Alice Roberts' article today on evidence based childbirth (HB/MLU/hospital)(261 Posts)
Not sure if this has been discussed elsewhere?
Seems a fairly balanced article to me, but I am an
evil patriarchal obstetrician.
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.
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.
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.
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.
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
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.
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.
"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.
"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.
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.
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.
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.
" 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.
I think the numbers of high risk women having HBs would be too small for any meaningful results LaVolcan
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.
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).
"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.
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)
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.
"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.
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.
Btw, I am assuming that your mistyping of my nn was accidental rather than an immature response to someone with a different viewpoint.
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.
"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.
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.
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