Alice Roberts' article today on evidence based childbirth (HB/MLU/hospital)

(261 Posts)
VinegarDrinker Sun 10-Mar-13 13:30:55

Not sure if this has been discussed elsewhere?

m.guardian.co.uk/lifeandstyle/2013/mar/10/alice-roberts-on-science-childbirth-risks

Seems a fairly balanced article to me, but I am an evil patriarchal obstetrician.

GettingObsessive Sun 10-Mar-13 14:01:11

I also thought it was pretty balanced. In every other aspect of my day to day life, if asked to make a choice, I will do some research, ask opinions and then weigh up the evidence and my feelings about the matter. When it comes to maternity/post-natal choices of all kinds (not just how to deliver my baby) I am expected to take on board the unsupported opinions or statements of HCPs or NCT teachers or whatever and simply treat it as unassailable fact.

There is no way I would accept that in any other part if my life; why should I just because I am PG?

I will be asking for the evidence to back up statements presented to me as "the answer" and, particularly when it's said "there's an increased risk of X Y or Z" asking how much of a risk and in what circumstances.

It's so patronising that women are treated as being unable to weigh up he evidence and decide for themselves.

MedicalEd Sun 10-Mar-13 14:28:16

Decent enough article but there are loads of problems with the Birthplace study and last I knew an ongoing row between various research analysts and the study authors and BMJ (that I think was the one to publish it).
The authors really pushed the 'home birth is safe' angle.
They were all low risk mothers, they skimmed off those that became high risk in pregnancy, there was a very low response rate from midwifery led units which could have skewed the results, the main outcome was a collection of conditions that could affect the baby but missed out some important ones.
The list goes on.
It is the same with some World Health Organisation studies into c-sections for non-medical reasons.
The politics of birth, medicalising it ect mean there are no studies I know of that have not been skewed in one direction or another.
What hope have ordinary frontline healthcare professionals got hen the researchers do this, let alone women themselves?
Getting the problem is the 'evidence' itself it skewed and manipulated, the figures are not all there, or the wrong ones collected ect.

LaVolcan Sun 10-Mar-13 14:43:22

I suspect she hasn't read the Place of Birth Study. If she had she would know that this statement doesn't stand up to examination.

Not at all surprisingly, there were fewer interventions (like forceps deliveries and caesarean sections) in the non-hospital settings. (This is something which is often put forward as a pro for home births, which I find odd. There are fewer forceps deliveries in home births because you can only do them in hospital. There are fewer –no – epidurals in home births, but that's to be expected, unless you happen to keep an anaesthetist in a cupboard at home for just such eventualities.)

If the woman had started labour at home and then transferred to hospital for forceps/ventouse/CS then it still went down on the home birth stats in the Place of Birth study. It's a pity she fails to realise this, because the question of why there are fewer interventions in non-CLU settings and, for multiparous women, without any additional benefit to the baby is a valid one.

Quite honestly, I would have expected a better understanding from her.

Shagmundfreud Sun 10-Mar-13 14:43:32

My response:

Big double page article by her in the Observer today complaining that mothers don't get unbiased information about birth choices. She talks primarily about the Place of Birth Study 2011 and the different ways its findings have been interpreted.

She says: 'Not surprisingly there were fewer interventions in the non-hospital settings. (this is something which is often put forward as a pro for homebirths, which I find odd, There are fewer forceps deliveries in home births because you can only do them in hospital. There are fewer - no - epidurals in home births, but that's to be expected, unless you happen to keep an anaesthetist in your cupboard for just such eventualities)'.

Now - surely, surely, she must have actually READ the study before writing a BIG article about it for a national newspaper?

But if she had read it she'd know that the intervention rates among the out of hospital mums in the study wasn't half that of similar mums giving birth in hospital because they can't do c-sections in birth centres or on the kitchen table at home. Surely she must know that women who opt for birth centres or homebirths whose labours become complicated GO TO HOSPITAL, and the interventions take place in these settings, but are included in the 'out of hospital' arm of the study?

I mean - that's a massive, fundamental misunderstanding to have made in the article isn't it? Why did nobody at the Observer spot it before it was printed?

It really worries me that so many people will take her opinion on this subject seriously because a) she's a doctor and b) she's being given a double page spread to talk about the issues in a national newspaper. And not realise how ill informed and biased she is.

Would add, she also has a little dig at the NCT here. She says that the way the NCT presents the birth place study 'prioritises the birth process over the risk to the baby'. An unfair accusation and an inaccurate one. The NCT clearly points out on its website that the Place of Birth study found that home birth is associated with an increase in the risk to the babies of first time mothers.

So in the process of complaining about mothers not having accurate information to make birth choices, Alice Roberts writes a poorly researched and inaccurate article, just to add to the confusion. It really is a shame.

Shagmundfreud Sun 10-Mar-13 14:44:08

And:

If you have a look on the NCT website and look at the page about the Place of Birth study the paragraph on homebirth says this:

"Women planning a home birth were more likely than women planning for
birth in other settings to have a normal birth: 88% of planned home births are
‘normal births’ compared to just under 60% of planned obstetric unit births.

For women having a second or subsequent baby, home births are safe for the
baby and offer benefits for the mother.

For women having a first baby, a planned home birth increases the risk for the
baby somewhat."

She has taken the fact that the NCT don't mention the higher rates of poorer outcomes for first time mums giving birth at home until the third sentence of this very short statement as evidence that they prioritise normality of birth over the safety of babies.

Apparently this makes the NCT's response to the Place of Birth Study 'spin'.

"No one should feel that having an epidural, a forceps delivery or a caesarean section is a failure"

Individual mothers shouldn't consider interventions a sign of personal failure, but if I was in charge of a labour ward, I'd be wondering why double the numbers of healthy mums giving birth under my supervision were needing them, in comparison to similar mothers giving birth in out of hospital settings. Particularly if the outcomes for the babies were no better.

Alice Roberts has also steadfastly ignored one of the most interesting findings of the POB studies which is that for ALL healthy mothers (including first time mums), giving birth in free standing birth centres where intervention requires transfer to hospital by ambulance, doesn't seem to make mothers any less likely to go home with a healthy baby.

VinegarDrinker Sun 10-Mar-13 14:46:51

That's very true LaVolcan and I did think that when I read the article. It was done by intention to treat, and I absolutely agree the reasons for higher interventions in CLUs are interesting and multifactorial.

Shagmundfreud Sun 10-Mar-13 14:47:13

"The politics of birth, medicalising it ect mean there are no studies I know of that have not been skewed in one direction or another."

Where is there clear and unequivocal evidence that encouraging healthy, low risk mothers to give birth in obstetric units improves outcomes for them and their babies, in contrast to the outcomes for healthy women giving birth in low tech midwifery led units?

I haven't seen any as yet.

Shagmundfreud Sun 10-Mar-13 14:49:26

"It's a pity she fails to realise this"

Actually it's really bloody annoying that a double spread article on such an important subject could have been ok'd for publication in a mainstream paper, when there is such a glaring and embarrassing error in it.

VinegarDrinker Sun 10-Mar-13 14:49:53

I do think the NCT are underpaying the difference in risk shag - IIRC it was double the rate of adverse outcomes for low risk first timers, so saying "somewhat" is a tad misleading imvho. But yes the intention to treat issue is a big error on her part.

VinegarDrinker Sun 10-Mar-13 14:52:00

The Observer don't have form for great medical editing. See: MMR.

I do agree the politicisation of birth muddies the water significantly. You rarely see the risks of HB discussed dispassionately.

LaVolcan Sun 10-Mar-13 14:53:09

The Place of Birth study authors didn't push any angle - they reported what they found. They kept to low risk cases because of the need for a like to like comparison. If they had found that all women starting labour at home had, say, transferred for a CS then the study would have shown that.

I am sure there is scope for a study to see how 'high risk' women get on. The chances of comparing a sufficient sample between MLUs and CLUs is I would suspect impossible, because MLUs won't admit high risk cases but a CLU/homebirth survey might be possible.

VinegarDrinker Sun 10-Mar-13 14:55:53

" Where is there clear and unequivocal evidence that encouraging healthy, low risk mothers to give birth in obstetric units improves outcomes for them and their babies"

Who does that?! We don't have capacity for low risk women on our CLU and when they do end up there, the Drs are the first to ask why they are there and encourage them to move to our attached MLU!

I think looking at overall figures is useless, not fascinating shag. Women having their second or subsequent vaginal delivery are totally incomparable to first timers, lumping them together is of no use to anyone.

VinegarDrinker Sun 10-Mar-13 14:58:20

I think the numbers of high risk women having HBs would be too small for any meaningful results LaVolcan

Shagmundfreud Sun 10-Mar-13 14:59:19

I don't agree VinegarTits. They provide links to the study and make the figures in the study available to everyone.

"You rarely see the risks of HB discussed dispassionately."

Or indeed the risks of birth in an obstetric led unit AT ALL.

Mothers in my area who opt for a home birth are sat down by the home birth team and are told about the risks of a poor outcomes being increased in certain obstetric emergencies because of the lack of immediate medical input. Birth in an obstetric led unit is never, never discussed in terms of risk, despite the evidence of higher rates of bleeding, infection, major surgery etc associated with birth in medical settings.

It's wrong. Our system is MASSIVELY biased towards obstetric settings and highly managed births. Because of this advocates of midwifery led births in low tech settings have to raise their voices to be heard, and are then - ridiculously given the bias against them - accused of dominating and distorting the debate.

VinegarDrinker Sun 10-Mar-13 15:03:02

I think the risks (of intervention) are well discussed actually, both in medical and non medical fora (ie NCT, here etc). Any they are well recognised, hence push for more MLUs. I haven't worked anywhere that would encourage low risk women to deliver in a CLU.

When my MW discussed HB with me, the risks were not mentioned at all. (yes I know n = 1, but the same happens in HB discussions on here and elsewhere online).

Shagmundfreud Sun 10-Mar-13 15:04:39

"Who does that?! We don't have capacity for low risk women on our CLU and when they do end up there, the Drs are the first to ask why they are there and encourage them to move to our attached MLU!"

90% of women in the UK give birth in obstetric units.

The whole direction of maternity policy for the past 40 years has been to move births from home into a hospital setting.

"I think looking at overall figures is useless, not fascinating shag. Women having their second or subsequent vaginal delivery are totally incomparable to first timers, lumping them together is of no use to anyone."

Who is doing that?

The POB study does look at the different outcomes for first and second time mothers.

VinegarDrinker Sun 10-Mar-13 15:05:07

Tbh you seem quite conspiracy theorist about this shag, who are all these people biased against midwifery led units? Most obstetricians I know have delivered in them! (and one of my Consultants had a HB)

VinegarDrinker Sun 10-Mar-13 15:08:23

Apologies, I misread your point about freestanding birth centres, as being about the overall finding that for all deliveries, differences in outcomes were not statistically significant.

"The whole direction of maternity policy for the past 40 years has been to move births from home into a hospital setting."

I agree with you - up til the 90s, maybe. But for the past 10-15 years, absolutely the opposite. In London, new MLUs (alongside and freestanding) are opening every year.

Shagmundfreud Sun 10-Mar-13 15:11:37

"I haven't worked anywhere that would encourage low risk women to deliver in a CLU."

No - they don't actively encourage low risk mothers to give birth in a CLU. Hospitals just concentrate capacity in CLU's so that healthy mothers end up being turned away from MLU's because there isn't room for them.

And women aren't routinely informed about the advantages of giving birth in an MLU apart from being given soft information like 'it's a bit more homely!'. Well - fuck that. Most MLU's are about as 'homely' as a travel lodge. What women really need to be told is what we know about the hard benefits of giving birth in an MLU - the increased likelihood of one to one care and the decreased likelihood of interventions.

VinegarDrinker Sun 10-Mar-13 15:16:02

Well, as I said, London are building new MLUs while closing CLUs (Sidcup and Lewisham spring to mind immediately). All women should be getting one to one care, this should be an absolute priority and it should be totally unacceptable for women to feel they have to opt for a HB or freestanding MLU to get an appropriate level of care. Unfortunately I do think sometimes the millions spent on beautiful MLUs takes away from the core service of providing good quality one to one care to all women.

VinegarDrinker Sun 10-Mar-13 15:18:13

Btw, I am assuming that your mistyping of my nn was accidental rather than an immature response to someone with a different viewpoint.

mummybare Sun 10-Mar-13 15:18:16

I think part of the problem is that, when giving birth, psychology as well as physiology can affect the outcomes as the process relies on a hormonal feedback response. (Disclaimer: I am not a scientist of any description, this is just my understanding...) It is very hard to measure the way someone feels about their birth environment and therefore tricky to give dispassionate advice, relying only on hard facts that provide one concrete answer. It just doesn't work like that.

Shagmundfreud Sun 10-Mar-13 15:20:48

"Tbh you seem quite conspiracy theorist about this shag, who are all these people biased against midwifery led units?"

It's not about the attitudes of individual doctors or midwives.

It's about a system in which resources are concentrated in obstetric settings, regardless of what women want.

From the NCT 'Place of Birth' policy briefing:

"Birthplace researchers estimated that about 50-60% of women meet the NICE ‘low risk’ criteria, but in 2007 only 2% of birth took place in an FMU, 3% in an AMU and around 3% at home. Although the number of AMUs has increased since 2007 – there were 53 identified AMUs in England in 2010, up from only 26 in 2007 - as many as 50% of NHS trusts still had no midwifery unit in 2010, so this effective and valued option for birth is very far from universally available.
Birthplace also identified 59 FMUs in England in 2010, up from 56 in 2007 (four having closed and seven new units having opened).37"

Given that there clearly is a shortage of capacity in low tech settings, it's really demoralising that the debate about issue seems not to recognise this as a central problem. And that anyone who raises their voice about it is seen as being 'biased' against obstetrics.

VinegarDrinker Sun 10-Mar-13 15:21:18

There is no reason that CLUs can't be made a heck of a lot more welcoming and homely, btw. Plus, obviously staffing them appropriately. I think we need to be getting the basics right - number 1 being good quality one to one midwifery regardless of setting.

VinegarDrinker Sun 10-Mar-13 15:22:55

A doubling of MLUs in just three years sounds like fantastic news to me, not part of an anti midwifery led conspiracy!

Shagmundfreud Sun 10-Mar-13 15:24:19

"It is very hard to measure the way someone feels about their birth environment and therefore tricky to give dispassionate advice, relying only on hard facts that provide one concrete answer. It just doesn't work like that."

Yes - which is why it's important to tell women what we know about clinical outcomes associated with different settings.

Shagmundfreud Sun 10-Mar-13 15:25:18

"number 1 being good quality one to one midwifery regardless of setting"

Well - no one could disagree with that.

Shagmundfreud Sun 10-Mar-13 15:27:15

Vinegar - I don't believe there's a 'conspiracy'.

Can we lay that one to rest then?

VinegarDrinker Sun 10-Mar-13 15:28:36

Yes, which is the point of her article - the majority of birthplace info and discussion is not evidence based.

Personally I would happily take a small increase in intervention for me vs doubling in risk for adverse outcomes for baby. Even better, deliver in an MLU (which is what I chose) and get the best of both worlds. But that's just me. Professionally I support women in whatever they want as long as they are fully informed about risks/benefits.

VinegarDrinker Sun 10-Mar-13 15:29:57

Sorry, "massive bias" not conspiracy.

LaVolcan Sun 10-Mar-13 15:32:28

I don't know where you live Vinegar, but in a lot of cases there isn't an MLU nearby, so it's either homebirth or CLU. According to BirthChoiceUK the homebirth rates for England in 2011 were 2.36%. I find it hard to believe that the other 90%+ are 'high risk'.

VinegarDrinker Sun 10-Mar-13 15:34:37

I think you may have misread a post of mine - I was talking about the number of high risk women having HBs being fairly low.

I know there are issues with access to MLUs in some parts of the country. As shag says though they have more than doubled since 2007 with more opening all the time.

Shagmundfreud Sun 10-Mar-13 15:46:01

"Personally I would happily take a small increase in intervention for me vs doubling in risk for adverse outcomes for baby. Even better, deliver in an MLU (which is what I chose) and get the best of both worlds."

Or deliver in a free standing midwifery led unit, which according to the POB study had the best outcomes of all - for mum and for babies, including for primips (despite the average transfer distance from the FMU's to the nearest CLU's being 17 miles). wink

Just out of interest, were you aware that in the POB study admission to ICU or HDU for primips was 0.2 for free standing MLU's, compared to 1.0 for alongside midwifery led units. That struck me as quite interesting, though I suspect that it's not statistically significant because of the small sample size from FMU's.

LaVolcan Sun 10-Mar-13 15:47:47

Vinegar, I don't think I misread your earlier post. I agree that the number of high risk women having home births is probably so small that a proper comparison couldn't be made.

The point I was trying to make was that many don't have MLUs but typical rates for homebirths are somewhere between 2-3%; the other 90%+ just get booked into the CLU because that's the default option, regardless of risk.

You say Personally I would happily take a small increase in intervention for me vs doubling in risk for adverse outcomes for baby and I think the majority of women would go along with that. However, what if women were to be told, "there is no advantage to the baby but your risks of intervention are tripled or quadrupled" how many women would choose to go along with that?

Shagmundfreud Sun 10-Mar-13 15:47:50

Problem is vinegar that MLU's never have enough beds or enough staff.

Our local hospital delivers nearly 6000 babies a year. There are never more than 2 midwives on duty in the MLU.

It's no point having the beds without the staff.

VinegarDrinker Sun 10-Mar-13 16:00:12

Yes I agree re staffing as you will see from my previous posts!

I am one of those low risk primip HDU admissions - had a lovely quick low risk, active first stage in MLU, pushed for > 2 hours in all positions so he was eventually delivered with the assistance of a lovely Consultant, who did a manual rotation and forceps. Unsurprisingly given the length of 2nd stage (4 hrs+) plus big baby + instrumental, I bled. A lot.

Obviously I would have been transferred in from a freestanding MLU or HB but regardless of clinical outcomes I can't imagine many things less pleasant or more stressful than a blue light ambulance transfer mid-second stage! Hence my personal choice of alongside MLU (for this upcoming delivery too) but I absolutely support both from a professional POV.

VinegarDrinker Sun 10-Mar-13 16:01:53

"Problem is vinegar that MLU's never have enough beds or enough staff."

And CLUs do?! Pull the other one!

What I am saying is the tide has already turned, there is massive investment nationally in building new MLUs and a widespread acceptance they provide a hugely vital service.

LaVolcan Sun 10-Mar-13 16:12:29

.....there is massive investment nationally in building new MLUs and a widespread acceptance they provide a hugely vital service.

I am not sure of that - it all seems to be cuts as far as I can see.

VinegarDrinker Sun 10-Mar-13 16:15:40

Look at the stats on shags post - there was a doubling from 2007-2010.

In London I know off the top of my head of three freestanding MLUs (one newly built, two downgraded from CLUs) and 2 new alongside MLUs in the last couple of years. And several CLUs being closed.

Shagmundfreud Sun 10-Mar-13 16:19:35

Vinegar, I think the situation in London is different. I'm not sure it's reflected in the rest of the country.

VinegarDrinker Sun 10-Mar-13 16:22:07

Yes but not all those 27 odd new MLUs opened between 2007-2010 were in London! I am not arguing the job is done by any means, just that I think the tide has already turned.

Shagmundfreud Sun 10-Mar-13 16:31:43

Vinegar, a bit OT - I know quite a few women who have tranferred from home to hospital, sometimes in blue light situations. I've done it myself. I've also had my own scary obstetric emergency at a home birth (shoulder dystocia). People always raise this issue of how bloody awful it must be tranferring in during labour, or needing to call paramedics to a home birth, but in my experience (and from talking to a good number of others) if the over all outcome is good, most women who transfer still feel the choice to try to give birth at home was the right one and are in no way traumatised by the experience of transfer.

[Proviso - obviously this depends on outcome. Your feelings about the events are obviously going to be hugely coloured by a baby being very unwell or worse, or you ending up in HDU].

Just thought I'd mention this as this is always flagged up in discussions about home birth.

Shagmundfreud Sun 10-Mar-13 16:35:20

Will say - we're very lucky in the UK compared to the US. We are in no way any where near as polarised in this country as they are in the States. I think I always need to remind myself of what it's like there to 'reset' my feelings about the situation here. To recognise how much luckier we are to have a system in which normal birth is managed by midwives, and that this is considered reasonable and sensible by the vast majority of people.

LaVolcan Sun 10-Mar-13 16:37:01

According to shagmund's figures there was a doubling of alongside MLUs i.e. those in the same hospital as a CLU, but only an increase of 3 freestanding MLUs in the same time period and 50% of areas have no provision.

Not so in Oxfordshire. Essentially in the last 30 odd years, precious little has changed for low risk women. There are 3 MLUs, Wantage and Wallingford being freestanding and the Spires co-located with the JR CLU. There's also a CLU in Banbury; there were plans to turn this into an MLU but I don't know what is happening at present. Chipping Norton MLU closed to births last autumn and to my knowledge hasn't reopened since, although this is supposedly temporary.

The JR is a regional centre so it does have more high risk cases than other places but they are not all from Oxfordshire.

RedToothBrush Sun 10-Mar-13 19:03:52

I despair.

A journalist writing an article about biased research and politics of childbirth who can't be fucked to read the report she's harping on about and pick it apart and report on it properly.

Not much better than the Telegraph's Science Correspondence who yesterday ran an article which he frankly should be sacked for (he doesn't know the difference between causation and correlation, much less know that ELCS are generally done for medical reasons.)

What fucking hope do we in addressing problems with the politics of childbirth have when we have journalism as piss poor as this?

HelloBear Sun 10-Mar-13 21:01:58

vinegar what this article failed to mention is that often people's 'choice' to have a HB is due to either hearing of others v poor experiences in clu or having previously experienced poor care.

Unlike CLU or MLU at a HB you are guaranteed 1-2-1 or 1-2-2 Mw care. This is certainly not a guarantee in hospital. If this changed women might not feel the need to go for a HB, alongside improved postnatal experiences.

Whenever I see these threads I get frustrated as there is rarely an acknowledgement by those questioning home birthers about the poor experiences women have in hospital and the sometimes shocking level of care they receive.. I'm not suggesting clu or MLU are bad but they need to be better.

However I work in the public sector in a service being cut to the bone so know this is a challenge in today's climate.

brettgirl2 Sun 10-Mar-13 22:04:58

Hello bear is right, plus I would add that in reality hospital birth should be safer than home birth. If it isnt its because of shit care. If all women had one to one care in labour the results may well be different.

I've always been a bit hmm about the study. For a start what 'low risk' means. For second time mothers it might mean people who have had both assisted and normal deliveries first time. Are people who had normal deliveries more likely to choose homebirth? Are those who had assisted more likely to end up with assisted again? Itay be coincidence but I have 2 friends who have wach had 2 ventouse deliveries. Therefore is there a chance across lots of factors (including pph etc) that women who choose hb tend to be the lower risk end of low risk?

Also if you have a hb (round here anyway) the midwife comes early in your labour to check all is well. If you go to hospital they stall you about going in. I have a friend who had an awful experience of dashing it at 9cm, baby's heartbeat low, cord round neck too late to intervene. If she'd seen a midwife at home a couple of hours before the issues may have been picked up earlier. That is about actually having care in labour wherever it might be!

When will we see that this isnt about home/clu/mlu its about the standard of care women receive in labour. Right now the best care is at home so surprise surprise that is what the evidence shows.

AmandaPayne Sun 10-Mar-13 22:32:13

Brettgirl - I agree. The 'care' in many CLUs can be shocking. I know we are talking about evidence based care, but the stories from just amongst me and my friends of the ways we were treated, the corners that were cut, etc are terrifying. No way on god's earth was I setting foot in a CLU again. And a freestanding MLU seemed to offer no real benefit over a homebirth in terms of medical facilities.

I would love to see a study that could, in some way, control for the level of care women received. Although it would be very difficult.

For me, the whole article is undermined by her comment about interventions decreasing in home births (doesn't she wonder why it's not a 0% forceps rate for home births? Did she think midwives grab the salad servers in an emergency). I also thought that language of 'had' to transfer was skewed - it's a bit like saying that a lot of women trying for an unmedicated birth in a CLU 'have' to have an epidural. It's about making choices as circumstances change - a lot of transfers are non-emergency for pain relief or slow progress.

Where she does have a good point is the difficulty of accessing real data that is relevant to you and your situation.

VinegarDrinker Sun 10-Mar-13 22:33:47

HelloBear I am very aware of those reasons why women opt for HB and in fact mentioned the same in one of my previous posts. In fact this is one of my real bugbears - why should anyone feel they have to take the increased risk of adverse outcomes just to get one to one midwifery care? (Obviously this isn't why all women opt for HB). Don't get me started on the shocking state of postnatal care across much of the country...

brett while I agree with much of what you say, , double the risk of adverse outcomes isn't exactly showing that HB is safer hmm And if your theory about HBers being the lowest risk women us true, surely those figures are all the more concerning?

AmandaPayne Sun 10-Mar-13 22:37:53

Vinegar - Just as an aside, the closure of the CLU at Lewisham is already resulting in women I know deciding not to give birth at that MLU. It is one thing to know that free-standing MLUs have good stats, but the thought of an emergency transfer across London in an ambulance just puts that MLU in the same category as a homebirth for many women. You've acknowledged that emotion yourself. It's removing choice, in what should be an amazing and relatively new facility.

And yes, I have heard of consultants already encouraging low risk women not to deliver in that MLU as it will no longer be an alongside.

mayhew Sun 10-Mar-13 23:06:07

Sigh. I used to rate alice roberts, this is really disappointing.

I am an NHS HB birth mw. Observations about my case load.
: half are primips. Average age 35. National average for primips 27. Half of them need to transfer to CLU during or just after labour.
: the multips even if "low-risk" often have not had straightforward, or at least unpleasant, first births. Often something crappy happened which made them never want to go to a hospital again. If their experience was fine, they book the same again. Less than 10% of these transfer. Average age 34.5.National average for mutips 29.
: I've had 3 bottom clenchingly scary experiences (out of about 150 Hbs). All utterly unpredictable (and came out ok in the end).

Lets hear it for the paramedics and the lovely del suite co-ordinators who are there when it all goes tits-up.

LaVolcan Sun 10-Mar-13 23:10:41

in reality hospital birth should be safer than home birth

Why should it be safer? OK the 'care' for too many women is rubbish, but assuming that it wasn't so, why else? If it's because "it's all there when things go wrong", how about starting to ask what we need to do to make things go right, to avoid the emergencies and problems happening in the first place?

Majorie Tew was famously a statistician in the 1970s who set her students an exercise to analyse the statistics which would back up the policy of moving birth towards hospital because the assumption had been that this was safer. She didn't believe her students when they said that the statistics didn't support this, and re-analysed the results and found that her students were right, the statistics didn't show hospital was safer.

It's known that positive outcomes are linked to things like access to ante-natal care, smoking and social class. Studies have shown that one to one midwifery care in labour with a known attendant improves outcomes. How about a real push forimplementing reforms in these areas?

Fallenangle Sun 10-Mar-13 23:16:07

Having read her piece in the Observer and many of the comments here. I sympathise with Dr Roberts in the point she seems to me to be making: that childbirth evokes emotional, rather than evidence based, reactions from professionals, charities and many individuals.

AmandaPayne Sun 10-Mar-13 23:23:44

But if you are trying to make that point, it tends to go better if you actually read the limited evidence you claim to be citing...

RedToothBrush Sun 10-Mar-13 23:23:51

Shag pointed out some stats for Edgeware Birth Centre last week, which I found pretty troubling.

It shows that over 95% of women there had an unassisted VB; sounds great. Almost unbelievable.

And thats it, they are. When you actually really start looking at how they worked out the figures. Figures that are used to compile the HES official maternity statistics btw, so the stuff you would want and think you would be able to trust the most and are most widely used.

What it doesn't show is the number of women who book in there who don't end up being admitted and giving birth there (off the top of my head without going back to look at the stats, it was something like 44%) and it has a lot of women 'go missing' from its stats.

It also doesn't show that the next nearest hospital has a particularly low rate of unassisted VBs - suggesting that rather than doing marvels in increasing the number of women having an unassisted vb, all it was actually doing was selecting the most suitable women to give birth there.

So the 95% headline (or whatever it was) gives such a different impression to the reality that women can expect if they plan to give birth there. Far from being almost certain to have an unassisted VB, there's a good chance of not getting through the door at all and ending at the hospital down the round that you were probably desperate to avoid when you looked at the HES stats for it.

Bare in mind that if you book into a CLU you are unlikely to change your intended place of birth. So if you are talking about continuity of care...

This is something the place of birth study wouldn't have picked up, due to the way they selected low risk women. The fact that all women are low risk until you find a high risk indicator isn't something that is talked about much but its important to someone's potential experience. Its all very well looking at the place of birth stats when you are a low risk woman, without considering what happens if you suddenly become high risk during the cause of your pregnancy or giving birth. If everything goes to plan... great! But that isn't the case for a significant percentage of women.

Add to that the rate of transfers, and the picture for MLU and homebirths don't look quite so shiny or reflective of real experiences as they are so filtered. Its useful to know, but without knowing the flaws of the data, it could be potentially misleading too.

Its awful. The data needs to be better to show up anomalies like the Edgeware one better so that women can make an informed decision.

The stats - both the place of birth study and the HES figures - give one picture and certain information which is very helpful and definitely worth taking into consideration, but without looking at things from afar too, you miss what the whole picture looks like and important details that might influence your decision, if you knew.

Which is why that article rather annoyed me, as its as blind as the very thing its criticising. Politics and poor data collection/presentation.

I wish people were asking more questions about the data we have and what its weaknesses are as well as the strengths they have so we can improve them so they are more comparable and meaningful than they currently are. Most of the time we seem to be comparing oranges and pears with the data that is being produced. The weakness of these stats and studies really do reveal the areas where we need to be focusing attention and trying to improve the care and experience that women get, if we take the time to study them properly.

I'm grateful for threads like this one for that reason. They are doing the job that journalists are being paid to do, and are doing very badly.

Welovegrapes Sun 10-Mar-13 23:28:25

I have such mixed feelings about this piece. I love reading Ina May Gaskin and in another world would have loved a birth with her midwives on the Farm in Tenessee. Their stats have incredibly low adverse outcomes.

In this world, I gave birth in a wonderful CLU (no mlu or stand alone option within driving distance where we lived at the time). The mw were amazing. I laboured in the pool from 6 cm on gas and air, got to 10 cm. labour then completely stopped. Got out of pool, they gave me ages to get it started again and walking around, kneeling over bean bags etc nothing helped. Waters broke during a vaginal exam.

Then agreed to augmentation, pushed for three hours, vb without instruments, followed by pph.

if I'd had a Hb

A) I would have had to transfer in when labour stopped and the same would have happened anyway.

B) if that pph has happened in the Hb i would have been blue lighted in anyway and it would have been risky.

Really want mlu next time , but the pph may exclude me.

Welovegrapes Sun 10-Mar-13 23:34:45

Edgeware are unbelievably strict with their criteria. They wanted a letter from my endo to say my well controlled hypothyroid did not make me unsuitable for a stand alone birth centre. This was despite the fact that I had blood test results in my maternity file showing my tsh and t4 were perfect for pg throughout my pg and that the obs consultant at st Mary's had reviewed them and considered me suitable for their birth centre.

we moved in the end before it was an issue.

VinegarDrinker Mon 11-Mar-13 07:00:53

Amanda don't get me wrong, I am in no way pro the closure of the Lewisham CLU. And actually I know the MW who set the MLU up fairly well, I'm pretty sure she isn't pro losing the CLU either. And I have no illusions about why it's being done, and it certainly isn't to benefit women. I just mentioned it in response to the claim that the UK is massively biased towards promoting CLU births.

RTB thanks for a very thought provoking post.

LaVolcan "what we need to do to make things go right, to avoid the emergencies and problems happening in the first place?" I agree you can do much, much more to enhance antenatal care (although some risk factors eg obesity seem to be increasing exponentially regardless of ublic health programmes) but that will never eliminate the true unpredictable emergencies of childbirth - the things that make people like me and mayhew shit our pants. Thankfully they are rare, but they will always exist.

exoticfruits Mon 11-Mar-13 07:10:15

It sums up my feelings exactly and are the reasons that I would always go for a hospital birth and peace of mind for being in the right place. We are all different - it would be very odd if there was 'the' way for everyone. I thought it a good article.

mayhew Mon 11-Mar-13 08:18:36

VinegarDrinker I'm feeling a bit of love for london ambulance paramedics at the moment. Speedy, competent and compassionate. I've needed them twice in the last 2 weeks in urgent circumstances.They were ace.

Without them, I wouldn't want to do this work.

glorious Mon 11-Mar-13 08:59:01

I too was disappointed with the misinterpretation of the study and have written a stroppy email to the Observer reader's editor. Fingers crossed they actually look into it...

Shagmundfreud Mon 11-Mar-13 09:39:20

"Hello bear is right, plus I would add that in reality hospital birth should be safer than home birth."

It depends where you stand on the issue of how environment impacts on the normal hormonal physiology of labour.

My personal view is that human beings are mammals, and we - to some degree - give birth like mammals. I know that we struggle more in labour because of our babies' big head and our narrow pelves, but why do we assume that all other golden 'rules' of mammalian obstetrics (ie, don't move, touch, disrupt or distress a labouring mammal unless you absolutely have to) simply don't apply to humans?

I'm not surprised so many women can't have straightforward deliveries in hospital. I think everything about the way care is organised in them militates against the normal physiology of birth.

Shag pointed out some stats for Edgeware Birth Centre last week, which I found pretty troubling.

"It shows that over 95% of women there had an unassisted VB; sounds great. Almost unbelievable."

I don't find it unbelievable. Look at Ina May's stats for The Farm birth centre: 98.6% of the women who gave birth there between 1970 and 1995 had unassisted vaginal births. 44.7% were women expecting their first baby. In the UK in the 1950's only 2% of women had a c/s. Now I know that we're talking about women who were a) thinner (much), b) younger (a lot), and in the case of the farm c) women who'd had case loading midwifery care, and also d) in the 1950's maternal and perinatal mortality was higher than today, BUT it does suggest that the incredibly low percentage of normal births today MUST have something to do with the health of modern mothers, and our modern systems of care, and is not simply a reflection of the intrinsic difficulty of human birth.

And if the very low rates of normal birth is primarily down to new mothers being older and fatter, and to the way care is organised, then surely something can be done to improve the situation?

Would also add, that in the POB study shows that 91% of multips who book a home birth complete the birth at home, and that only 5% transfer in labour.

"Most of the time we seem to be comparing oranges and pears with the data that is being produced"

I don't think you can say this is true of either the Place of Birth Study 2011, or the National Birthday Trust study 1994 - the two main UK studies of outcomes associated with place of birth done in the past 2 decades. Both studies try to only look at outcomes for healthy, low risk mothers in a range of settings.

RedToothBrush Mon 11-Mar-13 10:32:19

What about the Edgeware selection process and the figures of nearby hospitals?

Stats need to be taken in context, no isolation. They need to provide comprehensive methodology and be shown to be comparable with other stats if that is what you intend to do with them.

I find it troubling when stats produced are so far off 'the norm' that people don't question them more.

If Ina May had some found some miracle here I really do think that there would be a massive difference in disparity. Something simply does not ring true. Even advocates of her methods have been unable to replicate such good figures elsewhere.

My money is on a self selecting or deliberately selecting candidates; something that makes both sets of figures, non comparable against a wider population.

Thats not to say that there probably isn't a lot in what Ina May says; far from it. But to look at her figures and be blinded by them also helps no one. It doesn't improve our understanding unless we look at the demographics properly.

In terms of the changes in CS rates in the UK since the 1950 we must not loose sight of the fact that the population of the 1950s is not directly comparable with the population of today. The figures tell a story, but what is the story? Thats the question - you don't just look at the black and white figures without understanding the bigger picture behind them. People tend to lack the knowledge to look at stats and ask these questions and simply take them at face value. Not just your average person but also people who are educated and work in science and should have been taught about stats.

Age and obesity are the obvious and best known changes when it comes to changes in the British demographic but they are by not means the only ones.

Women's bodies have changed, not just because they are unhealthier but also because they are more healthy! The skeletal frame of a British woman has got bigger, with the exception of her pelvis. Profound changes that have outstripped our evolutionary ability.

Babies who would previously not have survived to child bearing age, now do; in theory this might mean in fact that women who never would have been designed by nature to give birth because of various underlying health issues, now do. The NHS has a lot to answer for!

Birth weights and head sizes have increased significantly from better diets and vitamin supplements. (Lets note the use of folic acid which has a proven effect on spine and skull development)

And we should look at changing ethnic populations. Certain groups have more problems and mixed ethnic couples have been shown in a few studies to have problems and a greater rate of cephalic disproportion because of genetic mixes that haven't previously be as common.

Indeed, there was a study a couple of years ago, that I was looking at over the weekend because of a crap article in the Telegraph that looked at a 'north / south' divide in CS rates. The study looked closely at the differences and picked up that these regional differences owed far more to the varying demographics than to women's choice or CS-happy Obstetricians.

At the moment the questions that really need to be raised for me are about this level of transparency and understanding. Its clear that something is different between a home birth and a hospital birth; thats what we need to find out. But there is absolutely no point in becoming obsessed with low risk mothers only, because again that does women a disserve.

How many women are low risk and then become high risk.
How many women are being rejected from MLUs far earlier in the process.
How many women plan a homebirth but don't even get a shot at it for x, y or reason.

These are things that seem to repeatedly be missed from these studies and stats. They are important. They highlight that choice is more limited than we are lead to believe.

This is stuff that I wish Alice Roberts had thought to look at in her article, rather than 'taking a swipe at the NCT' as someone upthread put. TBH, I don't actually blame the NCT for promoting stuff in the way they have. I blame the fact that statistics is poorly taught and understood and the fact that people are not taught to question comparisons more.

LaVolcan Mon 11-Mar-13 11:25:27

They are all good questions Red. They could go further. They could ask," since 90%+ of women give birth in CLUs, why are there such discrepancies between the outcomes for such hospitals?"

Just to take one example: I was looking at the stats for the Oxford region www.birthchoiceuk.com/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.com/Access.htm
You would expect the JR to have high rates of intervention because it's a regional centre of expertise, so women with problems are referred there from far and wide. I don't know the first thing about Kettering hospital, but they have a higher induction rate than the JR, a higher CS rate but lower instrumental delivery rate, but only have 38.3% of a normal birth rate as opposed to the JRs 37%. If they are not a regional centre with the higher proportion of high risk cases, why aren't their normal births higher? Maybe there is a reason which we don't know about until we dig deeper into the stats.

As you say, there is so much that Alice Roberts could have asked. She could have used her celebrity coupled with her medical knowledge to ask some hard hitting questions.

VinegarDrinker Mon 11-Mar-13 12:02:46

Not all high risk cases are concentrated in central units, though. I've worked in many DGHs that have a higher risk profile than teaching hospitals, in terms of BMI, ethnicity, non English speaking, HIV, multiple previous uterine surgeries etc.

No idea about that particular area, but it is worth considering.

Juggling toddler so can't reply at more length but reading all replies with interest.

VinegarDrinker Mon 11-Mar-13 12:03:55

Btw I don't think she (AR) is a practising Dr. Need Ben Goldacre on the case for a proper public dissection of the research and stats.

RedToothBrush Mon 11-Mar-13 12:06:09

LaVolcan, The Telegraph article I saw this weekend was slamming 'wealthy' Chelsea and Westminster for having really high CS rates and this apparently 'supported the idea of too posh to push'.

TBF the journalist was an absolute moron when he picked up on the particularly high ELCS rate. He didn't know the difference between an ELCS and maternal request, and the way the article reads it seems that he is under the impression that most ELCS are for non-medical reasons! hmm.

So he completely ignored the older demographic of wealthier women who have an increased risk of a medically needed ELCS, the wide disparity of wealth within the area which also has areas of high poverty as well as wealth and the diverse ethnic makeup of the area.

One of the comments below the article was very interesting, and something I would never have known. It turns out Chelsea and Westminster is home to rather large Somali population which has particularly complex needs; there is a specialist FGM clinic at the hospital...

This stuff is important. I think that perhaps there needs to be a modifier or indicator of these type of things on the data that is on NHS choices.

Welovegrapes Mon 11-Mar-13 12:25:32

RTB I wondered if Ina May's stats could also be affected by:

1) her being an unusually talented and experienced mw

2) for later births the placebo effect of having such a well known senior mw

3) the unusual self-selecting group on the Farm itself. Much more alternative, maybe more suggestible/spiritual?

I wonder if the figures have ever been independently audited?

Love love love Ian May and am proud to have had a natural birth myself, so in no way a hater.

Btw the clu I had DS at had a very low epidural rate, cs and instrumental delivery rate because the mw were highly experienced and really believed in natural birth and because almost all women there got one to one support in labour. I was really impressed when the obs deferred to the mw on a question about my care. The registrar and the mw seemed to really work like a team of equals rather than the dr seeing herself as senior. When they got the dr to do my stiching she said nicely to my mw "I'm sure you'd have done a great job of this -maybe better than me!"

BraveLilBear Mon 11-Mar-13 12:49:21

Reading this discussion with interest. As a former journalist who was particularly good on statistics, I was unimpressed with what reads as a bland feature with no real insight.

As to CLU units not accepting low-risk mothers or not wanting them, I am in an area where I have no choice. It's CLU or HB. The free-standing MLU was closed 18 months ago because they were incapable of safely staffing it - the hospital does > 6,000 births a year with a handful of HBs.

The Trust is supposed to be creating an AMU with, wait for it, 3 birth pools and a handful more delivery suites, but there is no sign of it as yet. It was supposed to open in January 2013. So currently there's an average of 17-18 births a day, in 20 delivery suites. It troubles me that my first-born is due in the middle of a baby-boom, where the next nearest facility is more than 40 miles away.

As I am so stricken for choice, I looked at the stats for the hospital, and was shocked to see a very high induction rate of nearly 25% - but fortunately coupled with low CS and instrumental birth rates. I can only imagine this is down to it being a MW teaching hospital, but will be discussing with my MW at my next appointment.

RedToothBrush Mon 11-Mar-13 12:57:16

Welovegrapes, I honestly would be surprised if they weren't also affected by those things. I think they are really valid and interesting ideas that we should be exploring. It would be wrong to dismiss what she's doing, as it seems like she's got 'something'.

But even if that is the case, I don't think that it would be possible to expand that to the entire population; I think it would only help a certain percentage of the population due to the different approaches to life we have. You simply are not going to get universal rates of 95% across the country and that be good for women or children alike.

You can not forget that The Farm does not exist in isolation, and its my understanding that although they do take on some higher risk pregnancies such as breech, twins and women who have had 5 or more children already, they do reject some women with more complex medical histories.

Like Edgeware.

Shagmundfreud Mon 11-Mar-13 13:07:15

Redtooth - Ina May's stats really aren't that exceptional for a low risk, healthy population of young mothers.

And you have to remember that women who have case loading care (which is what Ina May provides) really do have better outcomes than women who have the normal type of NHS midwifery care.

There was a study on outcomes associated with independent midwifery care in the UK a few years ago. 77.9% of women in the study who had independent midwifery care had a completely normal delivery, despite the fact that 21% had previous obstetric complications (including c/s) and 3.1% were carrying twins. When high risk cases were excluded, the neonatal outcomes were similar to those found in low risk women having NHS midwifery care.

Redtoothbrush - my concern about C&W is why they have a 33% c/s rate, whereas nearby St Georges in Tooting, which is also serving a high risk population (it's only about 3 miles from C&W) has a 26% c/s rate. St Georges attracts a lot of high risk cases because of its top notch neonatal unit.

I don't honestly think it's that complicated. We know what patterns of care and what features are associated with an increase in the normal birth rate:

- case-loading midwifery care
- one to one care in labour
- consultant input when a labour becomes complicated
- a healthy BMI at booking
- maternal age under 30

and there's a growing body of evidence suggesting that doula care in labour is associated with a significant raising of the likelihood of a normal birth.

If I was a first time mum thinking about where and how to have my baby, I'd be looking at this information on BirthChoice UK (which comes from the Quality Care Commission Survey) -

- 'how many midwives looked after you in labour?',

- 'Did you get the pain relief you wanted?',

- 'Were you (and/or your husband, partner or a companion) left alone by midwives or doctors at a time when it worried you?',

- 'Were you treated with respect and kindness?'

- 'Overall, thinking about your care during labour and birth, were you involved enough in decisions about your care?'

And maybe look at the number of births per midwife at the hospitals you can choose from and compare them to the number suggested by the RCM which allows for 'optimal' care.

Really - it amazes me that people aren't more interested in this type of information. Some of the information on BirthChoice UK is absolutely MIND BOGGLING!

- Some hospitals have episiotomy rates which are DOUBLE that of other hospitals (Ealing Hospital 40%, West Suffolk, 14%),
- What about birth positions? 44% of women giving birth at Barts in London give birth with their legs in stirrups, compared to only 14% at Kings in London!

I mean, seriously, WTF is going on here?

Shagmundfreud Mon 11-Mar-13 13:11:46

Case-loading domino care for all mothers who want it I say! That would bring the C-section rate down. <wanders off muttering>

here

LeBFG Mon 11-Mar-13 13:13:10

Such an interesting thread to read. One that is long overdue imo. Particularly interesting is the point that these out-of-hospital births are clearly not a random sample of 'low-risk' women - for one thing, these women are, for one reason or another, pretty determined to birth naturally.

Just a small point. In the Netherlands the referral rate for HB is lower than in the UK even though HB are at 30%. Plus I read that midwifery techniques (particularly for a natural 3rd stage) are very important to outcome (delivery of placenta, pph etc). I would like to see more comparative sort of research - what are the Netherlands doing to make HB so safe? Should we be revising MW techniques in the UK?

Hospitals certainly should be safer places for higher risk births. I would expect that to be the case - if they aren't, questions need to be asked. I can see how low-risk women in hospital situations however may be more likely to have interventions etc because the professionals in charge are used to seeing more high-risk births, some with poor outcomes. I would expect these people to act in a precautionary way to limit events spiralling. As these people have been 'enlisted' by the women to overlook their births, should it really come to a surprise to anyone that they intervene perhaps a little too hastily in low-risk births?

LaVolcan Mon 11-Mar-13 13:22:58

Red I take it this was the Telegraph article:
www.telegraph.co.uk/health/healthnews/9918384/Caesarian-rates-support-too-posh-to-push-theory.html

I haven't had time to read all the comments - some are sensible, some are the usual sorts of rants that you get on these sites. I was interested in the comment that it was a teaching hospital and therefore they wanted to give medical students hands on experience. I have a suspicion that there may be some truth in this.

The presence of the Somali community was interesting, but I doubt whether they are the cause of the high CS rates - which would link with shagmund's comment about St George's also serving a high risk population but with lower intervention rates.

Shagmundfreud Mon 11-Mar-13 13:32:06

"I would like to see more comparative sort of research - what are the Netherlands doing to make HB so safe? Should we be revising MW techniques in the UK?"

In the UK there are areas where only 1% of babies are born at home. In other areas it's more than 10%. Some areas have dedicated home birth teams who provide case loading care for all home birth mothers. In other areas women booking a home birth may end up being looked after by a midwife who's done very, very few home births, and who they've never met before.

I think you'll find that this might account for some of the differences, as well as the fact that mothers having homebirths in the UK are probably on average much older and fatter than their counterparts in the Netherlands.

It puts me in mind of an editorial in the BJM a few years back discussing how midwives used to work and train in the days when many many more women in the UK had homebirths (1950's and beginning of the 1960's). Midwives either focused on a career delivering babies in hospital, or a career working in the community. It was acknowledged that to some extent they needed a different focus and skill set for these two jobs. I think this is very much the case now, when some midwives working in hospital hardly ever see a completely normal labour that doesn't involve some sort of intervention or other.

LeBFG - I don't think doctors and midwives are cavalier about interventions. I think labours are more likely to go shit shaped in hospital and it's this that leads to higher rates of c/s and other interventions.

BraveLilBear Mon 11-Mar-13 13:46:20

God that Telegraph article is even worse...

LeBFG Mon 11-Mar-13 13:52:48

"I think labours are more likely to go shit shaped in hospital" why so? because women are less relaxed? or the effect of epidurals on labour?

VinegarDrinker Mon 11-Mar-13 13:54:53

shag I was so surprised by the lithotomy figures you quoted I checked the study and it was 26% - a 44% increase - NOT 44% of all women! (though I agree, oddly high)

LaVolcan Mon 11-Mar-13 13:55:11

Particularly interesting is the point that these out-of-hospital births are clearly not a random sample of 'low-risk' women - for one thing, these women are, for one reason or another, pretty determined to birth naturally.

In many areas this must be true, in that the only women who get home births are ones which specifically ask for them. Other areas, Torbay used to be one, did set up their services to offer home births, so that would include women who hadn't previously thought about having a home birth. In those cases it probably could be said to be a random sample.

I would be interested to know how many women get a straight choice: hospital pros/cons, homebirth pros/cons, MLU (if available) pros/cons. I would also question whether it's a choice based on actual conditions or ideal conditions. It's a fat lot of good having wonderful facilities if they can't be accessed because the unit is closed because of staffing issues, or because it's heaving and is closed to new admissions, but no one tells you that this might happen.

RedToothBrush Mon 11-Mar-13 14:13:31

As these people have been 'enlisted' by the women to overlook their births, should it really come to a surprise to anyone that they intervene perhaps a little too hastily in low-risk births?

Might be that these women WANT intervention sooner - or at least give the impression that they need it. The act of choosing a CLU so that you have this 'safety net' might mean you have lower tolerances and seek intervention sooner than others. It might be harder to decline this pressure, if you are working in a CLU as a result.

In answer to the Tooting / C&W difference, I think there's a lot of possible answers to that.

The ones I can are:
Does Tooting have the same specialisms as C&S? Even if they serve a similar population, it doesn't mean they would also have something like an FGM clinic; so women might be being referred to one rather than the other?

C&W has a private ward. Tooting does not. I think I'm right in saying that the figures for private wards are included in HES figures, which does distort them.

So again you are having women from outside the local area - who usually fit into a higher risk group - actively self selecting to a greater extent and further distorting the natural demographic of the area, making the figures less comparible.

Further still, when I've seen stuff about C&W I've heard it has a more pro-ELCS policy than perhaps Tooting has. If I lived equal distance from both and had a choice of the two hospitals, maybe this reputation would affect my decision based on my own personal opinion. Again, more self selection that fuels a difference in rates. If policies between hospitals were less variable and more consistent, maybe we would see less of this type of thing occurring.

I'm speculating here, but I think its worth doing. I don't think that even though Tooting and C&W initially look similar areas, that necessarily explains things fully. Thats what we need to fully explore; who exactly is being rejected and admitted into which hospitals (and why) rather than speculating on it too much.

I do think you raise some very important questions - that list you mentioned is now on NHS Choices too and would be high on my list of considerations (though its worth noting that patients in one area might naturally have higher expectations and standards than another, so patient scores can also be a little misleading too!). I do note the ratio of midwives to births is not on NHS Choices though. I think I know the reason why it isn't. Pure politics. Only Scotland and NI have a rate below the recommended 28 midwives to one birth according to this BBC article from 2011.

LaVolcan I've actually just looked at the data that you can download at the bottom of that BBC article too, which I find highly interesting. It gives details about the number of times a maternity unit has been closed and the number of women who have been diverted.

I think I'd like to see more made of this, as I've not seen this information anywhere else before. Knowing that Barnet and Chase Farm closed 140 times in 2010 alone would give me nightmares if it lived locally. I'd be re-mortgaging and going private faced with that as a possibility. No question. Its a simply scandalous figure. I haven't been able to find more up to date figures than 2010 though unfortunately.

Shag you are also dead right about stuff about episiotomy and birth positions. I think I've mentioned about similar concerns about those episiotomies figures before too.

RedToothBrush Mon 11-Mar-13 14:19:26

BraveLilBear, that Telegraph article made me want to strangle the man who wrote it. He clearly was way out of his depth with it.

Funnily enough its got over 240 comments and Kirsty Allsop wrote in to complain about it. The article about Kirsty's criticism published today had about 6 comments last time I checked.

I think it shows up the Telegraph for how it makes money. It generates more interest from an article which is monumentally piss poor and full of deliberately provokative judgementalness than one that has just a touch of intelligence and common sense.

So what hope do we have of evidence based childbirth with that?

Shagmundfreud Mon 11-Mar-13 14:21:28

Vinegar - I'm talking about the figures on the BirthChoice UK site - the results of the Quality Care Commission survey.

You are wrong about the 44% figure indicating a percentage increase. That figure represents the number of women who had their baby in the lithotomy position. The arrow doesn't mean 44% higher. It means 44% of women gave birth in the lithotomy position and the double arrow indicates that this is much higher than the national average.

VinegarDrinker Mon 11-Mar-13 14:22:40

C&W and St George's may be geographically close but that means nothing! They have totally different demographics - look at the ethnic makeup for a start.

And yes, St George's definitely are more pro normal delivery - eg they use STAN monitoring. (Although initial results don't appear to show a significant reduction in CS rates, having worked in units with and without STAN I am sure it makes a difference).

I do think the BirthChoices data is interesting but certainly doesn't tell the whole story.

VinegarDrinker Mon 11-Mar-13 14:30:53

Yes, my error, on phone and trying to do too many things at the same time.

One point - It isn't Barts though, it's the Royal London. Barts haven't had maternity services for years. Same Trust but a very different population amongst many other things.

Shagmundfreud Mon 11-Mar-13 14:33:45

My local hospital has a very high normal birth rate, despite serving one of the biggest African/Caribbean populations the the country.

I find it interesting that Epsom, which serves a very affluent, white population has an incredibly low normal birth rate.

There's probably some formula which would help you work it all out which would involve average age, divided by bmi, times ethnicity and smoking status. If someone gets to the bottom of it, can they let the rest of us know? grin

Shagmundfreud Mon 11-Mar-13 14:34:45

A population with very rigid perineums, or an enthusiasm for epidurals by the looks of things! (or very scissor happy midwives!)

Phineyj Mon 11-Mar-13 14:39:30

I booked a home birth (with independent midwife) so I could get one to one care, not because I wanted a home birth. I was alarmed by the regular stories in our local press about women giving birth in car parks etc because they had been sent away by the labour ward (I see it happened to someone on a train last week). In the discussions about place of birth, this issue of being sent away by hospital, possibly leading to an adverse outcome, does not get enough attention, imo. I think is it is going to get more common because of concentration of services in larger centres. I ended up transferring into hospital but having a MW with me the whole time was much more reassuring for me and DH than the alternative. I hadn't heard of 'Domino care' until seeing the post above, but that seems to be what I put in place for myself. Rather unfair if yo can only get it in some areas by paying for it!

VinegarDrinker Mon 11-Mar-13 14:40:31

Ethnicity doesn't tell the whole story either though - obviously it affects things like GDM, but I tend to look at % who don't speak English as a better marker of "soft" risk factors, such as late access to antenatal care, barriers to understanding what is "normal" (eg in terms of reduced fetal movements), attendance at AN classes and ability/wish to push for a certain outcome (eg normal delivery)..

LaVolcan Mon 11-Mar-13 14:43:46

Red I had never seen the BBC figures either, and they do make most interesting and depressing reading. I noticed that for Oxford Radcliffe Trust that there were only 5 midwifery vacanies, or 1.8%, but that the ratio of births to midwives was 36.38. On the face of it this sounds as though someone has set the staffing levels too low. A quick back of the envelope type calculation shows that it needs another 50 midwives to bring the ratio down to 28.

VinegarDrinker Mon 11-Mar-13 14:45:28

White and affluent could also mean older women, higher IVF rates, higher twins, more pressure from patients for CS, higher epidural rates etc though.... Swings and roundabouts!

Shagmundfreud Mon 11-Mar-13 14:57:51

I still don't think that it's reasonable to feel that big variations in emergency c/s between hospitals very close together in London can always be explained away by demographics.

LaVolcan Mon 11-Mar-13 15:03:38

Link for Kirsty Allsop's response:

www.telegraph.co.uk/health/healthnews/9920709/Kirstie-Allsopp-Too-posh-to-push-caesarean-label-unfair.html

i am not surprised that Kirsty has responded because she is the sort of woman that the writer probably had in mind. For once I agree with her. I did note though that she had an EMCS the first time round. These are some of the least safe births and I do think that why these are happening, to whom and whether some hospitals have higher rates than their apparent risk populations would lead you to expect, are all questions which should be asked.

I am a bit surprised at The Telegraph in the case of the original article: I usually find that their birth articles are straightforward and factual.

brettgirl2 Mon 11-Mar-13 15:08:35

Where is the evidence that environment is what makes the difference? The fact is it could be any number of things. I thought the original study showed for subsequent births low risk mothers were at greatest risk in hospital?

Kendodd Mon 11-Mar-13 15:17:45

I'm not a medic or NCT cheerleader and haven't read the whole thread.

But, I do think mothers sometimes focus too much on the birth process and not enough on the outcome. Birth is not hearts and flowers, it's blood and guts, personally I was just grateful that we both got through it alive and well. I do think it's a bit silly being upset if you didn't get to give birth in the pool with your plinky-plonky music on.

I didn't make a birth plan with any of my children because from what I could see it just goes straight out the window as soon as the birth gets going and just sets women up for failure.

LaVolcan Mon 11-Mar-13 15:39:02

I think it's obvious that you haven't read the thread Kendodd - we are not talking about "pools and plinky-plonky music".

We are talking about a couple of articles, one of which, The Telegraph one we, I think all, agree is badly written, and doesn't say anything but peddles a weary 'too posh to push mantra'. The other article by Alice Roberts, we have varying opinions on, but many of us feel that she ducked the opportunity of highlighting some major problems with the maternity systems in this country which could and should be addressed. I personally, and I don't think I am alone, think that she made some comments about a report which illustrates the fact that she can't have read it and therefore were ignorant and silly.

Personally, I do think it's worth getting upset if you gave birth in the car park, because your hospital was too busy to admit you, or you had an EMCS which might have been avoided with better care. I wish women would get more angry.

Shagmundfreud Mon 11-Mar-13 15:45:40

"I do think it's a bit silly being upset if you didn't get to give birth in the pool with your plinky-plonky music on"

I think that's quite insulting.

Birth is one of the hardest and most dangerous things you're ever likely to do. What happens in labour and how you feel about it can make a difference to your peace of mind and your relationship with your child and your partner in the first few months and sometimes even years of parenthood. I put a lot of effort into planning my care for my second and third birth because of how unpleasant my first labour had been. And I had a great midwife who used my birth plans to shape how she cared for me, even though neither of my labours progressed normally. It was fantastic to feel my feelings and wishes were important to her, and contributed to my feeling very positive afterwards about what was in essence a very difficult experience.

It's not about wanting a 'perfect birth'. It's about wanting to be listened to, and not be treated in such a way as to make a hard experience even harder.

If women want to give birth in a pool and that makes something that is really intrinsically very challenging more bearable, then who are you to sneer and ridicule it? Do you do the same to women who want epidurals?

BraveLilBear Mon 11-Mar-13 16:12:10

Thanks for the Tel link LaVolcan - fair play to them for publishing it, they must have realised how far wide of the mark the original was - and thanks to Kirstie for having the wherewithal and cajones to use her celebrity to fashion such a response.

The BBC piece linked upthread is indeed fascinating, but yet again, incomplete. My Trust is one of those for which 'no data is available' - despite more than 6,000 births a year!

I think it's wrong that some Tusts can hide behind their figures like this.

Kendodd I think it's worth pointing out that the birth process can have a significant outcome on mother and baby's health going forwards, not lease in terms of the mental health of the mother. There are also very real mental health issues connected to the perception of control - choice can have a big influence on that, the more choices you have, the more in control you feel.

Take away control and mum is more likely to have PND which can lead to bonding issues and other problems for the pair of them growing up. It is incredibly important, and not a flippant luxury, as some would have you believe, to choose the most appropriate setting for your circumstances in which to give birth.

BraveLilBear Mon 11-Mar-13 16:13:19

x post shagmund

HoldMeCloserTonyDanza Mon 11-Mar-13 16:30:12

I really don't see the evidence in the quotes given that she hasn't read the full studies she refers to. TBH in an article all about why she wants to educate herself with full studies I find the suggestion she didn't actually read them pretty far-fetched.

Her point about epidurals makes sense to me.

Be honest, folks - did you read the (gentle) swipe at NCT/natural birth/etc, and scour the article for SOMETHING, however small, to disagree with? Because that's kind of how it looks.

(I do that, btw, it's crappy and I try not to but I do do it blush).

HoldMeCloserTonyDanza Mon 11-Mar-13 16:36:41

But Bear - control in labour is an illusion - we are at the mercy of genetics/chance/unknown factors related to baby - there is no such thing as a labour a woman can control.

And I think the lie, that by subscribing to any set of beliefs - ESPECIALLY total faith in Ina May Gaskin or your consultant or whoever - you can have what you want, rather than what nature has in store - is just as big a contributor to PND.

There is a lot of money in saying "Oh do what I say, do X and you will microscopically increase your already quite tiny chance of Y". There is not a lot of money in telling people "honestly you will probably be fine but a not insignificant minority of people are not fine, and the main thing that will put you in one camp or the other is genetics and you have no control over it".

KatieMiddleton Mon 11-Mar-13 16:41:55

The only think I learnt from that article is that the quality of science journalism in this country is worse than I thought.

As you were.

RedToothBrush Mon 11-Mar-13 16:47:35

I've just waded through some of the stuff on Birthchoices.

Trouble is a lot of it is starting to really date now. The Healthcare Commission data is from 2007. Since then there have been a lot of updates in various areas in NICE guidance. Some of which has been taken up, some of which less so.

I focussed on the CS rates as a) its what I'm personally most interested in and b) its what everyone like to point to as an indicator of success and failure. I've not looked at all - just a random selection from the NW and London.

The average rate for VBACs for England was 32% at the time of publication. Yet South Manchester had a rate of 1.2% according to this data! Guys & St Thomas had 6.7%. And loads of Trusts didn't supply any data at all. Now the NICE guidelines have been updated since this report so it would be interesting to see what, if any, changes have happened since 2007.

Then you have EMCS undertaken within 30mins. English average 92.8%. Yet a significant number didn't supply data, and of those that did I've seen a significant percentage at around 65 - 70%. One or two fell far below that.

The percentage of women over 35 having a CS ranged between 26.2% and 43.4% at the ones I looked at. English average was 33.3%.

The ethnically and age adjusted figures were interesting. C&W which has been mentioned on this thread had an overall figure of 30.1% - the highest I've seen. But when adjusted this came out at 25.7%. Which was at the higher end, but not the highest. Conversely, St Helens and Knowsleys base figure was 23.2% but adjusted came out at 24.1%. The England average being 22.2%.

So actually, I really do not think that C&W is nearly as bad as it is being reported. (The lowest one I've spotted of the ones I looked at, was ironically Lewisham adjusted to 16.8% from 22.5%).

The other figure that jumped out at me, was the staggering 27.4% of CS done by GA at Mid Cheshire. The English average was 9.9%.

It really does seem to me, that what the base CS rate is, probably should be one of our lesser concerns. Not when you look at some of the other figures popping up all over the place. I really, really wish that the newspapers started looking at some of this, as its far more revealing.

From browsing, I could have easily looked at a bunch of other issues other than CS and painted a similar pattern. It just daft. And it annoys me more and more, when its constantly about the same old shit in the newspapers.

BraveLilBear Mon 11-Mar-13 17:00:34

As mentioned before, I read the article as bland and a wasted opportunity. Yes, it's about her choices, but with power comes responsibility, and it's important to recognise that not everyone has the same level of choice or care available.

And I agree that choice in labour is an illusion to an extent - however, there are choices that you can make along the way. Induction or monitoring, what pain relief options you want to to pursue, constant VEs or not, what plans you want in place if everything goes horribly wrong... while in some circumstances choices will be limited, there are often some elements of choice still available. Even if it's 'sod my health, save the baby at all costs'.

The issue is that it's difficult to make informed choices about such decisions when so much evidence is skewed by wonky data or biased reporting (by pro and anti-VB/CS camps, consultants, midwives and the mothers club down the road).

To me at least, it's a shame that such a useful platform to create a discussion around evidence-based childbirth misses this opportunity when it's a discussion that really needs to be had on a national scale.

Shagmundfreud Mon 11-Mar-13 17:15:03

"But Bear - control in labour is an illusion - we are at the mercy of genetics/chance/unknown factors related to baby - there is no such thing as a labour a woman can control"

Oh come on - you can't control the position of your baby (usually), or the rate at which your cervix dilates, or the shape of your pelvis, but you can often have some control over:

- what you do with your body in response to the contractions,
- how you mentally respond to the experience of labour,
- how you are treated by the people looking after you.

And I know this because I felt in control of myself through most of my second two labours, once I'd organised to be looked for by someone who shaped the care she gave me according to my specific needs, rather than the organisational needs and protocols of the NHS.

And there will be other women on this board who will tell you the same.

"And I think the lie, that by subscribing to any set of beliefs - ESPECIALLY total faith in Ina May Gaskin or your consultant or whoever - you can have what you want, rather than what nature has in store - is just as big a contributor to PND."

Nobody in their right mind would say or suggest that it's reasonable to lead women to feel that they can avoid all problems in labour if they plan it right, or have care from someone they trust. But it DOES make a difference to the majority. And that difference is reflected in the better clinical outcomes for low risk women cared for by independent midwives.

Really - it doesn't make sense to take that sort of fatalistic attitude, to insist that because you can't control some aspects of labour, you therefore can't control anything at all about the birth. It's also not true, as many women on this board will tell you in relation to their personal experiences.

Re: PND - actually I've got some research on this, one of the very few studies on expectations of birth and how they impact on women's feelings after birth. They show that women who go into birth with high expectations of being treated well, and an expectation that they will find it a positive experience (albeit with a realistic expectation that anything can happen), have the best psychological outcomes afterwards, independent of what actually happens during labour. Which of course runs pretty much counter to the stereotype bandied about on mumsnet.

"and the main thing that will put you in one camp or the other is genetics and you have no control over it".

If the POB figures are to be believed the single most influential thing when it comes to what sort of birth you have is WHERE you have your baby. You are a healthy mum, you appear to be really very much more likely to have an uncomplicated birth if you stay the hell away from a CLU to have your baby, and either head for a MLU or stay at home.

Redtoothbrush

I'm warning you - those tables on BirthChoice can suck the life out of you. I've spent hours goggling at them, saying, 'What? No! Eh? WTF!'

VinegarDrinker Mon 11-Mar-13 17:30:27

An uncomplicated birth .... But with double the risk of adverse outcomes for your baby. We can all spin statistics...

Mode of delivery is not the be all and end all. And by that I don't mean "as long as we are both alive that's OK".

I had a fantastic experience with DS's labour and delivery. Yes, you read that right. I was well supported, and the eventual forceps and PPH were all managed very well and efficiently. I was treated with respect and kindness throughout. The way he eventually exited my body is way, way down my wishlist after compassionate, caring, competent treatment.

(Btw I delivered somewhere I hadn't worked, where noone knew me as a Dr, so certainly didn't get preferential treatment).

KatieMiddleton Mon 11-Mar-13 17:37:41

I find terms like "twice as risky" "more than double the risk" "three times safer" unhelpful because there's no comparator.

A risk of 1:20,000 vs 1:10,000 is pretty unlikely in either circumstance. 1:4 or 1:2 both very likely in either circumstance and yet both show "double the risk" stats.

I want to be given data straight up (evidence) and then adjusted for my personal circumstances (subjective) so I can make better informed decisions.

Until we get information like this women cannot make informed decisions about their care.

RedToothBrush Mon 11-Mar-13 17:41:08

Haha I've figured that already. I think I'd be more interested in whats changed since they were published now though. 2007 is a lot time and the face of healthcare has changed a great deal since then. I like to know whether making that data public got rid of some of those glaring anomalies or not. If collecting all that data has done nothing, then its a absolute travesty - and the fact it has been so ignored would owe quite a lot to the unintelligent and backwards media coverage of the whole subject in my mind.

Peachy Mon 11-Mar-13 17:44:30

Interesting thread.

There seems to be an idea here that HB means you are all Ina May Gaskin hippy and NCT.

That's really not always the case.

I had a hb because I didn't have childcare within an hour's travel and I was warned my birth would be fast based on history.

Had I even tried to get to hospital DS4 would have been born in the Tesco Express car park at 12.35 am on a cold April night attended by DH, 2 autistic sons (hence the childcare issues- can hardly drop with a neighbour and as I have AS myself I really needed Dh to advocate for me).. instead he was born in a warm home after a 35 minute labour with a MW in attendance (just) and another arriving just afterwards, also with a doula there to help out.
The GP told me to drop my hippy ways and go to hospital when I asked about HB; he refused to do the post birth visit as well so I had to go to hospital for that. A MW at the hospital told me similar, and then argued with me about the number of children I already had (3) because one was born at a different hospital and she didn't have the notes in front of her so she proclaimed I must be wrong and only had 2. you will understand my confidence in that, new to us, hospital plummeted immediately!

And a day or two after ds4's joyous but rapid birth the hospital unit was closed as a risk to women due to two maternal deaths. My instincts were bang on.

But primarily it was the childcare / sn kids issue, and absolutely I would have transferred if needed- hence the doula to accompany me whilst DH drove to England to drop children with only childcare we had.

I wish people would not make assumptions, people and their reasons are all very different. I am neither under educated (think almost completed MA in Autism) nor anti NHS or medical care, I am just a normal person with a complex life who researched, read, and made the decisions right for her.

And yes I did feel much more in control than my previous birth: and healthier too, but that might be because I couldn't eat after ds3 was born until I went home, the maternity unit being unable to provide the dairy free diet I rely on. Toast with butter ('sorry it's buttered when it comes'), cereal with milk, those were the options.

RedToothBrush Mon 11-Mar-13 17:45:08

long time ago even*

VinegarDrinker Mon 11-Mar-13 17:55:23

Exactly Katie, hence my comment about spin.

Well I haven't read much of this thread or related links as yet, but I think it's a shame there can't be a smoother continuum between different kinds of care offered to women in labour.

For example there is talk of "having to throw out your birth plan when it doesn't go according to plan" whereas I very much felt I wanted to cover all bases.

A shame there is such a divide between midwife led care and obsetrician led care.
I'd like to see everyone coming together more to provide women with the care they need in sometimes unknown and changing circumstances.

jchocchip Mon 11-Mar-13 18:01:08

I had a hospital birth for my first, was advised by the director of midwifery to have a homebirth for my second and didn't even see an obstetrician for my third. At the time it was much safer for me to keep away from the local obstetricians who thought women should be designed with a zip. I wasn't prepared to accept the risk of interventions that would have followed a hospital booking at the time.

jchocchip Mon 11-Mar-13 18:03:45

lol peachy arguing with you about how many children you have grin

jchocchip Mon 11-Mar-13 18:05:27

Btw, I'm not anti hospital birth, I was very happy with my hospital induction and waterbirth but I moved house between ds and dd1 and the new hospital was run by scalpel happy obs.

LaVolcan Mon 11-Mar-13 18:17:13

Alice Roberts annoyed me because if she had read the Place of Birth study which she is purporting to quote she would know that it talks about planned place of birth at the start of labour. It shouldn't be too difficult to work out that the forceps and epidurals happen in a CLU after transfer, hence my comments that her statements about forceps and epidurals are silly.

She then pays credence to the ACOG source which she admits is hard line "choosing to deliver a baby at home… is to show preference for the process of giving birth over the goal of having a healthy baby", This is an opinion from a biased source which has a vested interest in hospital births. It can't be directly compared to the UK because the systems are so different. It isn't backed up by good quality UK research, nor do I believe is it a viewpoint backed up by our own RCOG.

Ultimately it's her choice. At present no one is saying that she can't have a CLU birth so really what is she going on about? Why bother with the swipe at home births and NCT?

Still, “not something I want, even though it's a safe option for the baby with proven benefits for the mother. End of." doesn't fill a two page article, does it?

VinegarDrinker Mon 11-Mar-13 18:24:55

How do you define "a safe option"? It certainly isn't the safest option according to the POB study.

Shagmundfreud Mon 11-Mar-13 18:34:20

What do you see as the 'safest option' for a second time mum like Alice Roberts Vinegar? Factoring in the doubling of the risk of major surgery that comes with a hospital birth? hmm

LaVolcan Mon 11-Mar-13 18:38:23

For multiparous women, there were no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units.

The bolding is mine. That would be good enough for me.

For multiparous women, birth in a non-obstetric unit setting significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy. That would be another bonus factor.

VinegarDrinker Mon 11-Mar-13 18:39:36

Btw, I hope it is obvious I am not anti HBs. I am anti people being uninformed about the true difference in risk profile. Which goes both ways for sure, I think in general we (MWs and Drs) are really bad at being honest about the unpredictable risks of childbirth in a non scary way. And the lobby groups do often get very emotionally involved in their way being the Right Way, hence the difficulty with getting hold of pure facts (the limited ones we do have).

VinegarDrinker Mon 11-Mar-13 18:40:29

Ah the multip bit I agree with, I didn't realise you were talking about her case specifically.

jchocchip Mon 11-Mar-13 18:42:58

Homebirth is a safe option in the same way that hospital birth is a safe option. Neither is guaranteed. But you chose your own risks and personally I would never book with an obstetrician again. They can undermine your confidence in your ability to birth vaginally, and increase your anxiety. Whereas a good midwife will stand back and only coach you through the process if you need help. Of course doctors have their place but they should not be let loose to influence women's decisions at the booking in appointment...

VinegarDrinker Mon 11-Mar-13 18:43:01

Also to say - you have to look at the risks to the woman and the baby separately if at all possible imho. Risks to women : much more common but to many people usually less "serious" (in terms of life changing). Risks to baby, much rarer but potentially devastating. (Oversimplification for sure!)

VinegarDrinker Mon 11-Mar-13 18:45:57

The use of episiotomy as an adverse outcome is an interesting one. I think of them as fairly value neutral - obviously unnecessary ones are Bad but they have their place and I certainly didn't give mine a second thought.

VinegarDrinker Mon 11-Mar-13 18:48:19

jchoc are you in the UK? You don't generally choose to be under Consultant care if you are low risk. It isn't offered as an option. And Drs don't do booking appointments here either.

Studiously ignoring the rest of your generalisations and insults

jchocchip Mon 11-Mar-13 18:52:52

They did do the hospital booking in appointment, they did tell me I needed a pelvic xray. That is my experience, personally I would never book with an obstetrician again. no insult intended.

RedToothBrush Mon 11-Mar-13 18:54:22

jcchocchip, don't you think the converse is also true. Midwives should also not be let loose to influence decisions and that midwives might give an overly rosy picture of birth? Just as much as an obstetrician.

The fact is NEITHER should be influencing you either way, and your comment is very biased in exactly the way that needs to be taken out of the equation and assumes that midwives aren't doing what you see obstetricians being guilty of.

There are good obs and bad obs. And there are good midwives and bad midwives.

I find your comment odd, given you say to choose your own risks first.

jchocchip Mon 11-Mar-13 18:55:01

Oh and they told me my baby might die if I chose a homebirth hmm

VinegarDrinker Mon 11-Mar-13 18:55:32

That is a very unusual part of the UK then, I think you would find you are probably to only person on MN to have had a booking appointment with an obstetrician. And pelvic x rays to predict CPD went out with the ark. Sounds very bizarre altogether.

LaVolcan Mon 11-Mar-13 19:02:26

Risks to baby, much rarer but potentially devastating. (Oversimplification for sure!)

Yes but in the UK it's not an either/or. If your birth starts outside a CLU but needs help then you can transfer. It's for you to decide whether this is something you are prepared to risk. Alice Roberts chose to put rather a great store by the ACOG. Not only is the record on maternity care in the US nothing to write home about, the midwifery situation is different. Some states don't recognise midwifery, and use 'lay midwives' so the option to transfer isn't there in the same way.

Now it may be that some PCTs have much smoother transfer processes than others, which may account for discrepancies in the stats. I have read comments from independent and community midwives that when they transfer a woman in, the hospital doesn't always take their word for it that the transfer is necessary and wastes valuable time. But the remedy here is to improve the communication.

Peachy Mon 11-Mar-13 19:11:12

Accepting the risks of your decisions is part of being a grown up; a good friend of mine had a HB that went badly wrong and caused her child to become very severely disabled indeed.

I wasn't her, my birth history was completely different, but as an adult I did accept that- whilst praying like hell it would never happen.

jchocchip Mon 11-Mar-13 19:15:21

Vinegar you may think I am bizarre but it was not that long ago - certainly not as long ago as the ark.

And what is wrong with choosing your own risks? I chose hospital for my first after the dead baby comment and I was happy with my ds's birth. I wanted to have a second hospital birth but had moved house and after discussion and seeing delivery suite I wrote to the director of midwifery to raise some concerns. She dealt with these by talking me into a home birth and I'm very glad she did. It was a very positive experience and one I would not have got in hospital with the consultants running delivery suite at the time.

LaVolcan Mon 11-Mar-13 19:16:28

Vinegar - who you book in with seems to depend on where you are in the country. Some surgeries send you straight to the midwife. One surgery in my town hardly seems to know that midwives exist, and says that you must be seen by the nurse first and then the GP. Your first visit used to be solely about which consultant you got referred to, but that might have changed in recent years. I say 'consultant' but in practice you were unlikely to see the consultant.

Peachy -I have had friends whose babies have died in hospital. It doesn't mean that the hospital was bad. As you say, you weigh up the risks, and decide what is acceptable to you.

VinegarDrinker Mon 11-Mar-13 19:21:24

I didn't say you were bizarre

Shagmundfreud Mon 11-Mar-13 19:23:15

"Also to say - you have to look at the risks to the woman and the baby separately if at all possible imho"

What about factoring in the risks to a baby of having a mother die or become catastrophically ill during or following emergency surgery? It can happen. It does happen - every year in the UK, although it's rare.

What about the risks to any babies born to mothers in pregnancies following on from a birth which ends in emergency surgery? What about the risks of going through another pregnancy and birth with a scar on the uterus (between 2 and 7 in a 1000 will experience a uterine rupture during pregnancy)? What about the 7 to 8 women in every thousand whose c-section leads to an unplanned hysterectomy? Possibly increased risk of stillbirth in the next pregnancy? These risks are listed in the consent guidance for C/S on the RCOG site.

We really need to take into account the risks and benefits of birth choices beyond that of the immediate baby, and acknowledge that an uncomplicated vaginal birth pays big dividends further down the line in most women's reproductive life, and that a c/s often results in diminishing returns in terms of pregnancy outcomes with each subsequent baby.

It amazes me that Alice Roberts clearly doesn't consider the doubling of the surgery rate for low risk multips giving birth in CLU's (without any improvement in neonatal outcomes) an important enough issue to give any weight at all to in that article.

VinegarDrinker Mon 11-Mar-13 19:30:02

Yes, funnier enough I've read the guidelines on taking consent for CS, I do it every day...
All obstetricians are very aware of the long term risks of CS hence the (some would say too) pressure to prevent the first CS.

But the risks to the mother also include her baby being permanently damaged or dead. It goes both ways.

VinegarDrinker Mon 11-Mar-13 19:30:16

*funnily

VinegarDrinker Mon 11-Mar-13 19:32:06

Btw, you say an "uncomplicated" vaginal birth pays dividends in the future. I'd disagree. Having an instrumental, or epidural, or episiotomy or other "non natural" interventions has no impact physically speaking on future deliveries.

VinegarDrinker Mon 11-Mar-13 19:36:06

Urgh, typos everywhere. Post two above should say "too much pressure" (to reduce CS)

jchocchip Mon 11-Mar-13 19:45:13

Vinegar do you count immediate cord clamping as an intervention? Just interested.

RedToothBrush Mon 11-Mar-13 19:49:56

Alice Roberts is having her second child. And if she's anything like the average women in the Uk she probably won't be too concerned about her future reproductive life as there is a fair old chance she's planning to stop at two.

It might be worthy of comment in the article - if it actually did what it promised to do - but then she missed so many other things too, that were actually IN the study she was referring to and were of relevance to her. Looking beyond things relevant to her circumstances perhaps really is a big ask, unfortunately.

VinegarDrinker Mon 11-Mar-13 20:10:45

Any kind of cord clamping is technically an intervention.

Chunderella Mon 11-Mar-13 20:17:33

This is a good thread, but there are two glaring omissions two groups of women who unfortunately go under or unmentioned in discussions about safe birth choices.

Firstly, in the article Roberts states that 'a normal vaginal birth with minimum intervention is undoubtedly an ideal to hope for'. At least she said an ideal rather than the ideal, as I have sometimes seen from NCB advocates. But even if we leave maternal preference entirely out of it, she is still incorrect. Because this idea utterly excludes women for whom such a birth is impossible and/or actively undesirable. Often, these women are disabled, have SEN or a serious health condition: that they are marginalised in other spheres too makes it particularly unacceptable not to acknowledge their existence when discussing birth.

I'll use examples of both from my own experience, but we probably all know someone to whom this applies. For example, my sister has SEN and basically the mind of a child. She cannot tolerate even discomfort, to the extent that getting her BP done requires careful planning and breathing techniques, and she has to be knocked out for a filling. There isn't a chance in hell that she could cope with normal birth, even if we were to include epidurals in the definition. The needle alone would cause her to have an episode. It would be like a 5 year old giving birth. Thankfully she doesn't want DC, but there are women like her who have them. For such women, a normal birth is not only actively unsuitable but would be an experience beyond horror. She would be in grave distress very early in proceedings. Or, a woman I know who had liver problems and took a lot of medication, who fell accidentally pregnant at 46. She opted to continue the pregnancy, but the medication was dangerous to the foetus so she stopped taking it. It was agreed by all consultants concerned that the furthest she could go without her medication was 30 weeks. I'm not sure whether she was induced or had ELCS, but clearly one of the two was necessary in her situation. I don't suggest that such women form the majority, but they exist and any suggestion that natural birth is the ideal or even an ideal, without suitable caveats, is flawed because it excludes them. Sometimes, it is at best an irrelevant consideration and at worst an impossibility.

The second group are DV sufferers. We know that DV is common and that it is disproportionately likely to begin in pregnancy. For a woman in this position, home is not a safe place to be, whether giving birth or not. There are no doubt women who would otherwise be considered low risk for HB, for whom it is a bad idea because of the home conditions (this would also apply to women who are in unsafe and unsuitable living conditions too). Again I don't suggest such women are the majority, but those who advocate HB as a safer option for certain women on MN never seem to even spare a sentence for women whose homes are unsafe. They exist, they give birth, and it is not ok to ignore them.

Phineyj Mon 11-Mar-13 21:16:27

LaVolcan - that was exactly my experience, that the hospital did not take the independent midwife's assessment that a transfer was required seriously at all, to the point that my DH had to drive me to hospital as they could not 'find' an ambulance! I still felt the experience overall was much better for having started at home and having been listened to properly throughout (I have no criticism of the hospital staff btw, they were great too, but the NHS seems to find it nearly impossible to be joined up in any way -- they insisted on repeating every single test and check the IM did).

AmandaPayne Mon 11-Mar-13 21:36:35

Vinegar - I realise that this discussion has moved on massively, but I've been out all day. Didn't for one second mean to suggest that you were pro closing the Lewisham CLU. What I was clumsily trying to say was that, in Lewisham, the illusion of promoting a MLU is really pushing CLU's because women are too scared of a MLU that doesn't have an on-site CLU.

Episiotomy is interesting. I would think of it as adverse. My mother still has aching from hers over 30 years later. I have some degree of discomfort (for example, when I needed an internal scan in a later pregnancy, the pain on the scar tissue resulted in my bursting into tears). Now I don't know if a tear would feel like that of course. Another area where data would be interesting and helpful...

HelloBear Mon 11-Mar-13 23:01:03

vinegar you say you are not anti HB. Do you think they have a place in the UK today? Or do you think the risks are too high?

I'm currious what are the risks you would identify?

Hope these come as genuine questions not hostility! I had two hb for both my DC so now wonder if I 'gambled' with my and their lives?

never having another so not a dilemma I'll have again smile

jchocchip Mon 11-Mar-13 23:14:56

sorry I know I am off topic, but vinegar I am very interested in the timing of cord clamping. Immediate cord clamping is not evidence based. The advantages of a physiological third stage to the baby in terms of establishing respiration are well documented. As such, the cord clamp can be dangerous as it can hinder physiology. My hospital birth had a protocol for third stage that meant that I could not have the cord clamped until it stopped pulsating which took a surprisingly long time. Dd1, born at home had immediate cord clamping which I found upsetting at the time because I wasn't expecting it.

jchocchip Mon 11-Mar-13 23:37:18

Chunder I would expect women suffering from dv have capacity to choose where and how they give birth and their home situation is one that they can factor into their decision. They have capacity to choose so no one is going to interfere. Unless they post on mn when they would probably be be told to ltb.

When a woman has a medical condition, they can make an informed choice about their care. We can all decide what sort of birth we would like but all know that we can't predict what will happen and have to take advice from doctors and/or midwives to increase the chances of a healthy outcome.

In the case of someone with extra special needs there is a serious question of capacity under the MCA and someone is basically going to have to make decisions in their best interests. Recent case law is interesting on this point and I think that capacity to consent to si could well have been lacking.

Shagmundfreud Tue 12-Mar-13 06:44:09

Hellobear - I'd like to point out that according to the POB study it's not 'out of hospital' birth that categorically appears to be associated with poorer outcomes for the babies of first time mums: it's home birth. In the study first time mothers who chose free standing midwifery led unit as their setting for birth had outcomes which were no worse than women who had chosen CLU's, even when you factor in a high transfer rate. Actually I say 'no worse' but in fact I mean that the neonatal outcomes were no different. The maternal outcomes were very much better for women in FMU's.

Vinegar is resolutely ignoring this point as far as I can see.

IMO this suggests that the increased risk of homebirth for first timers might be linked to issues surrounding the practices of home birth midwives. This wouldn't surprise me at all. IMO there is a huge difference in the quality of homebirth midwifery when the midwife in question is part of a busy and experienced case loading homebirth team, or when she's just snaffled off community to do the odd homebirth in an area with a low HB rate. The study didn't look at these issues. I'd very much like to know if case loading is associated with better outcomes. My common sense tells me it would be, and there is other research suggesting that this is so.

Funnily enough, the medical community don't seem to be interested in this - they - like vinegar, have pounced on the POB findings of higher neonatal deaths for first time home birth mums and have accepted this as clear evidence that this group should opt for a hospital birth as the safest option, resolutely ignoring the evidence on FMU'S.

VinegarDrinker Tue 12-Mar-13 07:12:17

shag I am not ignoring anything. I have mentioned and acknowledged reduced risks of intervention for women having HBs several times. I just said that for me personally, when deciding about my own deliveries, that was outweighed by the risks to the baby of being at home - hence choosing an MLU (which indeed I am lucky to be able to).

jchoc Please do start another thread on cord clamping. There is definitely a big lag in the evidence for delayed cord clamping being out there and known about and it being routinely practised.

HelloBear they certainly do have a place. If a woman wants one I totally support her. My job is to provide information. I
have several friends and colleagues who have had them. Personally I wouldn't have one for my first baby, and possibly not even then due to those pesky very rare but unpredictable situations mentioned above, but that's just me. I certainly wouldn't be feeling guilty for anything in your position!

VinegarDrinker Tue 12-Mar-13 07:21:29

I'd love to know how you think you are in any way qualified to tell me what I am interested in, shag hmm Would you be so rude to my face, or indeed if I hadn't been upfront about my job?

How can you presume to say that I think first time mums should have a CLU birth - I haven't ever said anything like that, anywhere here or IRL.

It's a shame what has been an interesting thread is being constantly falsely polarised by yourself. Use of terms like "the medical community" to make generalisations about is misleading and false. Do you realise just how dull it is to have a conversation with someone determined that you think a certain thing even when you state clearly that you don't?

Shagmundfreud Tue 12-Mar-13 09:18:10

discussion

An interesting lecture on place of birth by Professor Peter Brocklehurst UCL Director of Women's Health. FYI.

Vinegar - the point I was making was about FMU's. The findings of the POB study don't suggest that ALL out of hospital birth is associated with poorer outcomes for the babies of first time mums, only that home birth is. Would you address this point? I do accept that you are not making a case for low risk women to give birth on a CLU. However, you are making a case that primips should give birth in hospital.

Perhaps you have not recognised that when I'm talking about 'out of hospital birth' I'm not simply referring to home birth, but to the other out of hospital setting - free standing midwife led units. Perhaps this is what's causing the confusion.

VinegarDrinker Tue 12-Mar-13 09:34:29

No I'm not! You are putting words in my mouth. We have a freestanding MLU where I work now, I have no issues whatsoever with them, and all our low risk women are automatically offered FMU or attached MLU by their midwives, by definition they don't see me anyway.

I just didn't choose one myself, which should be neither here nor there. (In fact where I delivered it wasn't an option!)

LaVolcan Tue 12-Mar-13 09:43:23

It's often said on threads like this and in childbirth discussions that an MLU is no better equipped than the midwives would be at a home birth, so if you are considered OK for MLU you would be equally OK for a homebirth.

The PoB's finding that the freestanding MLUs were the safest place for mother and baby for a primip is an interesting one. So if it's not equipment, what is it that gives it the edge? Staffing, or staff being more familiar and hence confident in a known environment? Ease of transfer if there is a problem with the ambulance being more familiar with the MLU? It's something which needs further research.

Shagmundfreud Tue 12-Mar-13 10:02:15

"We have a freestanding MLU where I work now, I have no issues whatsoever with them"

Vinegar, it seems your primary concern about home birth for first time mothers is the lack of immediate medical input in the case of a severe obstetric emergency and the possible impact of this on the baby.

Why do you not have the same concerns about FMU's as women in these units also need to transfer for obstetric input?

LaVolcan - I'm convinced it's down to the experience of the staff working in FMU's. This would obviously impact on all areas of labour management, including those surrounding how transfer is handled.

TBH it's very frustrating that the response of many medics to the POB's findings about primips and home birth hasn't been to question why this disparity between outcomes in out of hospital settings exists and to consider how to address it, considering the considerable advantages of having a home birth in relation to the very much reduced rates of intervention. It's not fair to say that women can simply go to a birth centre to access these benefits - FMU's are few and far between in the UK, and alongside birth centres simply don't at the moment have the capacity to deal with all the women who would be considered suitable to use them.

Shagmundfreud Tue 12-Mar-13 10:07:00

Can I urge anyone on this thread who is interested in this topic to watch the discussion I posted a link to earlier?

It really does answer many of the questions about the POB study which have cropped up here.

It also shows Alice Roberts article up in a very poor light, particularly her comments about the ACOG stance of home birth. ( 5 or 6 minutes towards the end for the speakers reference to this).

VinegarDrinker Tue 12-Mar-13 10:26:07

Are we talking about my personal concerns or my professional concerns? Professionally I think women should deliver where they want. I think they should be aware of the comparative risks to mum and baby and make their own decisions. I would always emphasise to anyone the absolute risks of adverse outcomes are extremely low.

Personally I've seen enough unexpected unpredictable emergencies in low risk women that I felt more comfortable (and therefore probably laboured more quickly) in an attached MLU with an obstetric/anaesthetic/neonatal team a crash bleep away. From a purely personal POV the stats actually become quite meaningless - I know I personally would not have wanted to be the one in XXX where being near a theatre/anaesthetist/neonatalogist would have made a difference to the outcome in a life changing way.

I do think there are interesting questions about FMUs vs HBs stats. I have mentioned and agreed with this several times so I have no idea why you think I am uninterested. I think FMUs are actually better equipped, and also have more hands on deck in an emergency. But as I'm not a MW the amount of time I spend either at HBs or FMUs is limited, therefore I don't feel qualified to comment further. Furthermore, medics have zero input into commissioning and running midwifery led maternity services, so quite why you think doctors should or could be looking at FMUs vs HBs is beyond me. I am interested of course but I have no more influence over any of it than any other MNer. Maybe mayhew will come back to add her expert opinion?

LaVolcan Tue 12-Mar-13 10:49:11

Excellent link shagmund - thanks for posting it.

TBH it's very frustrating that the response of many medics to the POB's findings about primips and home birth hasn't been to question why this disparity between outcomes in out of hospital settings exists and to consider how to address it, .............. It's not fair to say that women can simply go to a birth centre to access these benefits - FMU's are few and far between in the UK,.......

I fully agree with your statement above.

I was annoyed by the biased reporting of the PoB study by the Daily Mail and others. For me the big story was that for multips CLUs are significantly less safe for her, without offering a compensating advantage for the baby. There was hardly a peep about this in the press and yet this potentially effects a majority of childbearing women in this country.

On a personal level the PoB was a revelation to me. I had often noticed women/partners saying that they had a homebirth/MLU birth but they were lucky it all went well. I'd noticed CLU births very rarely occured without some sort of intervention, with EMCS becoming increasingly common. As they say, anecdote is not data, so this study put some flesh onto the bones of my personal observations. It wasn't a matter of luck, outcomes really were better at home or MLUs.

LaVolcan Tue 12-Mar-13 11:20:34

I know I personally would not have wanted to be the one in XXX where being near a theatre/anaesthetist/neonatalogist would have made a difference to the outcome in a life changing way.

Which just goes to show that we are all different. My choice was: do I take pot luck in the CLU and get a share of a probably newishly qualified midwife who I have never met before, who has to scrabble through my notes to find the first thing about me, and then has to keep popping in and out to the next room? Or do I go with a midwife I have got to know over six months, who has twenty years experience, whose judgement I trust?

VinegarDrinker Tue 12-Mar-13 11:41:31

It is a bit of an oversimplification to say community MWs are all very experienced and those in MLUs/CLUs are newly qualified!. I do appreciate the attraction of having a MW you know, though. However, whilst the quality of midwifery is undoubtedly very important, it won't precent those rare but devastating complications where minutes matter.

I can't see why those complaints aren't better dealing with by campaigning for proper one to one midwifery in all settings rather than just campaigning for HB. It seems a very odd way of going about things.

VinegarDrinker Tue 12-Mar-13 11:44:11

Btw as clarified above, these are my personal reasons for choosing an attached MLU, completely separate to what I think anyone else should do.

LaVolcan Tue 12-Mar-13 12:03:54

I wasn't saying that all midwives in the CLU were newly qualified - just basing it on what was likely to be the experience for me. Others having a homebirth wouldn't have a caseloading midwife so for them the choices might be different.

Many people are campaigning for one to one midwifery in whatever setting. I think there are actually precious few specifically campaigning for homebirth.

lrichmondgabber Tue 12-Mar-13 12:05:50

Sorry thought it was politics

I haven't had time yet to read through the thread, but have just read the article.

Knowledge is always power - women should always be aware of their local POB, transfer rates, intervention rates etc.

It's often said on threads like this and in childbirth discussions that an MLU is no better equipped than the midwives would be at a home birth, so if you are considered OK for MLU you would be equally OK for a homebirth.
I would've been ok for a homebirth, but the MLU was already 40 minutes (that's at top speed on a windy rural road that is often closed during the winter due to snow) away, so I never would've risked a homebirth. The hospital itself is 2 hours away from home, so we felt the MLU was a happy medium. Having had all the information from the MW's, I was able to make the best decision for us both, which was the MLU.

I would prefer a campaign for proper one to one MW care using 'birth centers', rather than a campaign for HB.

LaVolcan Tue 12-Mar-13 12:25:18

I think we took the wrong direction when we started concentrating on the place of birth rather than the quality of care, and hence the present mess where one midwife is covering two or three women in strong labour. Professor Peter Brocklehurst, in the discussion above, was an accidental home birth when his mother was sent home because she was deemed not to be in labour. He didn't say whether she was able to get hold of a midwife or not, but who was attending her later stages of labour in the car home? At a guess, no-one.

I would prefer a campaign centred round one to one care from a known and appropriate attendant. It's just as bad for someone who needs consultant care not to get it.

KatieMiddleton Tue 12-Mar-13 12:27:54

I would prefer a campaign for proper one to one MW care using 'birth centers', rather than a campaign for HB.

Well obviously, because that is what you would prefer! A campaign for proper one-to-one care for all would be better and I could support that. I couldn't support something that takes away a choice (that for many women is a good option and saves the NHS money) any more than I could support something that takes away MLU or CLU care.

Shagmundfreud Tue 12-Mar-13 12:36:53

"I would prefer a campaign for proper one to one MW care using 'birth centers', rather than a campaign for HB."

Do you not feel that home birth should be an option for women?

Because if you do then there DOES need to be a campaign to make sure the homebirth service is a) safe b) available in all areas and b) that women aren't subject to misinformation about it.

Shagmundfreud Tue 12-Mar-13 12:41:43

I think we need a campaign for one to one care for all women in labour.

And a campaign to make sure that women have a free choice as to where they have their baby.

Some women need an epidural to have a birth they can cope with emotionally and physically. Some women need not to go to hospital. If you feel it's reasonable to raise your voice against misinformation regarding epidurals, and covert restriction of their use because of funding issues, then it's also reasonable to raise your voice in support of women having the right to access a good quality home birth service, the appropriately presented information to make an informed choice.

HB should always be an option, alongside MLU and hospitals....so maybe I should've written 'I would like a campaign for one-to-one care' fullstop. I agree that maybe stopping concentrating so much on the place of birth, and thinking more about the actual human support during pregnancy and labour is the way forward.

Are there figures for how many women actually prefer or want to have a MLU/Hospital birth? I personally don't ever want a homebirth (unless I'm lucky enough to live next-door to the MLU!).

VinegarDrinker Tue 12-Mar-13 12:44:28

" I think we took the wrong direction when we started concentrating on the place of birth rather than the quality of care"

Yes absolutely. I also feel for those women who have to deliver in CLUs for valid medical reasons - it often seems they get forgotten in the sea of lobbying. They often end up with a raw deal both in terms of midwifery staffing, and in terms of making their environment more pleasant to deliver and labour in (private postnatal rooms, flat screen TV etc) .

VinegarDrinker Tue 12-Mar-13 12:47:07

And actually I think the polarisation of birth and emphasis on moving low risk women out of hospitals is deskilling midwives and undermining their confidence in managing normal labours.

KatieMiddleton Tue 12-Mar-13 12:53:23

I don't think there are figures because that is considered to be the norm. What is still not thought of as the norm is homebirth so there is more data about that abd you could argue that everyone else wants care in a hospital/MLU by default.

I wonder if there's a difference in unplanned interventions (ie those agreed to and planned prior to labour) for those who receive one-to-one care and those who do not?

Shagmundfreud Tue 12-Mar-13 12:54:22

I disagree.

I think we took a wrong turn when we started ignoring the hormonal physiology of mammalian birth when deciding how we were going to organise maternity care for women.

IMO it doesn't matter how nice hospitals or birth centres are - going to one still involves moving a woman in labour to an environment she's pretty much unfamiliar with, and putting her care in the hands of people she's unlikely to see again.

I know some people think these things are irrelevant or unimportant, but IMO they're not.

"on moving low risk women out of hospitals is deskilling midwives and undermining their confidence in managing normal labours."

The biggest barrier to encouraging midwives to learn how to support normal physiological birth is their working in a highly risk averse environment where practice is primarily driven by protocol and a fear of litigation, and where epidural is seen as the only humane and sensible response to a challenging labour.

Shagmundfreud Tue 12-Mar-13 12:56:19

Part of what causes a polarisation of opinion are biased, poorly written and inadequately researched articles like the one you praise as being 'balanced' in your OP.

hmm

Shagmundfreud Tue 12-Mar-13 12:59:50

"I wonder if there's a difference in unplanned interventions (ie those agreed to and planned prior to labour) for those who receive one-to-one care and those who do not?"

From the Cochrane Pregnancy and Birth reviews:

"The review of studies included 23 trials (22 providing data), from 16 countries, involving more than 15,000 women in a wide range of settings and circumstances. The continuous support was provided either by hospital staff (such as nurses or midwives), women who were not hospital employees and had no personal relationship to the labouring woman (such as doulas or women who were provided with a modest amount of guidance), or by companions of the woman's choice from her social network (such as her husband, partner, mother, or friend). Women who received continuous labour support were more likely to give birth 'spontaneously', i.e. give birth with neither caesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. Their babies were less likely to have low five-minute Apgar scores. No adverse effects were identified. We conclude that all women should have continuous support during labour. Continuous support from a person who is present solely to provide support, is not a member of the woman's social network, is experienced in providing labour support, and has at least a modest amount of training, appears to be most beneficial.

KatieMiddleton Tue 12-Mar-13 12:59:52

I think what is deskilling midwives is not having the opportunity to use their skills. Any midwife who is mainly doing antenatal and postnatal checks and the odd homebirth every month or so is going to be more rusty than one delivering 3 babies a day.

So I would take issue with the assertion the problem is moving low risk women out of hospitals; imo the issue is one of protocol and organisational fragmentation making it impossible to deliver an optimum service.

KatieMiddleton Tue 12-Mar-13 13:03:05

That last bit you've bolded is interesting Shag.

KatieMiddleton Tue 12-Mar-13 13:03:29

Thank you

LaVolcan Tue 12-Mar-13 13:04:47

I believe places which have well organised homebirth services find about 10% want one. I don't know how the split is between primips and multips - I suspect it's higher for multips. I think when the service is organised on a "we'll start at home and see how things go" the numbers are higher.

Flisspaps Tue 12-Mar-13 13:15:36

I think what is deskilling midwives is not having the opportunity to use their skills. Any midwife who is mainly doing antenatal and postnatal checks and the odd homebirth every month or so is going to be more rusty than one delivering 3 babies a day.

Indeed. In my area (Shropshire) MWs work on each area in rotation - 6 months or so on the CLU/delivery suite at the hospital, 6 months or so in one of the MLUs, 6 months or so on Community.

RedToothBrush Tue 12-Mar-13 13:22:15

One to one care wouldn't be appropriate for everyone either though.

One to one care would undoubtedly help a lot of women and solve a lot of problems. It is simply unacceptable that there are midwife shortages to the extent talked about upthread and that some maternity units are closing their doors as regularly as they are. Barnet effectively closing once every three days is nothing short of utterly scandalous.

However the problem I see in campaigning for it, is it then becomes THE solution politically rather than also supporting good quality research. Everything becomes focussed on it being the way to solve all problems rather than still looking at women as individuals in need of individual care. Certainly I fear that, it would still pressure women in certain circumstances - ie to have a VBAC or to not have pain relief - if ideological beliefs are allowed to remain the dominate force over evidence and women's individual feelings.

Please do not forget that just because you have one to one care it will mean the person caring for you, is going to listen to you, respect your views or not try to impose their own beliefs and agenda on you.

I would support one to one care campaign, but ONLY if this is recognised and that better scientific understanding both of issue and how women feel and respond in different ways is ALSO made a priority.

If evidence based medicine and an acceptance of individual needs - that sometimes might not fit into the bracket of 'preferred practice' - are ignored, you will STILL have massive problems for women.

LeBFG Tue 12-Mar-13 13:26:52

I think we took a wrong turn when we started ignoring the hormonal physiology of mammalian birth when deciding how we were going to organise maternity care for women.

The biggest barrier to encouraging midwives to learn how to support normal physiological birth is their working in a highly risk averse environment where practice is primarily driven by protocol and a fear of litigation, and where epidural is seen as the only humane and sensible response to a challenging labour.

THis ^ is spot on.

It occurred to me the other week that natural drug-free birthing conjures up images and words like 'physiological'....whereas we should be thinking of these sorts of births as the norm. Bit like talking about bf as the norm, default option. I would like to see a sea-change in attitudes to childbirth and pain etc. How often do we read, see, talk to people in abject fear of birth? (this included me 2 months ago wink) - it's almost a cultural acceptance. Whilst we all go around brandishing this fear, the dependancy of low-risk women on CLUs and hospitals will continue.

LaVolcan Tue 12-Mar-13 13:32:34

I would like to see more emphasis placed on proper preventative work e.g. more research on what is the optimum diet, what you can do to get the baby into the optimum position for a couple of starters. And much more emphasis on nurturing the pregnant woman instead of a catalogue of you mustn't do this, or that.

HelloBear Tue 12-Mar-13 13:32:35

Heck this thread moves quickly!

Anyway I agree vinegar with:

" I think we took the wrong direction when we started concentrating on the place of birth rather than the quality of care"

Yes absolutely. I also feel for those women who have to deliver in CLUs for valid medical reasons - it often seems they get forgotten in the sea of lobbying. They often end up with a raw deal both in terms of midwifery staffing, and in terms of making their environment more pleasant to deliver and labour in (private postnatal rooms, flat screen TV etc) ."

Interestingly in between giving birth to my 1st dc and 2dc a MLU opened up at the hospital. The MWs I saw in the community said that as a result their experience of doing Hbs had DECEEASED as women were going for MLU rather than hb so the rate of hb had dropped. This worries me as I think the key to hb is experienced Mw. Thou interestingly with my 2nd birth I had 6mws in total (long labour) and ALL also did shifts at the clu and MLU.

Another point is I had decided to not have a hb with my second dc but in the weeks running up to my EDD I heard some really scarry stories about poor staffing and the resulting care at the hospital. This swayed my decision for another hb. So vinegar I also wanted the full medical team on hand at my birth like you did. But I also wanted the BASICS being done correctly, for ex. Having babies heart rate checked, being able to labour in private. These are NOT being done in my local hospital. What we need to do is replicate the benefits of hb in a setting with the medical emergency staff on hand if needs be.

But as I said up thread I suspect this would cost £££££ and there aint any in the pot sad

PS sorry for typos, receiving from norovirus!

HelloBear Tue 12-Mar-13 13:34:07

Recovering

VinegarDrinker Tue 12-Mar-13 13:38:04

Well this has been a useful and thought provoking thread but I'm out. Just not interested in having discussions that involve immature eye rolling at me, sorry, especially following on from ascribing random opinions to me and making ridiculous generalisations about me and my colleagues. I think it's rude and unnecessary.

I shall stick to discussing inane crap and fruit shoots I think.

HelloBear Tue 12-Mar-13 13:38:37

Sorry vinegar I realise I'm repeating my point about improving care at all settings and that you agree with this!

HelloBear Tue 12-Mar-13 13:40:21

I hope that was not directed at me vinegar as I really only have respect for you and your profession, honest!!!!

HelloBear Tue 12-Mar-13 13:41:12

I'm personally all for the odd fruitshoot smile

VinegarDrinker Tue 12-Mar-13 13:45:24

No, it was at shag. Having re read the post I think it was a sarcastic raised eyebrow rather than an eyeroll but my point still stands. Imvho we should be able to have discussions on a slightly more mature footing.

My DS won't touch fruitshoots, more's the pity!

KatieMiddleton Tue 12-Mar-13 13:47:17

Eh? This is hardly a bunfight. No need for anyone to flounce off.

Obviously if you have more important or exciting things to do fair enough but getting the humpf about a bit of disagreement with one poster and putting down your bat and ball is a bit wimpy.

<deliberately provocative in a tongue in cheek way>

I was just getting interested!

RedToothBrush Tue 12-Mar-13 13:50:37

LeBFG, I think where fear comes from is really really misunderstood and not really known.

I think this is something that needs research rather than to make assumptions about.

The most common one I see, is that it comes from TV.
The next is from women sharing birth horror stories with each other.
Both annoy me, as I can not relate to this.

I first started saying I didn't want children when I was about 10 or 11. There was no reason for it. None at all. No one around me told me horror stories or spoke in a way I consider to be negative. I didn't watch stuff on tv that left me with this fear. It just sort of 'happened'.

And actually when they have looked at this in studies for primary tokophobia, the very basis picture they seem to have is that it often comes from childhood; usually at a similar age. They think it might come from a trigger - maybe the way a mother talks about birth or seeing something but they don't know and there doesn't seem to always be something there.

In my experience I genuinely can't pin point something 'bad'. The only thing is the fact my Mum had me by EMCS, but she's never really talked about it much other than to say I was in distress, late and needed to come out. Nothing scary or particularly emotive; she's always been pretty neutral in what she said.

I think my point is, that I do believe that, perhaps a good deal of fear is quite deep and goes back far further than we might initially give credit for.

Unless we understand where its coming from, how can you start to change it?

edam Tue 12-Mar-13 13:51:13

I had crap, neglectful care in labour. In a major London teaching hospital. I'm sure the midwife was perfectly competent, but there was only one of her, with seven women in active labour, so she just wasn't there most of the time. Hence I sustained a birth injury. It's sheer good luck that it was a normal delivery; had there been any problems, no-one would have noticed.

Fear of litigation may affect some consultants but sadly not hospital managers who can't be bothered to employ enough midwives. Compensation doesn't come out of their budgets.

VinegarDrinker Tue 12-Mar-13 13:52:29

Don't spoil my fun, I'm enjoying my first ever obviously not very effective flounce!

Tbh though I think I have exhausted my opinions on the subject (the ones that I can type one handed on a phone coherently anyway). Everyone else keep going if you're having fun!

PS I can bunfight with the best of 'em, I'm just bowing out politely before I get riled and regret it

LaVolcan Tue 12-Mar-13 13:59:32

No don't flounce off vinegar. Although we have different perspectives from each other and would personally weigh the risks differently, we have had quite a lot of agreement about issues.

I see this as being a vital debate about the provision and quality of maternity services and as edam implies we can't leave it to the hands of hospital managers.

KatieMiddleton Tue 12-Mar-13 14:21:46

Yes I was thinking about this while changing a nappy just now clearly I do not have anything more important or exciting to do! and one-to-one care is a starting point. You can have the best, most competent advocate with you (either birth companion of any ilk or family member) but if there's no-one to advocate to then that's probably worse.

I chose to have my babies at home mainly because of the one-to-one care. I'm also very close to two maternity units. I have come into contact as a patient with 3 ob registrars, 5 GPs, 5 sonographers and about 30 midwives. The only one who was negligent in any way was a community midwife. She is only practising in the community. Part of the issue with her is that she is rarely observed and so goes unchallenged. She is unreasonable, unhelpful and lazy (she routinely goes missing apparently hmm) and yet complaining about her does nothing. Those issues of poor practitioners need fixing too.

Shagmundfreud Tue 12-Mar-13 14:43:58

Look Vinegar, I'll stop eye rolling and being snarky if you'll admit, on consideration, that the article you linked to in your OP was far from balanced, and was in fact poorly written and researched.

No need to flounce.

You need to toughen up. I've been on mumsnet for a long time, and and am a raddled, battle hardened old bint.

But I'm sorry I called you vinegar tits. grin

Interestingly in between giving birth to my 1st dc and 2dc a MLU opened up at the hospital. The MWs I saw in the community said that as a result their experience of doing Hbs had DECEEASED as women were going for MLU rather than hb so the rate of hb had dropped. This worries me as I think the key to hb is experienced Mw. Thou interestingly with my 2nd birth I had 6mws in total (long labour) and ALL also did shifts at the clu and MLU.

I find that very interesting - So some women are opting for a HB because they really don't want a hospital birth, and there is no 'middle ground' if you like. The fact that it's a full-on hospital obviously doesn't appeal to many women.

VinegarDrinker Tue 12-Mar-13 15:24:25

shag apology accepted. Seriously, I don't think you do your cause any favours by being so combatative though. The idea of the obstetricians as patriarchal anti-women baddies is so outdated it's laughable. For starters, the overwhelming majority of doctors training in O&G now are female, which males a huge difference. Honestly we are all in this together to provide the best outcomes for women and their babies

I don't think the article is amazing. I think it's more balanced than many I have read. At least it actually mentions evidence! Most are just ill educated "my friend X had Y and my sister A had B" or unilaterally pro one agenda. But yes, I am embarrassed not to have mentioned the glaring intention to treat issue, which I definitely noticed (and in fact mentioned elsewhere online where I was discussing it....).

I enjoy a good online barney, honest. I may be a MN newbie but I'm a member of several fora, none of which are in the least fluffy. I just run out of patience after a whole with the dull stereotypes, especially when 80% of what we are all saying is in agreement.

Shagmundfreud Tue 12-Mar-13 15:43:14

Vinegar - honestly I don't see obs as 'anti woman' or as 'baddies'. I'm in awe of the work you do. You are very very lucky to be able to go to bed at night knowing that your work is probably the single biggest contributor to some women's life long happiness and well being. smile

though just to stop it getting a bit too peace and love round here I have to confess that I have been patronised and bullied by a couple of utter cunts in my personal dealings with obstetricians (yes, 'Mr Cesarean' with your tiny hands and your oily bedside manner, I'm talking about you..).

LaVolcan Tue 12-Mar-13 16:17:00

I thought her article started off OK but then degenerated when she started on about forceps and epidurals - but I have already said enough about that.

At the end though I found myself thinking that she was a bit crazy - she would take a known biased source i.e. the ACOG who don't have the faintest idea about home birth in the UK and let that inform her decision that in preference to good quality UK research? Since she wasn't contemplating homebirth why do their opinions matter?

It's up to her, but she could have been asking herself so many better questions about the actual care she will receive. Questions like: 'how often does my maternity unit close to new admissions?' What will I do if that happens? Will I get one to one care or will I be sharing with 6 other women? If I want an epidural, will I get it? What are the postnatal standards like, or should I go for immediate discharge?

In the process instead of setting up a straw man about home births and a bit of a dig about the NCT she could have done women a real favour in highlighting the standard of maternity care in this country.

Shagmundfreud Tue 12-Mar-13 16:43:49

She also has a nasty dog at the NCT for 'prioritising the birth experience over the health of the baby' while utterly ignoring the fact that the NCT's website is the only one aimed at parents which provides links to the evidence and a full discussion of the methodology of the POB study.

KatieMiddleton Tue 12-Mar-13 17:06:40

Yes that bit about NCT pissed me off. It doesn't even make sense. Anything that compromises the health of the baby is going to negatively impact the birth experience. Surely that's obvious?!

I can honestly say I have never met anyone who does not put the health of her baby as a key priority. I have read online people who use infant and maternal mortality rates as the only measure for successful outcomes. Health of the baby and maternal wellbeing, including birth experience, are not mutually exclusive. They are intrinsically linked and when we start suggesting they are separate that's when we allow women to be subjected to poor treatment.

Peachy Tue 12-Mar-13 17:14:19

Experience of MW for home births varies enormously; my CM had worked in a local PCT where the stats for Hbs are some of the highest in the UK, so she was very positive. OTOH I had to fight for mine so of course availability of Hb was a key factor for me to campaign on afterwards; unless of course the CMU (much further away anyhow) could look after a couple of autistic children whilst we waited for my husband to arrive from work. Now there was the risk of needing emergency transfer (and luckily the baby arrived when Dh had taken a day off) but for a 4th time mum that was a relatively low risk compared to relying on someone else- there was a paramedic neighbour who could help if needed but who knows where her shifts would have fallen? I just didn't want to be alone,, mainly due to a first experience that was pretty rotten.

So I will always back a wide diversity of facilities- ds1 wouldn''t be here without a CLU. DS2 was born in a MLU that was amazing, ds3 was due to be born in a MLU (a different one) but they changed their minds as I was 0.05 below my anaemia cut off point. DS4 was a HB. Each choice was made at the time, with the information and options available to me, in different sets of circumstances. And for a woman with a risk of precipative labour like me, who lives some distance from the CLU and further from the MLU a HB surely is a very valid option? The attending MW lived in my village. I had raised an induction as an option in hospital, but was refused as social- yet another women was given one because her husband was going away, my MW was bemused and angry. There are no protocols to deal with a family like mine though as we are pretty rare. I suggest families with additional needs being forced (or choosing in our case but same outcome) to move away from support networks will be a key factor with the imminent changes to social support howeve.


Apols for strange typing, annoying new keyboard with everything in the wrong place!

hackmum Tue 12-Mar-13 17:48:40

Excellent posts from Shagmund. I just wanted to add if it hasn't been said already (haven't read every post) that it shouldn't be just about mortality rates of babies and mothers. That quote from the ACOG is so snooty and completely misses the point. I despite the attitude that says "Well, your baby's healthy, you're still alive - stop making a fuss about the fact that you had umpteen interventions you didn't want and are now suffering from postnatal depression!" It's as if wanting a birth where you feel safe and looked-after rather than one where you're treated like a piece of meat is a completely unreasonable and prissy expectation.

I've read the article by Alice now and kind of think it's OK as far as it goes, but it's a bit simplistic. At least she acknowledges at the beginning that what you will hear as a potential new mother will depend on who you listen to. The same applies with what she has to say though, no-one is without some bias based on their experiences, both personal, and through the people they've listened to.

Chunderella Tue 12-Mar-13 18:23:13

Jchocchip I don't disagree with anything you said in your post yesterday at 23.37, but none of it addresses the points I made in my post. Perhaps women suffering DV are able to choose the place they give birth, though I wouldn't assume that's always the case. But that doesn't mean that it isn't utterly flawed to fail to mention in a discussion about HB that home is not a safe place for many pregnant women. And the suggestion that NCB is an or the ideal is utterly ableist because it entirely fails to consider all the disabled and ill women for whom it isn't.

LaVolcan Tue 12-Mar-13 18:37:59

But that doesn't mean that it isn't utterly flawed to fail to mention in a discussion about HB that home is not a safe place for many pregnant women.

Chunderella, I wouldn't disagree, but at the moment the default option is hospital birth. Out of curiosity - has anyone who has recently been pregnant been told that they must have a home birth, and that hospital is not an option, as they probably would have been told in 1953?

Disabled women need to have choices too, which by the sound of it, they are not getting.

Bear in mind that the discussion started with Alice Roberts and as far as I know none of the above apply to her.

Chunderella Tue 12-Mar-13 18:56:43

But my point is that Roberts made an ableist comment, one that excluded women for whom an NCB would be a terrible idea or impossible. She just didn't acknowledge their existence. Probably she did this because none of the factors I mention apply to her- doesn't make it ok!

That's another important aspect of her arguments being a bit simplistic Chunderella.
Also a bit patronising - don't many women seek to weigh up the evidence in the light of their own circumstances to inform their decision making about birth choices ?

Shagmundfreud Tue 12-Mar-13 19:17:52

I've had another look at that article and it seems to me that what she's saying in relation to her own experience is this: I'm a low risk second time mum. I could give birth at home but the most important thing to consider in my view is the safety of the baby. Therefore I'll be giving birth in hospital.

I'll be reassured by knowing that there are obstetricians and neonatologists close by. For other women, home might seem like an enticing option. But surely the most important thing to consider when making this choice has to be the safety of both mother and baby.

She then has a good old laugh at people saying that one of the advantages of hb is that it's associated with lower rates of intervention - something she doesn't understand because, hey ho, you can't do c-sections on the kitchen table!

She refers to the POB study, which she describes as 'good, robust information'. Information which disproves her view that as a low risk second time mum you need to give birth in hospital to be safe. But she's not interested in the very striking findings of the study on rates of intervention in different settings, which the author describes as 'highly statistically significant'. No, she's not interested in discussing this. She's interested in pointing the finger at the NCT for mentioning the possible additional risks to the babies of first time mums only third in an article about home birth.

Actually the more I look at the article the worse it seems.

Shagmundfreud Tue 12-Mar-13 19:27:08

"But that doesn't mean that it isn't utterly flawed to fail to mention in a discussion about HB that home is not a safe place for many pregnant women"

I think all the discussions of home birth make the point that there is only evidence for it being a safe option for healthy mothers with uncomplicated pregnancies.

"And the suggestion that NCB is an or the ideal is utterly ableist because it entirely fails to consider all the disabled and ill women for whom it isn't."

You'd kind of hope that women and health professionals would use their common sense on this one, but you can never be sure. Personally I read the 'NCB is an ideal' I interpreted that as meaning 'NCB is ideal when it can be safely achieved'. Which of course it can't for everyone, and I'd assume all adults are aware of this fact.

RedToothBrush Tue 12-Mar-13 19:49:26

To be fair to Alice Roberts, I probably wouldn't think of things like that, Chunderella - I think there is a reason for this - I think she's merely reflecting what is going on when it comes to promoting birth more generally.

There is currently a real focus and promotion on low risk women at the moment - for political and financial reasons. The idea of promoting choice looks, on paper, as a good move. It might be much more of an illusion than the reality out there, but promoting it is politically advantageous.

Its being pushed hugely by a number of groups. Its not just the NCT - its the RCM AND somewhat more surprisingly the RCOG. They put out a joint paper aimed at CCG commissioning some months ago about 'normalising' birth.

I happen to dislike terms like this; it puts anyone outside this box into the 'abnormal box' and whilst that might be being precious about terminology to some, I think numerous discussions on MN about terminology repeatedly show up how important this is to women and how it can affect their mindset. There must be a way to achieve similar purposes without using the same damaging phrases.

The thing is, whilst these groups are hugely publicising the options of low risk women, there is a tiny amount of discussion on any high risk women and their choices and what their actual risks are, even for groups that are significant in size. Its mentioned in passing, but then bypassed in discussion unless you end up finding yourself in one of these groups and facing these kind of discussions with your midwife or consultant. It means women don't know if there ARE other ways to do things other than what they are being told by the person treating them. And given that low risk women are being told things by professionals that reflect the professionals personal opinion rather than being balance and unbiased, it puts higher risk women in a very weak position indeed.

I think its up to these groups to be leading the way opening this area up for discussion. Being honest if journalists can't do a good job discussing the issue over what information is out there for low risk women, and don't hold high hopes for what they would add to the presently none existant debate. It does needs to be discussed, and I would like to see a journalist tackle the issue at some point in the future, but the driving force behind this needs to be someone with first hand experience or knowledge rather than repeating the cliches as its an even more sensitive area than perhaps low risk women are.

So in the context of what she was talking about - her own approaching birth as a low risk woman - then I think Alice Roberts can be let off it.

LaVolcan Tue 12-Mar-13 19:52:43

I think all the discussions of home birth make the point that there is only evidence for it being a safe option for healthy mothers with uncomplicated pregnancies.

I think we have already touched on the difficulty of being able to do research on higher risk cases, simply because there are relatively few going for home births and MLUs are usually closed to them. Maybe a comparison of outcomes for large teaching hospitals and more run of the mill CLUs would give some useful results? I don't know.

I think that Majorie Tew's research back in the 70s did show that for higher risk women things were not necessarily safer in hospital. I can't lay my hands on the research right now, and besides which, so much has changed over the last 50 years it's debatable to what extent the information would be useful.

Shagmundfreud Tue 12-Mar-13 20:03:42

Redtoothbrush - would 'physiological birth, be more acceptable and less loaded for you than 'normal birth?

In relation to bodily functions I do think the word 'normal' is useful and not discriminatory.

Re: 'high risk' - I had a high risk pregnancy (gestational diabetes and massive baby) but chose a home birth. I also chose not to be induced. I know only a small handful of women who have made choices like mine and all of them have found the experience very difficult.

LaVolcan Tue 12-Mar-13 20:18:48

Do you mean making the arrangements or the birth itself, shagmund?

RedToothBrush Tue 12-Mar-13 20:32:21

Yes I think its a less loaded word.

No one wants to think they are 'abnormal' even if that happens to be a convenant description.

The fact is its something beyond the control of many if we are being completely accurate their bodily functions ARE behaving in a normal way in situations where intervention is needed.

It is normal to want pain to stop. It might be normal for labour to stall under certain conditions.

Death is a normal outcome of birth in humans afterall.

edam Tue 12-Mar-13 20:33:04

hospital is not necessarily a safe place for a labouring woman either. I posted about my experience earlier but there have been a succession of truly appalling cases at Queen's Hospital Romford, Morecambe Bay and probably other hospitals as well - let alone the more routine ones that never make it into a news story but cause considerable harm and distress to new mothers and babies.

We need a mature discussion that acknowledges that there is no completely 'safe' place, that you need to weigh up the likely risks to mother and baby and make the best judgement you can in an individual case with the individual's medical history, wants and needs. And that hospitals and health providers can do a hell of a lot more to make giving birth safe wherever you do it.

Chunderella Tue 12-Mar-13 20:42:48

Shagmund you blur the two issues I raised. I have a problem with the fact that DV and unsafe home environments generally are hardly mentioned in discussion of whether HB is safe or not. And they weren't in this thread, until I did it. The great big fuckoff elephant in the room is that the DV risk increases during pregnancy. Your statement that nobody is suggesting HB as a safe option for high risk women does nothing to address that. Not all women who are low risk second timers would be safe giving birth at home, because some of them aren't safe at home full stop. That needs to be acknowledged. As for practitioners using their common sense, not always, and I wasn't just talking about professionals. There are posters on MN (you've done it, but I'm aware you have a child who has SEN so I assumed the ableism was unintentional and let it go) who make blanket suggestions that an uncomplicated vaginal delivery is an or the ideal, or that all women want care that will give them the best chance of such a delivery. Those attitudes can be quite pervasive, and do nothing to help women with disabilities, SEN and chronic illnesses. just another way in which they are overlooked and othered.

Redtoothbrush if Alice Roberts had been talking only about herself, she ought to have said that an NCB was her ideal or the ideal for women in her position. the latter would still have been somewhat problematic as it would discount maternal preference, but at least she wouldn't have ignored all the women for whom NCB is not an ideal or anything close to it. So I'm afraid I can't be as charitable as you're being here.

Shagmundfreud Tue 12-Mar-13 21:05:45

"I have a problem with the fact that DV and unsafe home environments generally are hardly mentioned in discussion of whether HB is safe or not. And they weren't in this thread, until I did it. The great big fuckoff elephant in the room is that the DV risk increases during pregnancy."

How is having a hospital birth safer in cases of DV if a mother may well be spending a good part of her labour alone with her dp in a room on the labour ward, and is then discharged to go home within 3 - 24 hours? Particularly if the mother ends up having surgery, which is more likely if she opts for a hospital birth, and which leaves her much more vulnerable and reliant on a possibly abusive partner for weeks after the birth.

"who make blanket suggestions that an uncomplicated vaginal delivery is an or the ideal"

But it is the optimal outcome in health terms for all women who can achieve it safely (and I use 'safe' in the widest possible sense to include emotional safety), for disabled women as well as the able bodied. Obviously it's not the best option for all women, able bodied and otherwise because it simply isn't viable for everyone.

Chunderella Tue 12-Mar-13 21:17:55

I didn't say a hospital birth would automatically be safer for a DV victim, I'm not big on blanket statements that any setting is automatically optimum for any group. Although there's obviously the possibility of excluding the partner, whereas there isn't really at home. Unless you call the police maybe- not ideal. The point is that it's a factor to be taken into consideration, and that it needs to be included in any discussion about the safest birth options. When it isn't even considered, as it hadn't been on this thread, that isn't happening. That is a problem.

'But it is the optimal outcome in health terms for all women who can achieve it safely (and I use 'safe' in the widest possible sense to include emotional safety), for disabled women as well as the able bodied. Obviously it's not the best option for all women, able bodied and otherwise because it simply isn't viable for everyone. '- That is not what Alice Roberts said, though. If she, you, and every NCB advocate said exactly that, always with all the caveats you included, there'd be no problem.

Shagmundfreud Tue 12-Mar-13 21:47:13

Oh lord Chunderella - all midwives are supposed to consider DV and all other possible impediments (poor housing, aggressive animals, ease of access etc...,,) when they discuss birth options with mums who have shown an interest. I don't think it's reasonable to expect this to be detailed each and every time home birth is mentioned in the media.

Shagmundfreud Tue 12-Mar-13 21:48:34

Re: Alice Roberts - She probably didn't say it because she's trying not to state the bleeding obvious.

Chunderella Tue 12-Mar-13 22:11:38

There was ample room for it to have been mentioned in the six pages of this thread that existed before I mentioned it though, Shagmund. Your responses are continually failing to address my point. The fact that MWs are supposed to assess it and it's in the green book doesn't mean that people who advocate HB as safe for low risk second timers, like you, aren't ignoring women whose homes are unsafe when you say that. And DV isn't the only reason a woman's home might be unsafe. I have no problem with the fact that Alice Roberts didn't mention DV in the article, but rather with her blanket assertion that NCB is an ideal. Alice= bad because she said NCB is an ideal which ignores the women for whom it isn't. HB advocacy that doesn't consider the safety of the home= bad because it ignores women whose homes are unsafe. Two different groups of women being made invisible, though probably some people fall into both categories.

Now I cannot believe that you don't understand that I'm making two separate points here, therefore the consistent blurring must be deliberate. Easier than thinking hard about how to address privilege in HB and NCB advocacy, I suppose.

jchocchip Tue 12-Mar-13 22:17:04

Chunderella. Most people do not advocate one thing or anothe but trying to support people to make their own decisions.

Shagmundfreud Wed 13-Mar-13 07:21:35

Chunderella - if there is a discussion of epidural in the media and someone is advocating for the wider availability of it, would you expect them to mention all the clinical conditions that render epidural unsuitable as an analgesic? No? Then why insist on the same for home birth?

There is no one specific 'group' of low risk mothers for whom home birth is categorically unsuitable or inaccessible and each woman needs to be assessed on a case by case basis. There are places for a discussion about widening access to home birth - that place is probably NOT Alice Roberts article.

LeBFG Wed 13-Mar-13 09:07:40

Defining a process by the exceptions seems a bit pointless to me. For the vast majority of women, birthing is uncomplicated. It is not normal to lose the baby - if it was our species would have gone extinct long before now. Death might be a natural consequence of poor fetal positioning, or poor maternal health etc but it is in no way 'normal'.

Phobias of birth are by definition irrational fears. What I dislike is what I now see as a 'consitutional' fear of labouring and birthing. Even my electrician has an opinion on whether I should have had an epidural shock. Wrt pain, I was genuinely surprised that the pain I had in cb was endurable. Painful, yes, but not overwhelmingly so. We are led to believe that all labouring pain is too painful, that the pain is bad (i.e. non-productive) and should be stopped. THAT is now the norm for births in Western Europe and I feel it is this 'normal' that needs to be questioned and challenged.

This is why I don't like the term 'physiological' birth. It may be less loaded from one perspective but from another it is just as loaded - labelling women who have straightforward births as different - equating the word 'physiological' with whale music and the like. We shouldn't be ashamed to point to the norm and label it as such. For me this should be just the same as with bf.

Shagmundfreud Wed 13-Mar-13 09:13:37

It's not labelling women, it is a label used to indicate a function of the body. There are no moral or cultural values attached to it if we are using it in a medical sense.

Chunderella Wed 13-Mar-13 09:38:29

Sigh. Yet again Shagmund, I don't have a problem with Alice Roberts not mentioning DV in her article. I have a problem with people who were talking about HB as a safer option ON MUMSNET not giving it even a sentence. I don't think Alice Roberts ought to have addressed it in her article, I think you ought to have done it in one of your posts on this thread. My problem with Alice Roberts is her ableist comment, not her not addressing a topic which was outside the scope of her article. It isn't outside the scope of a discussion about the safety of HB, though.

Chunderella Wed 13-Mar-13 09:41:37

And as regards your first paragraph, no I don't expect someone to list all the conditions that render epidural unsuitable. I would, however, expect them not to say that it is an ideal. Their ideal, or an ideal for some women, fine- but not to make a blanket statement. If that's what they'd done, it would be the same as what Alice did and would be equally objectionable.

LeBFG Wed 13-Mar-13 09:51:27

If we pee without help, this is known as peeing - it isn't called anything else. If we need help to pee because the normal process does not work then a catheter is placed - one might call it assisted urination. Giving a process a name neccessarily labels it. With labels come prejudices/associations - this is inevitable. If the majority of births happen spontaneously and without medical intervention we are being a bit precious giving it a special name. We don't talk about natural peeing, unassisted peeing or, god forbid, physiological peeing.

LaVolcan Wed 13-Mar-13 10:14:30

We don't talk about natural peeing, unassisted peeing or, god forbid, physiological peeing.

No, but if it got to the stage where only 41.8% didn't pee without some sort of intervention, then we almost certainly would. The 41.8% BTW comes from BirthChoiceUK stats.

LaVolcan Wed 13-Mar-13 10:24:23

I have a problem with people who were talking about HB as a safer option ON MUMSNET not giving it even a sentence.

It's nearly always been discussed in terms of medical or health needs, which is where the expertise of HCPs lie. They are not experts in whether the woman's environment is a safe one. As you said yourself, DV increases when a woman is pregnant. What would you expect HCPs to be able to do about that?

Newspapers are in a different position: it could be seen to be part of their remit to raise issues. The Observer could have written an article about that instead of Alice Robert's article, but obviously in this case chose not to. They could be asked why they didn't.

LeBFG Wed 13-Mar-13 10:29:52

And so we go full circle. Because of the medicalisation of cb, we view an interventionist birth as the new norm. We need to change the way we think about birthing and the vocabulary we use to describe it. As you say LaVolcan, normal birth is no longer the norm in the UK...both the reasons why normal births are no longer the norm and our cultural attitudes to cb need an overhaul.

KatieMiddleton Wed 13-Mar-13 11:03:32

Ime most discussions about home birth on Mumsnet are begun by women who are planning or considering a home birth. Rocking up on one of those threads to say something about DV might be considered a little odd or even patronising in that context.

I also can't recall any thread where home birth has been suggested as a safer option. Admittedly I'm not on the boards all the time but I have been around long enough to know if that was the norm and ime it is not.

RedToothBrush Wed 13-Mar-13 11:36:57

If the phrasing of stuff has a medical impact on people's well being, it needs to be looked at and considered a great deal more.

Phobias of birth are by definition irrational fears.
I think there are a lot of women who would argue the toss on that one and say their fears are completely rational for a lot of reasons. Fears cover a wide spectrum; some are irrational. Some are completely rational. Or are we going to say that women who want an unassisted vb are irrational in their fears about intervention?

It is normal in this day and age to have an assisted birth. Yes, its is. Accept it. You might want to make it less normal, and thats fine, but that is the reality.

But in trying to do that you shouldn't penalise or use prejudice against women who actively choose that or indeed are compelled to do so by others 'in their best interests' (which may or may not be the case). Its not fair.

Its the women who end up bearing the cross, not the medics and not the natural birth evangelists.

By all means think about other strategies, but not ones that create this sense of failure.

Chunderella Wed 13-Mar-13 11:50:25

That's not how this thread started though Katie. It's a thread about an article purporting to discuss evidence about safe birth, which not surprisingly progressed into a wider discussion of birth choices and outcomes generally. Which absolutely included posts suggesting that low risk women may be safer with a HB. Now, given the prevalence of DV and the fact that pregnant women are at increased risk from it, the idea that it is odd to feel this has a place in a discussion about birth is itself, well, odd. At best.

LaVolcan Wed 13-Mar-13 11:53:38

It is normal in this day and age to have an assisted birth. Yes, its is. Accept it.

Why? 50 years ago shaving and enemas were considered an essential part of childbirth. Women didn't accept this, and they no longer are. Surprise, surprise it hasn't made birth any less safe.

Let's take modern examples:

Obesity causes more problems. Do we just say, accept it, it's one of those things? Or do we say, what can we do to tackle obesity?

Certain groups are low users of ante-natal clinics. Do we just say, accept it and deal with the problems when they arise. Or do we say, what can we do to go out and meet these women, to prevent as many problems as we can arising?

RedToothBrush Wed 13-Mar-13 12:01:21

LaVolcan, I think its pretty clear that being insensitive in your approach to dealing with obesity adds to the problem. Language is as important here as in child birth. If its aggressive or confrontational, it just alienates and hurts and is counter productive to the very thing you are trying to achieve.

Some obese people avoid going to the doctors, generally, because they fear they will be nagged or bullied about their weight in the process. Why do you think that certain groups are low-users of ante-natal clinics? I suspect I can think of a few answers...

Shagmundfreud Wed 13-Mar-13 12:15:16

"I don't have a problem with Alice Roberts not mentioning DV in her article. I have a problem with people who were talking about HB as a safer option ON MUMSNET not giving it even a sentence."

Sorry - people who discuss hb on mumsnet are generally very clear that it's not suitable for EVERYONE.

Is that not good enough for you?

There is no 'category' of women who are excluded from having a homebirth in the uk. Some disabled women will have their babies at home, and some women who have experienced dv. It goes without saying that individual circumstances -whatever they are, are always taken into account when assessing the suitability of home birth.

LaVolcan Wed 13-Mar-13 12:15:33

RedToothBrush - yes to all those, but to take it a step further back do accept that this is just the way health professionals are? Or do you say, no I am not prepared to accept being talked to like that? (It's hard to do, I know: right now my DH is avoiding the Dr because he expects to be nagged about his blood pressure).

IMO there is usually scope for questioning. We could question things like: are these interventions happening,(or in some cases necessary interventions not happening) because our staffing levels are inadequate? Why does your protocol dictate that I 'must' be induced at 40+ 10/12/14 - how does it apply to my circumstances? What are the alternatives?

Personally, I am very glad that there are people prepared to question and not to 'just accept'.

Shagmundfreud Wed 13-Mar-13 12:17:21

"HB advocacy that doesn't consider the safety of the home= bad because it ignores women whose homes are unsafe"

And hospital birth doesn't consider the issue of safety in relation to infection issues, something no particular study has looked at, and something which is absolutely endemic in UK hospitals.

Really - this is a slightly pointless discussion, and I think I'm going to check out of it.

LeBFG Wed 13-Mar-13 12:47:29

RedTooth: there are fears and phobias - these are two very different things. I have very much talked about fears surrounding cb rather than tokophobia for example. I think the fears come from a cultural idea of cb - one that involves pain relief and hospitals. It's so prevalent that the majority of UK births follow this model.

As in any righting of a societal norm, the side proprosing change may go too far in their evanglising, or perhaps be seen to be undermining the other side. Following the bf analogy: I live in France where ff is the norm. I've never seen promotion of bf like in the UK - my MW said this was so ff mothers wouldn't feel guilty. Whether true or not, the point is, it's very hard to promote physiological births without immediately feeling like we're aleinating others who can't/don't want these sorts of births. Should this ultimately stop the debate? I think that would be unfair.

RedToothBrush Wed 13-Mar-13 12:47:55

LaVolcan, I've had very bad treatment by a GP before. I don't/didn't accept it.

I appreciate questions being raised; but my experience was far from that.

Discussion of certain things, has to come from the patient, on their own terms and in their own time. A doctor can mention it, but can not push it beyond a certain point.

It might not be what the doctor wants, nor may it even be in the patients 'best interests' at times - but having a good relationship between the patient and doctor trumps that - doors need to be always left open rather than slammed shut by the doctors actions.

It comes down to free consent rather than coercion and bullying ultimately. I don't think all medics know where the boundary lies.

Beyond that I don't think I can really comment as I don't feel my personal experience in this really helps this debate much beyond that.

cardamomginger Wed 13-Mar-13 13:00:15

I've read some, but not all of this thread (dealing with an ill DD), so apologies if this has been mentioned elsewhere.

I'm interested to know which outcomes are measured in these type of studies and how they are measured. Clearly it's not just about mortality, it's also about morbidity. But what is measured, how is it measured, and when is it measured? A data collection point 1, 3, even 6 months after giving birth may not be long enough to capture the true picture of what is going on for that individual.

In my case (1st timer, MLU transferring to CLU, epidural, medium bleed, 2nd degree tear), the full extent of the damage (cystocele, rectocele, enterocele, uterine prolapse, displaced coccyx, severe trauma to pelvic bones, detached puborecalis) and the toll on my health (PTSD, double incontinence, pain, infection, mobility problems) has only become apparent as the months, and indeed years, have gone by. The labour unit where I gave birth is, as far as I can deduce, not aware of any of this, as nothing has yet to come to light when I was discharged from the CM service. None of this will show up in their data, internal audits, whatever, and my birth which was a catastrophe for me, I assume, is categorised as having a pretty good outcome.

I can't imagine that this just applies to me - birth injuries often take some time to reveal themselves.

Shagmundfreud Wed 13-Mar-13 14:00:40

Cardomomginger - details of what the study was looking at here: here
You'll have to watch the whole film to understand it.

The study talked about in the OP only looked at these aspects of maternal morbidity: unplanned c/s, forceps, third degree tears, and admission to HDU.

"my birth which was a catastrophe for me, I assume, is categorised as having a pretty good outcome."

The study doesn't refer to 'good outcomes' in relation to maternal outcomes - only to rates of intervention.

cardamomginger Wed 13-Mar-13 14:12:02

Thanks shagmund.
I guess my point is a general point concerning outcomes, as well as a question about this particular bit of research. Will have a look at the link.

LaVolcan Wed 13-Mar-13 15:05:58

Good questions cardamom.

If later outcomes could be related back to the birth, we might hear a bit less of this 'the only thing which matters is a healthy baby', (with its implication 'what are you making a fuss about?'), and have equal attention paid to the mother's health.

MedicalEd Wed 13-Mar-13 16:15:28

It's not only longer term problems for the mum that were not included but also the baby.
I asked the authors at the press conference presenting the findings about milder cases of cerebral palsy caused by birth trauma which quite feasibly might not be diagnosed until after six months of age. Was told those would be mild and so were dismissed as not mattering, in terms of the study.
There were also a collection of other infant morbidities which were not included in the aggregate infant outcome measure but I forget what those are now.

Shagmundfreud Wed 13-Mar-13 16:30:44

MedicalEd - have you watched the film I linked Cardamom to?

LaVolcan Wed 13-Mar-13 16:49:49

'In terms of the study' is a key phrase here. It doesn't mean it wasn't important in itself, just that they have to draw a line somewhere, otherwise they would still probably be collecting and analysing data now.

Chunderella Wed 13-Mar-13 17:48:16

No Shagmund it isn't good enough because you still don't get it. If you thought DV was irrelevant I would've hoped you'd at least have the honesty to say so, or just not post about it. Instead, you have tried to both respond and shirk the issue, posting confusion after irrelevance. Citing the lack of studies on hospital infection rates entirely fails to engage with my point, yet again. Your checking out now is only what I would expect after your several posts of total fail on the matter.

jchocchip Wed 13-Mar-13 19:46:48

Please can you stop being so mean Chunderella? Just because someone disagrees with you doesn't mean they are wrong.

Chunderella Wed 13-Mar-13 20:22:35

And just because someone holds a different view to you doesn't make them mean, or indeed wrong. Actually if I were you I'd steer clear of calling anyone mean: while it's easier than confronting privilege and othering, it sounds rather like a personal insult and we all know how MNHQ feel about those.

Shagmundfreud Wed 13-Mar-13 20:22:44

Chunderella doesn't bother me - she's on a hiding to make a massive beef out of fuck all.

Every proposed h/b for a low risk mum needs to be assessed in light of her specific circumstance, which will include whether she is subject to dV.

What more needs to be said?

Chunderella Wed 13-Mar-13 20:28:21

I thought you were going to check out, Shag. It seems not. Now that you have deigned to acknowledge that the safety of a woman's home is a factor to be taken into consideration and, by extension, that some women don't have safe homes, nothing. Took you long enough, but we got there in the end.

Shagmundfreud Wed 13-Mar-13 20:40:02

Chunderella - a woman at home will probably spend fewer hours labouring without a health professional present than the equivalent mother in hospital.

If DV is an issue to the point where the mother is not safe to labour in the presence of the partner then I'd say that birth setting is probably the least important issue.

jchocchip Wed 13-Mar-13 20:48:49

Its what you said about posts of total fail that I thought was mean. I thought mumsnet was a supportive place where people encouraged each other. Not belittling what others have to say if their opinions are not exactly what you sanction.

Chunderella Wed 13-Mar-13 21:08:49

Jchoc if you say posts are mean I think rules-wise you're fine, as that's about what someone's written. Whereas saying someone is being mean is about them as an individual. Regardless, as you're not applying the same standards to other people on this thread who have done exactly what you criticise me for, it becomes obvious that it's actually my ideas you object to.

Good to see you engage further with the DV issue Shagmund. I don't think we can categorically say birth setting is the least important issue though, it would depend a great deal on the individual woman and circumstances.

jchocchip Wed 13-Mar-13 22:40:34

Hang about I don't object to your ideas. Just the putting down of other people's.

Chunderella Thu 14-Mar-13 19:21:40

That's clearly not the case, though. Because others on this thread have stubbornly refused to agree with me just as I with them, and have been as dismissive of my views as I have of theirs. So if that were really what you objected to, you'd have said something to others too. Don't get me wrong, I have no problem with you disagreeing with me. but let's have no double standards.

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