the particularities of their health and their pregnancy. 'Should' only comes in to it as far as I'm concerned in the sense that women 'should' be given information about maternity care based on the evidence that we have, and a sensible discussion of the research should form part of the decision making process.

Waffle, coercion and ill-informed speculation is what needs to be left out of the decision making process about where and how you have your baby.

x-post

I think there are many factors that affect whether a woman has intervention or not. I think there are many factors that affect where a woman gives birth, that cannot be neatly captured in the data.

I think you have sort of illustrated why I think the intense focus on location is problematic -- because location often becomes a proxy for psychological factors, like confidence and relaxation. So when people emphasise the importance of location, it is not long before they are talking about confidence and relaxation (as indeed, you have done) and then we are back to what the OP is talking about, which is attributing outcomes to a woman's state of mind instead of the condition of her body.

I'm not saying psychological factors don't matter at all. I just think at the end of the day it's really quite difficult to predict or even explain afterward why things went well or not.

SusannaB Sat 26-Jan-13 16:02:25

You can't just take that stat out of the NPEU Birthplace Study, though. Women considering a homebirth need to be aware of all the facts, summarised nicely here:

www.rcog.org.uk/what-we-do/campaigning-and-opinions/statement/rcog-statement-results-npeu-birthplace-study

What the study doesn't take into account is the wishes of the women who are choosing each of the different units. There are some women who actually ask for intervention; induction of labour, instrumental deliveries, caesarean section, who would have been entered into the study and deemed low risk.

In addition, what most people don't realise is that, if you choose to deliver in an obstetric led unit, it doesn't mean you're automatically under the care of the obstetricians. In most units, women who have had no medical intervention (and that includes low risk women who have chosen epidural analgesia) remain under midwifery led care, unless they request to see a doctor, or develop complications in labour.

I'm not flatly dismissing it. I'm not saying it's wrong or invalid. I just think these kinds of studies can't capture the complexity of childbirth in a way that lends itself to making strong predictions.

I don't know what to tell you about my case. I very much wanted a homebirth or MLU but my midwife said no, I had to go to the OU. But she also insisted that she still considered me low-risk. I think it was a 'better safe than sorry' situation.

I don't think I'm alone? I know I have read on threads here where women were technically considered low-risk but because of family history or other things which might potentially cause problems they were assigned to OU.

Hence, my thinking that there may be other differences, in addition to location, accounting for outcomes. If low-risk women are being sent to OUs based on sort of informal criteria, that could also help account for differences.

I have absolutely no agenda, by the way. I could care less where women choose to give birth. I just think the situation is far more complicated than X percent do this and Y percent do that so you should do X instead of Y.

shagmundfreud Sat 26-Jan-13 15:55:49

"Given that the two populations are not entirely similar/randomly assigned, you can't say definitively it's just down to location"

Just to play devils advocate, there have been suggestions that the reason women who plan birth centre and home births have fewer complications in labour than similar mothers who plan an OU birth is because they have more confidence in their ability to cope with labour and more belief in the normality of birth, and that this increases the likelihood of a straightforward birth. In other words it's the psychological characteristics of women who choose out of hospital births which makes a difference as to the likelihood of their labours being straightforward. But that would completely contradict the ideas expressed here in the OP, that what your labour is like is affected by nothing more than physiological factors - the size/position of your baby, how efficiently the uterus contracts, the presence of infections etc.

I have suggested that how a mother is cared for in labour makes a difference to the outcome, but you can't seem to accept that this is true, or that the mother's own personality or confidence matters.

What do you think accounts for the huge difference in intervention rates across birth settings? Because they are pretty marked aren't they? And it's not just in this study that they're found - it's also the case that these same things have been found in study after study after study.

shagmundfreud Sat 26-Jan-13 15:45:11

"I had a large baby and was still considered low-risk. That's the whole point of my story"

I don't get it. You were clearly NOT considered 'low risk' if you were 'made' to go to hospital.

A baby is not considered 'large' (or 'macrosomic') unless believed to be over 9lbs 15oz. If a mother is believed to be carrying a baby which is macrosomic she will be advised to have her baby in hospital and will no longer be considered 'low risk'.

"Yes, I do think it's good to avoid the word 'normal' in most cases, given that 'abnormal' is often seen in a negative way. 'Intervention-free' works and is more precise anyway."

So would you refuse to say you could 'breath normally'? Had a 'normal conception'? Can you not see that in medical terms the word 'normal' has an important meaning?

"I don't see the study saying location determines outcome. It's saying interventions differ across location. Given that the two populations are not entirely similar/randomly assigned, you can't say definitively it's just down to location. Correlation is not causation etc."

There is no study in the world which can compare two completely identical populations, other than those who use identical twins. Do you reject the findings of all other trials on the same basis as you are rejecting the findings of the Place of Birth Study? Even those which like the POB study are pretty rigorous in their attempts to match the subjects in different arms of the trial?

Why is it that the RCOG and the RCM have released statements saying that birth out of hospital has 'very significant benefits for mothers' because it appears to 'increase the likelihood of a normal birth', but you can't accept this?

Honestly - when someone is flatly dismissing really good quality evidence which is widely accepted by experts in that particular area, then I usually think they have a vested emotional interest in denying the reality which is staring them in the face.

"What seems problematic to me is being predictive about the difference, to say -- especially to first-time mums -- that one location will be better than another. Maybe it will, maybe not. I think a 40-50% chance of having to transfer to hospital anyway means that predicting anything for first-time mothers is pretty problematic."

Except I didn't say 'one location WILL be better than another', but 'planning a birth in a MLU or at home is associated with a significantly lower rate of complications.

And it is!

1. Yes, I do think it's good to avoid the word 'normal' in most cases, given that 'abnormal' is often seen in a negative way. 'Intervention-free' works and is more precise anyway.

2. I had a large baby and was still considered low-risk. That's the whole point of my story.

3. I don't see the study saying location determines outcome. It's saying interventions differ across location. Given that the two populations are not entirely similar/randomly assigned, you can't say definitively it's just down to location. Correlation is not causation etc.

4. Sorry but I do think it's slightly irresponsible, given how knowledgeable you seem to be about this study, to say 'If you want to influence your chances of having a normal birth, consider a homebirth', when you know that for first-time mums there is a higher risk of complications with homebirth.

5. Obviously location can make a big difference. What seems problematic to me is being predictive about the difference, to say -- especially to first-time mums -- that one location will be better than another. Maybe it will, maybe not. I think a 40-50% chance of having to transfer to hospital anyway means that predicting anything for first-time mothers is pretty problematic.

shagmundfreud Sat 26-Jan-13 15:10:11

Wanted to add, re: the term 'normal' - this from the BirthChoiceUK site (the main source of information for mothers about individual maternity services in the UK):

"The term normal birth is not meant to be judgmental in any way. We are instead trying to produce some measure of how much technological intervention is currently used in birth. These statistics of course do not tell us anything about a woman's experience of birth which is likely to be of far more importance to her than whether she was induced or had an epidural or had her waters broken. It is hoped that every woman can have a fulfilling and positive experience of birth regardless of the interventions she has received. This is, of course, much harder to measure!"

Because this thread is about expectations of having an uncomplicated birth, and the actual likelihood of having an uncomplicated birth.

I agree it's really important to acknowledge that a birth doesn't have to be straightforward to be fantastic and fulfilling. I know this from my own experiences.

LaVolcan Sat 26-Jan-13 15:03:34

- I was soooooo lucky to get away with delivering DS2 "normally" - I was just about to be prepped to go to theatre when they turned me onto my back and he dropped clear of the anterior lip and shot out of me in 2 quick pushes.

For me your statement highlights an important issue - should that just be put down to luck, or should it be considered as a result of competent midwifery?

shagmundfreud Sat 26-Jan-13 14:39:26

I think the bottom line is this. First time mum who is low risk, healthy and has a choice of birth setting?

46% of first time mums who give birth in an OU have a normal birth.

71% of first time mums who give birth in free standing midwife led units (with no immediate access to medical care) have a normal birth.

The outcomes for the babies of first time mums in both these groups are the same.

That is a MASSIVE difference.

IMO you can't have any sort of sensible discussion about realistic expectations of birth without acknowledging the impact of setting on birth outcomes.

shagmundfreud Sat 26-Jan-13 14:33:48

"Well first off, the study itself says that a birth without medical intervention is sometimes referred to as a quote-unquote 'normal birth'. So I don't think it's imperative to use the phrase yourself, especially in a forum where you know women have very strong feelings about their experiences."

No - it's not imperative. But it's a standard medical term. The Royal College of Midwives even have a website called 'Campaign for Normal Birth' with information for midwives on midwifery practices that increase the likelihood of mothers having births without complications.

That said - I'm happy to substitute a different term to describe birth without complications. What would you suggest? Are you unhappy with the term 'normal' used in relation to any other aspect of having a baby? Do you object to the term 'normal conception' to indicate a conception which takes place without medical intervention?

" You seem to be saying that the planned location of birth is a determining factor of outcomes, but this ignores the fact that planned location is decided in part based on risk factors that will also affect outcomes -- even within the low-risk cohort."

With respect - it's not just me who is saying that planned location of birth appears to determine outcomes. The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists are saying it too:

"Maternal intervention rates were much higher in births planned for OUs with lower ‘normal births’ and spontaneous vertex deliveries." (comment by the president of the RCOG in response to the findings of the Birthplace study)

"Women who planned birth in a midwifery unit (AMU or FMU) had significantly fewer interventions, including substantially fewer intrapartum caesarean sections, and more ‘normal births’ than women who planned birth in an obstetric unit." (statement by the RCM in response to the Birthplace study).

"I note the study does not include large baby size as a risk factor"

Only low risk women were included in the study. A woman who was identified as carrying a large baby would not be classified at 'low risk' as macrosomia is an identified risk factor for a range of complications in birth. That's not to say that some women in ALL arms of the trial wouldn't end up delivering very large babies.

"Finally, if you want women to be fully informed, why not mention some of the other study results? Like, "For women having a first baby, a planned home birth increases the risk for the baby", or the fact that around 40 percent of first-time mothers giving birth in midwifery units will have to be transferred to obstetric units anyway. "

Yes - transfer is an issue. And yes - homebirth seems to increase the risks to the baby for first time mothers. However, birth outside of hospital (ie in a free standing midwifery led unit, with no access to doctor care without transfer) is not associated with poorer outcomes for babies. To me that suggests it's not birth away from a medical setting which puts the babies of first time mothers at increased risk, but issues surrounding the way care for women birthing at home is managed.

"What I get out of this study is that there's still an awful lot of luck involved. Nearly half of first-time mothers giving birth at home end up going to hospital. So how important is that choice really? It's still 50/50 whether you wiill go to hospital or not."

But even though half the first time mums in the study were transferred as a group they STILL had a MUCH lower rate of emergency surgery than women who'd opted to go to hospital in the first place, and I think this is very important!

"So you might want to be a bit more careful in your advice there."

If the RCM and the NHS are happy to recommend home birth as a 'safe' option for first time mums (they are - birth at home is still considered very safe as over all poor outcomes were rare), then I don't see what's wrong with encouraging those women who are keen to avoid an emergency c/s to 'consider' it? Obviously 'considering' it means taking all important factors into account.

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