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

[VinegarDrinker]

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.

"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.

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

Well - no one could disagree with that.

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

Can we lay that one to rest then?

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.

Sorry, "massive bias" not conspiracy.

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'.

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.

"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).

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.

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?

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.

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.

"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.

.....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.

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.

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

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.

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.

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.

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.

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?

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.

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 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.

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.

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 And if your theory about HBers being the lowest risk women us true, surely those figures are all the more concerning?

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.