Frederick Leboyer on Woman's hour today on childbirth without intervention

[queenceleste]

listen again here.

Amazing considering he's a man, he was one of the first promoters of waterbirth.

Jane Garvey obviously totally disagrees with him but it's all in her tone...

whoah!
I do think vaginal birth is the best way to have a baby. A csection is for a high risk birth or for another medical reason, or for a mother who elects to have one.
Of course a normal delivery should be the aim of maternity services for economic reasons at the very least. Csections should be for the births that need it, not for low risk or births that have no need of it.
But there is if you look at the stats a steady and worrying increase in csections in the developing world.

Of course no woman should be blamed or criticised for having had a csection.
I just think policy should be based on what's best for the majority.
Highly medicalised maternity services have great costs imo, it's hard to talk about the benefits of natural childbirth if people are taking it personally.
I don't blame any woman for what she chooses to do or what is done to her.
I just think that there are massive benefits which we have lost through the present system.
There are maternal and infant deaths in the present highly medicalised system too and babies who have all sorts of post natal problems and problems related to interventions.
It's not that hospital = risk free
Home = massive risk
But that is how it looks from the medical point of view.

Re bf. I have repeatedly been told that bf is more challenging for women who have had cs because of the milk partly being triggered by the process of labour.

The whole process of intervention can militate against the kind of calm beginning that can contribute to early bf.

Again, no criticism of anyone who does not bf. I happen to think that it can be very beneficial for mother and child.

I successfully breastfed for a year after a CS.
How on earth can a mother being in agony and out of control facilitate a calm beginning for baby?
If thats what the mum wants then fine, she should be supported but please stop knocking women who want medicalised births in a hospital with pain relief.
I have little experience of the NHS maternity services but I have never met anyone denied a homebirth if they want it within the NHS, in fact those who have wanted it have had really enthusiastic midwives and have had a great experience.

I understand his POV to the extent that modern childbirth practices start from the premise that medicalisation is neccessary and desirable, rather than the last resort in exceptional cases. I can also understand why he might seem a little extreme in putting his case, as he must feel as if he is fighting a losing battle. However I think it is not a good idea to say that anything is bad or wrong when it comes to a process that is so personal to an individual woman.

Re bf. I have repeatedly been told that bf is more challenging for women who have had cs because of the milk partly being triggered by the process of labour.

I had no problems BF DD after a cs, but lots BF DS after a VBAC.

WidowWadman
"If a CS is statistically safer than a VB for breech, is there really any value in holding on to the breech VB, or is it just nostalgia?"
I looked into this issue a lot when DD1 was stubbornly breech. The big RCT research that, almost overnight, drove the change to recommend CS for breech throughout the Western World because it was "safer" has been widely discredited and it is now generally accepted that the conclusions (primarily that CS should be recommended for all babies presenting breech at term) should be ignored.^

The guidelines written based on this research have yet to be updated - and if things don't change soon the midwifery/obstetric skills that make vaginal breech an equally safe option to CS will become lost. At which point CS will be the only safe option.

Is there value in holding onto the skills for VB? As 1/2 babies presenting breech at term are undiagnosed, yes - I would consider those skills invaluable. Such babies are often only diagnosed when the MW looks at the baby "crowning" or feels the presenting part and realises its not a head coming out. At that point there isn't always time to do a CS and knowing how to support a VB is a potentially life saving skill.

(sorry - steps off soapbox - just something I've reason to feel passionate about)

ajmama
"I have never met anyone denied a homebirth if they want it within the NHS, in fact those who have wanted it have had really enthusiastic midwives and have had a great experience."
If you've only talked to me through the internet does it count as having "met" me?

I was always interested in a HB for DD1 (DC1). The CMW was not supportive, and told me hospital was a much better place for a HB as "we don't know what your pelvis is like". Our GP (we have shared care) said we should just book a hospital birth as "even if you book a HB there might not be a MW available so you may have to go in anyway". When we insisted on booking a HB, our CMW did not become anymore supportive, but used the HB booking/visit to run through all the ways she lacked training and/or confidence (hadn't had training in waterbirth so we could only do that if the 2nd MW had experience. Couldn't remember the last time she'd sited a canula so better hope the other MW was good at that too...). We never got to find out whether she'd have been wonderfully supportive at the birth (supported by a team of about 50 MWs form 4 areas, so "you'll have to be very lucky to get me") as by then we were so fed up with the negative attitudes and confidence sapping approach that we opted out and booked IMs (and we appreciate just how lucky we are that we were able to afford that).

WidowWadman
"Why are women made to feel like failures when they need help in the shape of instrumental delivery or CS? I don't want to downplay that an emergency situation in which this is needed is traumatic, I'm sure it is, but I also think often too much emphasis is put onto the method of delivery.

If you tell a woman often enough, especially in a vulnerable postnatal stage, that she missed out on something and that you feel sorry for her, rather than celebrating the fact that she had a healthy baby, than I'm sure that won't do her mental health any good."

I agree with you here up to a point - however, from my personal experience the friends I have that have suffered most mentally didn't have the most intervention ridden labours and nor did they have labours where it all went pear shaped in a big hurry - they had labours where they felt ignored and/or not listened to and/or unsupported. Making a woman feel like she's failed is unforgivable - but if she feels traumatised by the birth then telling her none of that matters as she has a healthy baby is equally bad IMO.

Ina May's statistics are amazing - I think they've got a 1.5% c/s rate at her birth centre (over 2000 deliveries) and they've safely delivered twins, breech babies, face and brow presentations (considered 'unbirthable' vaginally everywhere else) with lower infant mortality rates than hospitals."

But surely aren't the patients who go to Ina May Gaskin essentially self selecting? She isn't getting local general referrals, she's a private practitioner, and the women who choose her aren't like to be those who are even ambivalent about c sections, never mind the significant numbers who request ELCS. So perhaps her low CS rate isn't quite so remarkable afterall...

"But surely aren't the patients who go to Ina May Gaskin essentially self selecting?"

Yes, they are. She's getting mainly low risk women at her birth centre. Though she does get a lot of older mothers, first time mothers and VBACS. Also breech and grand multips (the Farm serves a community of Quakers I think - they have very big families).

But then the majority of women in the UK would also be categorised at 'low risk' at the end of their pregnancies.

The emergency c/s rate in the uk is 14% overall, and c/s rates for birth centres are not massively lower than for consultant led units.

"please stop knocking women who want medicalised births in a hospital with pain relief."

I don't think anyone is doing that here are they?

"I have little experience of the NHS maternity services but I have never met anyone denied a homebirth if they want it within the NHS"

I have a lot of experience of NHS maternity services and I have met MANY women who have felt completely unsupported in their wish for a homebirth.

"when you earlier argued that a few dead babies and women might be a price worth paying for the allegedly improved mental health of women who give birth without intervention?"

But actually it's not such a cut and dried issue. Far more women can give birth without interventions than are currently doing so without increasing the infant or maternal mortality rates. Most obstetricians and midwives believe this to be true.

My community midwife (who presumably went into midwifery because Traffic Warden school was full) said "We don't support homebirths in this area." End of discussion. My friend DESPERATELY wanted a homebirth and decided to just sit it out at home and call the midwife when she thought things were far along. Midwife turned up, said "We don't support homebirths" and phoned an ambulance to hospital, where my now knackered and scared friend had a totally normal delivery which she could have had in her own bed. But the midwife didn't support her and at that moment she didn't feel confident enough to argue. Such a shame.

Where I live a homebirth is almost impossible because of staffing.
I have heard twice in the last year of women being taken into hospital because the midwife is needed. Homebirths seem to be always overruled by labour ward's needs.
The women I know who have had homebirths talk of themselves as 'very lucky' because everyone knows it's a staff issue.
I think it's great if you've bf successfully but I think that the amount of medical intervention in labour and birth is thought to decrease one's likelihood of successful bfing statistically. Obviously there will be exceptions.
I think the problem with this debate is that somehow there is a perception that it is an 'achievement' somehow to have a 'natural' labour or to have a homebirth and that in some way is a judgment on the women who have interventions, need interventions or choose interventions.
I would argue that it does take courage and determination to have a homebirth or to resist medical intervention.

Of course it's courageous because the whole system uses fear to persuade women to conform even very low risk women are pressured to conform. This is the way systems work but it doesn't have to be a comment on anyone else. It seems to me that it is brave and it is an achievement of those women to go against the system.
Making it into a competition is just wrong in my opinion.
And like it or not, it does take real courage to go for labour without pain relief when you're in a unsupportive environment, I really think it does!

Tangle, I am only talking about friends in real life. Maybe in my area there is more support for homebirths as I can off the top of my head name half a dozen ladies who have had homebirths and 2 who did not intend to but ended up with homebirths.

I have heard twice in the last year of women being taken into hospital because the midwife is needed. Homebirths seem to be always overruled by labour ward's needs.

• but they are not "labour ward's needs," they are the needs of other labouring women, who happen to be in the labour ward.

Planning a homebirth for DC3, due next month (though have to be cleared by consultant for it next week due to age). DCs 1 & 2 were hospital births, fairly straightforward (just gas & air and quite quick), though I did tear (I think through being told to push when I didn't have the urge).

I've done a lot of reading up about homebirth over the last months, and I understand where supporters like this French doctor (disclaimer - I haven't read/heard his particular views) - are coming from. I think that the hospital environment and experience disrupts the natural physiological process and makes birth harder and interventions more likely. So, for low-risk pregnancies like mine, a home birth may well be a better experience (and statistically have just as good outcomes for babies, and better ones for mothers). However, I also think that for problematic pregnancies, all the hospital care and intervention is life-saving.

In the Netherlands, 30% of births are homebirths - it is a normal process for low-risk pregnancies there. I do think that the entire process has become too medicalised - I didn't think of home birth as being a realistic option until my doula this time talked it through with me and I began looking into it. It is something the mother has to initiate and drive, rather than being an option that's explained and supported from the start.

Still, don't want to tempt fate by talking up home birth too much at this point, will wait a month till after I've had (or not had!) mine...

Balloon slayer - hospitals can always snaffle staff from antenatal or postnatal to cover labour ward, and bring in bank or agency staff to fill their shoes. It's simply a matter of money. Anyway, Mums need one to one care whether they're on the labour ward or at home. It's completely unreasonable to expect women to expose themselves to the risks that come with labouring on an understaffed labour ward when they have planned to stay at home. the only responsibility a labouring mum has is to herself and her baby. (funnily enough you rarely if ever here these sort of arguments used against epidurals, despite the fact that some labour wards will be sharing their anaesthetists with ITU, and despite the fact that epidural use places big additional pressures when it comes to staffing levels....)

Re bfing and intervention. I had lots of intervention in the form of an instrumental delivery, never had any probs with bfing and did it for 14 months.

I think that the idea that intervention/cs makes bfing harder is an outdated myth. Even my mum, who had her babies by CS 40 years ago, has been poo pooing this for ages. She was up against old-style general anaesthetic CSs, and the unfashionable image of bfing in the 70s, and still bf'd successfully.

eastegg, if babies born after c/s are more likely to go to special care than babies born after a straightforward vaginal birth (they are), and babies born after assisted deliveries are more likely to be fractious and jaundiced in the first week, you can see how it might interfere with establishing breastfeeding FOR SOME WOMEN, especially in the absence of good quality help and support, which is often the case for UK mums.

Mums are more likely to be unwell following surgery - it's not beyond the bounds of reason to see that if this happens then bf is going to be more of a challenge for her.

Spudulika - I think you're getting things arse about face here, though - it's not the CS which neccessitates SCBU and causes feeding difficulties, but it's the underlying conditions which make the CS neccessary.

Or do you reckon those sick babies would probably alright and problem free if they had been birthed vaginally?

I don't deny that there are iatrogenic problems, but not it's not true for every birth.

Other than that, breastfed babies are more likely to be jaundiced than bottlefed babies, but I've never seen that uses as an argument against breastfeeding.

Personal anecdote - breastfed with no problems first child for 18 months after EMCS, and now am feeding no 2 after ELCS a week ago. The only trouble I currently have is too much milk, despite a good latch and frequent feeds.

And the solution to breastfeeding issues is not altering the mode of delivery, but supplying proper support. I had a midwife spending hours with me getting the latch right, demonstrating hand expressing with a fake boob etc first time round.

As for 1-1 care - would be great in an ideal world - (although surely it's 2 mw's per mother in homebirth?), but we don't live in one and there are finite ressources. I guess it's probably easier to run a labour ward economically than making sure that there will be enough midwives to tend to all women who might go into labour at the same time at home.

How likely you are to get a homebirth depends on your local NHS trust, I guess. In my area they're very pro homebirth - which I don't think is a bad thing. However, one of my friends had to beg her midwives to transfer when she felt she didn't want to be at home anymore, and they refused until her husband called an ambulance himself. I guess the hospital is not the only place where a woman can be made feel powerless.

But don't home births have to have two midwives, Spudulika?

"I don't deny that there are iatrogenic problems, but not it's not true for every birth"

No. I agree! I didn't say or imply that this was ALWAYS true, I'm just reflecting on some of the stories I've heard from people who have struggled with breastfeeding after difficult/operative births.

"Other than that, breastfed babies are more likely to be jaundiced than bottlefed babies, but I've never seen that uses as an argument against breastfeeding."

I'm not using the higher rates of jaundice found in babies born after instrumental births as an argument against instruments being used in birth.

"And the solution to breastfeeding issues is not altering the mode of delivery."

No, of course not.

"As for 1-1 care - would be great in an ideal world"

No - not an 'ideal world'. Some hospitals are already managing this. I agree there are finite resources, but that's never used as an argument for restricting the availability of epidurals for labouring women, despite the fact that epidurals are not linked to better clinical outcomes (worse actually), whereas providing one to one care is linked to better clinical outcomes for mothers and babies, which decreases overall costs to the NHS.

"(although surely it's 2 mw's per mother in homebirth?)"

The second midwife usually only stays an hour or so for the actual birth. You also have to factor in that mothers who labour at home have about half the rate of c/s, compared to similar low risk mums labouring in hospital. They're also less likely to need an epidural. Both these things mean that homebirth has economic benefits for local providers of maternity services.

" I guess it's probably easier to run a labour ward economically than making sure that there will be enough midwives to tend to all women who might go into labour at the same time at home."

It's easier to continue with dangerous levels of understaffing if you have all the women in one place. I would prefer for the government to accept that it's unacceptable for staffing levels to be so low that women and babies are put at risk, and do something about it.

Have to say, this issue is of real interest to me at the moment. My local maternity unit is currently being investigated following 3 maternal deaths in the space of 8 weeks last summer. At least one of the deaths is known to be the result of malpractice, and the Quality Care Commission has flagged up dangerously low levels of staffing at the hospital as being part of the problem.

As for homebirth provision in our area - we have a specialist caseloading team who only do homebirths. Women here who opt for this pattern of care are IMO making a very rational decision for themselves and their babies, given the poor provision currently available at our hospital.

I have friends that have had lovely experiences during a homebirth, and also some that absolutely hated it or couldn't cope and went to hospital.

For me, what really puts me off a homebirth is feeling that it's not just about me labouring, it's about a baby who might need urgent help and will probably be better off in a place where there are relevant facilities and trained staff.

And, most importantly, that in a hospital there are lots of trained professionals, midwifes, doctors and nurses rather than the two midwifes I would get quite randomly at home. I have met lovely midwifes and some not so lovely ones, I wouldn't trust my or my baby's live in their hands.

At least at hospital I can have more choice over who is with me, theoretically ask for a different individual if it's not working out, and also opt for pain relief if I can't cope. Those options make me feel far more relaxed and probably will help me give birth in a positive spirit.

With my first, due to umbilical problems I was advised to be monitored and get an epidural so they could give me an EMCS if he got distressed. He did get a but distressed but I pushed him out without any instruments so it was as natural as it could be. I had a lovely midwife, a really nice anaesthesiologist, a couple of obs and a paediatrician in hand. They were not pushy, they wanted to avoid an CS, they helped deliver my son in a most caring and non patronising way. I prefer that over two midwifes, and I hope it's a choice any woman can make.

"For me, what really puts me off a homebirth is feeling that it's not just about me labouring, it's about a baby who might need urgent help and will probably be better off in a place where there are relevant facilities and trained staff."

Are you suggesting that women who opt for a homebirth are putting their baby at increased risk?

"At least at hospital I can have more choice over who is with me, theoretically ask for a different individual if it's not working out"

In theory. In practice it's rare for women to do this. And at home you're more likely to have a confident and experienced midwife, because the less confident ones tend to steer away from doing homebirths as they find the responsibility worrying.

"and also opt for pain relief if I can't cope".

Fair enough, as long as you realise that the bargain you strike in opting for a hospital birth is: easier access to pain relief + greater likelihood of needing it.

And of course, the flip side to the benefit of marginally easier access to medical care is that there's greater likelyhood you're going to need it (because births are more likely to become complicated in hospital than they are at home)

In a similar vein, quicker access to SCBU when you book a hospital birth goes hand in hand with the higher likelyhood that your baby will need special care (babies born at home are less likely to have low APGAR scores and to need to go to SCBU).

" Those options make me feel far more relaxed and probably will help me give birth in a positive spirit."

Anyway, each to their own. I think it's hard to be hard-headed about these things. If you don't feel safe at home (despite knowing that it's as safe for you and your baby as going into hospital) it's probably not going to help you labour well.

"They were not pushy, they wanted to avoid an CS, they helped deliver my son in a most caring and non patronising way. I prefer that over two midwifes, and I hope it's a choice any woman can make."

If I had an epidural in situ and was marooned on a bed for my labour, I'd certainly want a paediatrician and an obstetrician on hand for my delivery. Epidurals turn a low risk labour into a high risk one - hence the need for the additional monitoring and ready access to doctors. You'd certainly not want to be in this position at home (even if it were possible, which of course it isn't!).

"In a similar vein, quicker access to SCBU when you book a hospital birth goes hand in hand with the higher likelyhood that your baby will need special care (babies born at home are less likely to have low APGAR scores and to need to go to SCBU)."

Surely that is not because of the hospital birth, but because these babies have already been risked out from being born at home.

"Surely that is not because of the hospital birth, but because these babies have already been risked out from being born at home."

No - these figures come from large studies which match mums who've opted for a homebirth with similar mums who've chosen to give birth in hospital.

The largest and most influential study in the past decade has included in the homebirth arm the outcomes for those babies whose mothers transferred into hospital PRIOR and DURING labour, who would be expected to have poorer outcomes as a group.

Read here:

here