Childbirth- inherently risky or inherently safe? Painful or not?

[WhatTheHellJustHappened]

My friend recently made the fatal mistake of saying in the company of some female colleagues that childbirth was the most painful, horrifying thing she had experienced. An argument ensued and majority of the ladies there believed it was wrong to call childbirth risky or painful. They said they pitied women who looked at such a beautiful and empowering experience in such a negative manner. They said that even sitting on a lawn was risky but sensible people didn't spend time fretting over it. My friend asked me later "When did it become a crime to call childbirth painful or risky? ".
While I personally agree that childbirth can be very empowering and rewarding, I also do agree that it is painful and potentially risky.

What are you views? Do you think childbirth is painful? Do you think it is inherently risky or safe?

Endless
"there is evidence based medicine. -Though of course if someone wants to make different choices to those indicated by the evidence relevant to their case that should be supported "

But it depends whether the evidence is about what matters to you.

For instance, midwivery led units result in less intervention but one of those interventions that there is less of is access to epidurals.
Some women might not want less access to epidurals.

For low risk women, there are also more neonatal deaths in midwifery units - only a tiny number more but some women might think they would rather be in a unit where doctors intervene early rather than late if things start to go wrong.

So it is not only evidence - it is whether the evidence is the right evidence - and measures what matters to you.

Endless
It doesn't matter to me how many different studies about low intervention in MLUs were made. What matters to me is that if I have a spinal and a cesarean there will be close to zero risk of death to my baby, zero risk of perineal injury or fistula, but only slightly increased risk of death and other complications to me. This is how I read these studies because these studies are eventually about my health and the health of my baby, not about the average woman and her health.

Ushy
I agree again.

But Raluca - though I don't have all the stats to hand I'd think the risks to mother and baby (especially in terms of survival) were quite low for all types of birth in UK. And it is such a major event in our lives that the experience we have during birth is very important too, and contributes to our emotional and psychological well-being as we set out on the journey of being a mother.

But I think it's quite right that all women should have the opportunity to weigh up these different considerations for themselves and make informed choices for their care depending on the evidence relating to them, and on their priorities.

Juggling
Priorities, that's it! Everyone has different priorities and the birthplace stats support the idea that birth is safe wherever you decide to go and which way you decide to follow. That's why all these natural vs. medical debates are even more absurd nowadays, when these two choices are perfectly equal in risk.

Raluca - but there's a higher rate of breathing difficulties for babies born by C-section. The evidence isn't 'C-sections are safer'. It's, in population terms, C-sections have risks and benefits, normal delivery has risks and benefits, epidurals/pethidine/spinals/gas and air and everything else has risks and benefits. You don't know until afterwards how those risks and benefits will apply to your labour and your baby - you can only guess.

Edam,
but that's exactly it. All ways and procedures have risks and benefits and everyone should be able to do her own maths according to her priorities and personality because in the end it's all down to luck.
However, if you choose something willingly without being pressured or brainwashed (by withholding information) into it, you have a better chance of not feeling like a failure if something goes wrong. Simply because it was your own decision and you were not just a helpless victim in all that, but went into it with full knowledge of what are the risks.
And yes, I know full well about the breathing difficulties and it doesn't put me off at all. Better breathing difficulties than a brain damaged or a dead baby.

edam The evidence isn't 'C-sections are safer'.

I don't think Raluca was saying that edam

She is saying that c-section and vaginal birth both have risks and benefits, and, having considered them, she thinks the risks of caesarean are more acceptable to her.

Ushy
Thanks for interpreting me. This is exactly what I want to say. I'm doing different things at the same time, so I guess my replies get confusing.

I can relate to everything Raluca is saying, and that's why I chose ELCS. She says "better breathing difficulties than a brain damaged or dead baby." If a baby is deprived of oxygen during VB, that's potentially so much harder to deal with, especially if there's just one overworked midwife looking after several labouring women. Meanwhile, the ELCS woman is surrounded by doctors, nurses and midwives from the outset, so if anything goes wrong, at least it will be dealt with quickly.
I'm not trying to say ELCS is safer, just following on really from Ushy and Raluca.

It does annoy me that those having a more natural, straight-forward delivery are given such sparse resources, as in one over stretched midwife between several labouring women. The lack of resources around maternity care is just so shocking to me. I think more women need to speak up about it and make it a higher profile political issue.

Also I was asked to pay for the lining of the water-pool in which I laboured and gave birth in the hospital. I politely declined to do so (it was only a request) as I reckoned I wouldn't have been asked to pay for the cost of a C/S had that been necessary !

If I go to a hustings again before the next election I'll ask a question about resourcing of maternity care, and let that contribute to my voting decision.

BTW Using the water-pool for labour was for DC1s birth. DC2s birth was your more basic share a midwife scenario.

Juggling - yes, it seems that supposedly high-risk women ironically have safer labours than the low-risk, midwife-led women. The high-risk ones are watched carefully by consultants and midwives, while the low-risk group have to just hope they won't be ignored if something goes wrong.

Seoladair "it seems that supposedly high-risk women ironically have safer labours than the low-risk, midwife-led women. The high-risk ones are watched carefully by consultants and midwives, while the low-risk group have to just hope they won't be ignored if something goes wrong."

You are absolutely right about that. I work in litigation (mostly clinical) and most of the brain damage/high value claims I have seen involve low risk women who have had a perfectly healthy pregnancy and who have no obstetric problems.

Lack of staffing is not the main cause IMO - it is lack of skills and inadequate training of registrars and midwives - not recognising when to call for help being the leading problem.

Ushy - that's very interesting. I felt so much more confident once my ELCS was agreed, knowing that I would be under consultant care.
Incidentally, I found it easier to talk to the doctors. Some of the mws were great, but others seemed over-confident and under-informed. I wouldn't have liked to have been under their care during labour.

That IS interesting Ushy. I have always wondered about this 'low risk' thing. Just because you can very easily have a healthy pregnancy but a difficult birth, for all sorts of reasons.

The Forrest Gump 'box of chocolates' analogy seems very apt when it comes to childbirth, so it seems odd to group women beforehand according the the sort of birth they are 'supposed' to have.

ermm..higher risk women are called higher risk for a reason. the Birthplace study did find worse outcomes in the minority of known higher-risk women it covered.

though actual actionable malpractice may be more common in low risk cases for the reasons detailed below.

and, as i said, everyone should be supported in their choices - though the evidence shows all choices are not in fact the same in terms of outcomes.

There are a number of issues with the Birth Place Study, which I plan to write about properly when time allows.
Just to mention one thing here though - the study excluded stillbirths. This is very important to note since one of the cited benefits of a planned cesarean is the fact that your baby is born at 39+ weeks (unless earlier delivery is medically indicated), while the risk of stillbirth increases at later gestational ages.
It's also worth noting that one of the problems with 'evidence' around birth plans is that very often the authors present and/or interpret data in a way that best suits their pre-existing philosophies or ideologies.

it included stillbirths under 'adverse outcome' (along with lots of other things)

what do you mean?

the evidence on higher risk mothers is better documented from other areas (eg, the data tables at base of Guidelines for induction - cites many many studies).

there are problems with the study, but that isn't one of them,

EdlessAllenPoe:
The study excluded a very important group of stillbirths: those "prior to onset of labor". The reason they're important when comparing outcomes is because there will be women who were waiting for natural onset of labor with a planned homebirth or midwife-led centre birth whose baby died in utero at a late gestational age. If a planned hospital birth would have meant induction or a caesarean at an earlier gestational age, this stillbirth might have been avoided.

I'm not suggesting that there are huge numbers of these cases, and I am making no comment on an individual woman's decision to await the onset of labor, since clearly this benefits as well as risks (and is where individual, informed choice comes in), but in a study that is meant to fully examine the health outcomes of different place of birth plans, then in my opinion, all stillbirths occurring at "full term", should have been included.

That said, I stand corrected in that my earlier post should have said that the study excluded "some" stillbirths. The way I typed it reads as though "all" stillbirths were excluded, which obviously they were not. Apologies for this.

" If a planned hospital birth would have meant induction or a caesarean at an earlier gestational age, this stillbirth might have been avoided"

If a planned hospital birth would have included planned induction or planned c/s then the mother wouldn't have been included in the study.

"but in a study that is meant to fully examine the health outcomes of different place of birth plans, then in my opinion, all stillbirths occurring at "full term", should have been included"

Sorry - meant to add that the study only looked at mothers deemed low risk at the start of labour.

This means that women opting for induction or c/s were excluded completely.

"This is very important to note since one of the cited benefits of a planned cesarean is the fact that your baby is born at 39+ weeks (unless earlier delivery is medically indicated), while the risk of stillbirth increases at later gestational ages."

Worth acknowledging of course that the risk of stillbirth in subsequent pregnancies following c/s appears to be higher because of abnormal placentation caused by scarring on the uterus).

Really? BJOG Sept 2008 Wood Chen and Sauve a study of over 158000 births!

CONCLUSION: Caesarean section in the first birth does not increase the risk of unexplained antepartum stillbirth in second pregnancies.
PMID: 18410656 [PubMed - indexed for MEDLINE]

I thought that stillbirth rates over the last 20 years hadn't changed much, despite the significant increase in caesareans.

I think you'd have to persuade thousands of women to undergo labour with no medical intervention and see how many died in order
to come to any scientific conclusion on that one.... probably not going to happen!

Just look at maternal and foetal mortality rates in Africa.