Natural birth

[Weirdbigtoe]

What is classed as a natural birth-is it vaginal birth with no pain relief at all?
I had a vaginal birth, but requested epidural. My mum to this day still asks why, I can’t remember being massively informed at the time, but just basically not wanting any pain, is this weird? It seems incredulous to my mum. It wouldn’t have affected my Dd would it?
Where I am they don’t have gas & air, the only option was epidural or not, hence why I went for it, if they had gas and air I would have had that

In that strange country we call "France". Which invests a lot more in women's healthcare.

That’s genuinely really interesting. I’d love to read some good research on this.

You do get limited movement though which isn’t great for labour generally

I can only speculate about the reasons why the NHS appears to discourage epidural use.

But I can dig out some statistics comparing the rates of obstetric interventions in the UK versus France, if you're interested.

Obviously it's difficult to directly compare data from different countries because there may be differences in how it has been compiled. But the data I have found appears to show beyond any real doubt that France has lower overall rates of C-sections, assisted vaginal births and episiotomies than the UK, which is the opposite of what you would expect to see if epidurals did actually increase the likelihood of these things.

I feel quite strongly about this because when I was planning to have a baby in France I was still mostly informing myself about childbirth from UK based sources. Everything I read put the fear of God into me about epidurals and I was convinced that in order to avoid having all the interventions under the sun I needed to refuse the epidural at all costs, but without access to other pain relief methods that women in the UK routinely use. I was incredibly stressed about it. As it happened, I did end up having to have an emergency C-section with my first child, but it was clearly heading that way even before I had the epidural. I tried labouring for long enough with the epidural to realise it wasn't actually hindering my mobility the way I had been told it would. Second time round I desperately wanted a VBAC and so I did an enormous amount of research about the different factors affecting VBAC success rates. That's when I stumbled across the statistics for different maternity units in France (and panicked again because the place I had chosen to give birth had a very low VBAC rate) and I realised that across the country as a whole France had lower rates of every single one of the interventions recorded than the UK. If only if found this information when I was first pregnant I would have been so much less stressed about giving birth here and I would have taken the NHS information with an enormous pinch of salt.

In my first labour I had a good strong epidural and wasn't expecting to be able to move around at all, so it came as a great surprise to me to discover that I could. Obviously I was hooked up to stuff and couldn't go wandering off anywhere (although many hospitals in the UK offer walking epidurals, in which case I guess you could?) but I was perfectly able to move around.

In my second labour I asked for a low dose epidural just to take the edge off, fully planning to move around and bounce on the ball and so on, as soon as I'd rested for a little while. I know I could have moved around but I didn't have time in the end because by the time I woke up from my nap it was time to push!

The reason is cost and the “ideal” that unmedicated birth is best and should be encouraged.

They also don’t expect first time mums to speak up for themselves.

Epidurals are safe and effective, if the woman wants one then she should be able to get one.

She shouldn’t be dismissed and told that she can “manage”.

OK here are some stats.

It is really quite difficult to get directly comparable data. I have not been able to find all the information I want for both countries in the same year, but this is the best I can do. Some of the most detailed data for France is taken from an interactive map of all the maternity units in the greater Paris area which compares the statistics for that unit against the national average, but they are compared against the national average for that type of maternity unit, ranging from a basic level 1 maternity unit to a full service level 3 maternity unit with an attached NICU. So when I give a range, that is why.

France

C-sections:

19.9-21.6% in 2021 depending on type of maternity unit according to the interactive map or 21.4% overall according to the 2021 perinatal health enquiry.

Information from the French health ministry clarifies that in 2020 the overall C-section rate was 20.4% of which 13.9% were EMCS and 6.5% were ELCS. This is expressed in the link below as 68% and 32% of C-sections respectively.

The most common indication for a C-section is having had a previous C-section birth, which ties in with my own experiences. The VBAC rate appears to be significantly lower in France than in the UK.

Spontaneous vaginal births:

64.2-68.3% in 2021 depending on type of maternity unit according to the interactive map (significantly lower for first time mothers in all cases). It's not entirely clear whether this means non-induced vaginal birth or non-induced, non-instrumental vaginal birth. Unfortunately the interactive map doesn't give induction rates so I've had to take that from a different source.

Inductions:

25.8% in 2021 (has increased from 22% in 2016) according to the 2021 perinatal health enquiry.

Epidurals:

77.1-83.7% of vaginal births in 2021 depending on type of maternity unit according to the interactive map or 82.7% overall according to the 2021 perinatal health inquiry (decreasing as more women opt for physiological methods).

Assisted vaginal births:

11.6-13.6% in 2021 depending on type of maternity unit according to the interactive map.

Note: It's not clear from this source whether this is a percentage of vaginal births or a percentage of all births.

Episiotomies:

2.9-3.8% in 2021 depending on type of maternity unit according to the interactive map.

UK:

I found it much harder to access the same statistics for the UK and it's not clear whether the data used relates to births which actually took place in 2021 or whether there is a time lag. I've done the best I can.

C-sections:

27% in 2021 (16% EMCS and 13% ELCS) according to NHS Digital.

Spontaneous vaginal births:

53% in 2021 according to NHS Digital. They clarify that this means non-induced, non-instrumental vaginal births.

Inductions:

33% in 2021 according to Summary Report 3 of the Excel data set for 2021 used by NHS Digital (you need to scroll to the bottom for this).

Anaesthetic/analgesic use:
59% in 2021 according to Summary Report 4 of the Excel data set for 2021 used by NHS Digital.

Note: I am not actually sure what this means. Obviously it would include all vaginal births under epidural, but I am not sure whether it includes C-section births or the use of drugs such as pethidine.

Assisted vaginal births:

According to NHS Digital and the related dataset the rate of instrumental births in 2021 was 10% overall, which is slightly lower than France. The National Maternity and Perinatal Audit (published in 2022 but using data from 2019) puts the rate of instrumental births at 23% for a first time mother and 12.3% overall (you need to click on the full report) which is about the same as France.

The NHS Digital page clearly expresses the 10% as a percentage of all births, not as a percentage of vaginal births.

Episiotomies:

The only data I could find about episiotomies was from the National Maternity and Perinatal Audit which says that 44% of the first time mothers who had a vaginal birth had an episiotomy. That seems shockingly high to me, especially since the data comes from a time when reading Mumsnet put the fear of God into me about episiotomies being performed routinely in France.

Anyway, that's the best I can do. I really hope these links work.

@Ididivfama @MargotBamborough so the initial studies on the use of epidural Anaesthesia leading to increase in risk of operative delivery has some issues. the two groups compared had significant differences and some of the studies only studied the effect in induced labour.

more recent studies demonstrate no significant relations between epidural use and increased risk of operative delivery.

the NHS website and the Royal college of obstetricians use careful language to demonstrate that the evidence base is not solid. studies around labour are always difficult as there are so many variables at play.

also, the dose is very important. now with patient or midwife controlled dosing, the doses used are much lower, we are using different drug profiles and therefore the risks are reduced. one of the things I have observed is that mums come in with a very anti epidural mindset and only ask for one when they are exhausted. so by then their ability to push has also been reduced. an early epidural can help mums conserve their energy for the second stage.

the NHS is not trying to reduce the number of epidurals due to cost. they are not that expensive. the main issue is cultural as well as myths in the community (and even among doctors!) about epidurals. there is also a staffing issue as anaesthetists may not always be available as labour ward is a very busy place with emergency sections etc which the anaesthetist has to prioritise.

interestingly there is not much talk of the Remifentanil PCA which is almost as effective and given through a cannula so avoids all injections in back scenarios. they are widely used in Ireland I believe.

Thanks @therealcookiemonster, that's really interesting!

"Epidurals are safe and effective, if the woman wants one then she should be able to get one."
Of course. But it is also fine not to want one.

Of course it is. Just as long as you don't not want one for the wrong reasons.

@CurlewKate I am yet to meet anyone who opposes women having a vaginal birth without assistance. certainly in this country provision is made for low intervention births with a wide range of options.

i have no issue with that but there is definitely a 'natural' birth movement with a strong presence online and generally in the community which push women to make decisions without proper information. this I have a big problem with. because when these women are in the throes of labour and begging for an epidural (often when it's too late to put one in) those that misinformed her are not there to help her.

that's it. no one is taking anyone's right to labour with less intervention away.

But the data I have found appears to show beyond any real doubt that France has lower overall rates of C-sections, assisted vaginal births and episiotomies than the UK, which is the opposite of what you would expect to see if epidurals did actually increase the likelihood of these things.

That is an observation that you are associating with epidurals. The lower rates of c-sections and so on could have nothing or very little to do with epidural rates even if epidurals do increase risk of c-sections and other interventions because there are a multitude of factors involved.

I don't understand what point you're making here.

This article puts epidural use in England at 31%, although it's not clear whether this means 31% of vaginal births or 31% of all births.

https://www.independent.co.uk/life-style/health-and-families/health-news/epidurals-are-for-wimps-479369.html

In France it is over 80%, i.e. almost three times as high.

If epidurals actually led to these other interventions you would expect to see a higher rate of them in France than in England, wouldn't you?

What other factors do you think might be at play here to explain the fact that we don't see that?

But it should never be ‘too late’. That’s an issue that is separate. Getting through a large chunk of labour without is not a bad thing.

I would take 'natural birth' to mean without any interventions I.e. vaginal, not induced, no instrumental assistance, no epidural, etc.

I had a 'natural birth' for my second (after epidural/ventouse with first). I then ended up with shoulder dystocia, haemorrhaged and went into intensive care with sepsis, for good measure. I had an elective section for my third!

Natural birth is great when it works. I am grateful for modern medicine for when it goes horribly wrong, like it did with me.

Your mum needs to wind her neck in. Why does it even bother her?!

@Ididivfama of course it can be too late. if someone is 9 cm dilated and can't keep still because they are in agony or can't get into the right position it is no longer safe to do an epidural. I sometimes might do a mini spinal at that stage but really not ideal.

please explain why its a good thing to go through most of labour without solid pain relief? and please let us know the source of your expertise on this.

I wouldn’t expect epidurals alone to affect c-section rates all by themselves, no. The research has only shown increased risk as in epidural can contribute to higher c-section rates. Even something as minor as the timing of an epidural can affect the risk of c-section.

Other things affect c-section rates

• obesity- U.K. mums are more likely to be obese than French mums

• Inductions increase risk of c-sections- more in U.K. than in France

• different thresholds for acceptable fetal distress- U.K. may be quicker to call it for an emergency c-section

• lack of birthing support- women left alone to labour increases c-section rates- we know U.K. NHS is understaffed meaning many women are not attended by a midwife while in labour for hours at a time.

As far as I know our high rate of episiotomies are largely cultural rather than driven by medical necessity and not linked to epidurals.

So what interventions DO you think epidurals increase the risk of, and what evidence are you using?

I had one dd with nothing but gas/air. The next one I chose an epidural...marvelous.
There's no such thing as Natural dentistry..why should you go through childbirth in pain because it's ' natural.

@therealcookiemonster "I am yet to meet anyone who opposes women having a vaginal birth without assistance."

Well, if I was reading this thread considering it, it would certainly put me off. Being told that you're being a martyr, being competitive and putting your baby at risk will do that.

I found this article while I was searching for UK based stats and this is exactly the kind of dangerous nonsense that made me afraid to give birth:

https://www.independent.co.uk/life-style/health-and-families/health-news/epidurals-are-for-wimps-479369.html

This is just glorifying pain for no good reason. The bold claims she makes about the risks of epidurals simply aren't evidence based, and the wonderful feelings she describes having when her children were born are by no means unique to drug free births.

I found delivering my baby affirming and uplifting too. I breastfed her within minutes. She had perfect APGAR scores. I was fully with it the whole time and so was my baby. Literally the only difference between my experience and this woman's is that I never suffered excruciating pain or wished myself "anywhere but here".

I'm glad she can tell herself she had a good experience despite the unimaginable pain. But she shouldn't be allowed to publish this kind of nonsense in a newspaper. It's just irresponsible.

I tend to go by peer reviewed scientific studies rather than looking at statistics and drawing my own conclusions like you have done. After all the USA has a C-section rate of 32% but an epidural rate of 67%.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4718011/
Showed some increased risk of csection for first time mums having an epidural in Australia circa 2015

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.14175
Shows no added risk of csection when looking at all mums as a whole in the USA (Cochrane) circa 2022

I think it is an unknown.

I agree the message that “epidurals are for wimps” is a damaging one, but why do you feel a need to discount her experience at the moment of birth as something she has told herself as if she were deluded? And to think that you also felt what she felt when it is literally impossible as you did have epidurals?

I have done childbirth both ways- ‘natural’ and with an epidural and I can tell you that during unmedicated childbirth there is a rush of endorphins that is a hundred times more powerful than the best orgasm you have ever had. I did not get that rush when I had the epidural.

There is more difference between the two of have pain or have no pain. Your comment this is the only difference is just as damaging as her comment that epidurals are for wimps.

A doctor on this thread has already explained that the studies aren't reliable.

Any studies using UK data aren't reliable because there aren't enough women having straightforward vaginal labours with epidural to function as a control group.

Data from the US is even more problematic for a whole multitude of factors including their for-profit healthcare system, litigation culture and very short maternity leave leading many women to request an elective C-section or an induction the day they stop working in order to maximise time off with their babies. If anything I'm surprised the C-section rate in the US isn't even higher.

If the best you can do it "it's unknown", despite the fact that countries such as France don't appear to show any correlation between epidural use and interventions, why are women in the UK being discouraged from having epidurals? Why are they being told that it increases their risk of interventions when there appears to be no reliable evidence that this is actually true?

I'm all for women making their own choices about their birth preferences. I just think those choices should be informed and evidence based, not based on scaremongering.