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.

[mayhew]

Sigh. I used to rate alice roberts, this is really disappointing.

I am an NHS HB birth mw. Observations about my case load.
: half are primips. Average age 35. National average for primips 27. Half of them need to transfer to CLU during or just after labour.
: the multips even if "low-risk" often have not had straightforward, or at least unpleasant, first births. Often something crappy happened which made them never want to go to a hospital again. If their experience was fine, they book the same again. Less than 10% of these transfer. Average age 34.5.National average for mutips 29.
: I've had 3 bottom clenchingly scary experiences (out of about 150 Hbs). All utterly unpredictable (and came out ok in the end).

Lets hear it for the paramedics and the lovely del suite co-ordinators who are there when it all goes tits-up.

[LaVolcan]

in reality hospital birth should be safer than home birth

Why should it be safer? OK the 'care' for too many women is rubbish, but assuming that it wasn't so, why else? If it's because "it's all there when things go wrong", how about starting to ask what we need to do to make things go right, to avoid the emergencies and problems happening in the first place?

Majorie Tew was famously a statistician in the 1970s who set her students an exercise to analyse the statistics which would back up the policy of moving birth towards hospital because the assumption had been that this was safer. She didn't believe her students when they said that the statistics didn't support this, and re-analysed the results and found that her students were right, the statistics didn't show hospital was safer.

It's known that positive outcomes are linked to things like access to ante-natal care, smoking and social class. Studies have shown that one to one midwifery care in labour with a known attendant improves outcomes. How about a real push forimplementing reforms in these areas?

[Fallenangle]

Having read her piece in the Observer and many of the comments here. I sympathise with Dr Roberts in the point she seems to me to be making: that childbirth evokes emotional, rather than evidence based, reactions from professionals, charities and many individuals.

[AmandaPayne]

But if you are trying to make that point, it tends to go better if you actually read the limited evidence you claim to be citing...

[RedToothBrush]

Shag pointed out some stats for Edgeware Birth Centre last week, which I found pretty troubling.

It shows that over 95% of women there had an unassisted VB; sounds great. Almost unbelievable.

And thats it, they are. When you actually really start looking at how they worked out the figures. Figures that are used to compile the HES official maternity statistics btw, so the stuff you would want and think you would be able to trust the most and are most widely used.

What it doesn't show is the number of women who book in there who don't end up being admitted and giving birth there (off the top of my head without going back to look at the stats, it was something like 44%) and it has a lot of women 'go missing' from its stats.

It also doesn't show that the next nearest hospital has a particularly low rate of unassisted VBs - suggesting that rather than doing marvels in increasing the number of women having an unassisted vb, all it was actually doing was selecting the most suitable women to give birth there.

So the 95% headline (or whatever it was) gives such a different impression to the reality that women can expect if they plan to give birth there. Far from being almost certain to have an unassisted VB, there's a good chance of not getting through the door at all and ending at the hospital down the round that you were probably desperate to avoid when you looked at the HES stats for it.

Bare in mind that if you book into a CLU you are unlikely to change your intended place of birth. So if you are talking about continuity of care...

This is something the place of birth study wouldn't have picked up, due to the way they selected low risk women. The fact that all women are low risk until you find a high risk indicator isn't something that is talked about much but its important to someone's potential experience. Its all very well looking at the place of birth stats when you are a low risk woman, without considering what happens if you suddenly become high risk during the cause of your pregnancy or giving birth. If everything goes to plan... great! But that isn't the case for a significant percentage of women.

Add to that the rate of transfers, and the picture for MLU and homebirths don't look quite so shiny or reflective of real experiences as they are so filtered. Its useful to know, but without knowing the flaws of the data, it could be potentially misleading too.

Its awful. The data needs to be better to show up anomalies like the Edgeware one better so that women can make an informed decision.

The stats - both the place of birth study and the HES figures - give one picture and certain information which is very helpful and definitely worth taking into consideration, but without looking at things from afar too, you miss what the whole picture looks like and important details that might influence your decision, if you knew.

Which is why that article rather annoyed me, as its as blind as the very thing its criticising. Politics and poor data collection/presentation.

I wish people were asking more questions about the data we have and what its weaknesses are as well as the strengths they have so we can improve them so they are more comparable and meaningful than they currently are. Most of the time we seem to be comparing oranges and pears with the data that is being produced. The weakness of these stats and studies really do reveal the areas where we need to be focusing attention and trying to improve the care and experience that women get, if we take the time to study them properly.

I'm grateful for threads like this one for that reason. They are doing the job that journalists are being paid to do, and are doing very badly.

[VinegarDrinker]

Amanda don't get me wrong, I am in no way pro the closure of the Lewisham CLU. And actually I know the MW who set the MLU up fairly well, I'm pretty sure she isn't pro losing the CLU either. And I have no illusions about why it's being done, and it certainly isn't to benefit women. I just mentioned it in response to the claim that the UK is massively biased towards promoting CLU births.

RTB thanks for a very thought provoking post.

LaVolcan "what we need to do to make things go right, to avoid the emergencies and problems happening in the first place?" I agree you can do much, much more to enhance antenatal care (although some risk factors eg obesity seem to be increasing exponentially regardless of ublic health programmes) but that will never eliminate the true unpredictable emergencies of childbirth - the things that make people like me and mayhew shit our pants. Thankfully they are rare, but they will always exist.

[exoticfruits]

It sums up my feelings exactly and are the reasons that I would always go for a hospital birth and peace of mind for being in the right place. We are all different - it would be very odd if there was 'the' way for everyone. I thought it a good article.

[mayhew]

VinegarDrinker I'm feeling a bit of love for london ambulance paramedics at the moment. Speedy, competent and compassionate. I've needed them twice in the last 2 weeks in urgent circumstances.They were ace.

Without them, I wouldn't want to do this work.

[glorious]

I too was disappointed with the misinterpretation of the study and have written a stroppy email to the Observer reader's editor. Fingers crossed they actually look into it...

[Shagmundfreud]

"Hello bear is right, plus I would add that in reality hospital birth should be safer than home birth."

It depends where you stand on the issue of how environment impacts on the normal hormonal physiology of labour.

My personal view is that human beings are mammals, and we - to some degree - give birth like mammals. I know that we struggle more in labour because of our babies' big head and our narrow pelves, but why do we assume that all other golden 'rules' of mammalian obstetrics (ie, don't move, touch, disrupt or distress a labouring mammal unless you absolutely have to) simply don't apply to humans?

I'm not surprised so many women can't have straightforward deliveries in hospital. I think everything about the way care is organised in them militates against the normal physiology of birth.

Shag pointed out some stats for Edgeware Birth Centre last week, which I found pretty troubling.

"It shows that over 95% of women there had an unassisted VB; sounds great. Almost unbelievable."

I don't find it unbelievable. Look at Ina May's stats for The Farm birth centre: 98.6% of the women who gave birth there between 1970 and 1995 had unassisted vaginal births. 44.7% were women expecting their first baby. In the UK in the 1950's only 2% of women had a c/s. Now I know that we're talking about women who were a) thinner (much), b) younger (a lot), and in the case of the farm c) women who'd had case loading midwifery care, and also d) in the 1950's maternal and perinatal mortality was higher than today, BUT it does suggest that the incredibly low percentage of normal births today MUST have something to do with the health of modern mothers, and our modern systems of care, and is not simply a reflection of the intrinsic difficulty of human birth.

And if the very low rates of normal birth is primarily down to new mothers being older and fatter, and to the way care is organised, then surely something can be done to improve the situation?

Would also add, that in the POB study shows that 91% of multips who book a home birth complete the birth at home, and that only 5% transfer in labour.

"Most of the time we seem to be comparing oranges and pears with the data that is being produced"

I don't think you can say this is true of either the Place of Birth Study 2011, or the National Birthday Trust study 1994 - the two main UK studies of outcomes associated with place of birth done in the past 2 decades. Both studies try to only look at outcomes for healthy, low risk mothers in a range of settings.

[RedToothBrush]

What about the Edgeware selection process and the figures of nearby hospitals?

Stats need to be taken in context, no isolation. They need to provide comprehensive methodology and be shown to be comparable with other stats if that is what you intend to do with them.

I find it troubling when stats produced are so far off 'the norm' that people don't question them more.

If Ina May had some found some miracle here I really do think that there would be a massive difference in disparity. Something simply does not ring true. Even advocates of her methods have been unable to replicate such good figures elsewhere.

My money is on a self selecting or deliberately selecting candidates; something that makes both sets of figures, non comparable against a wider population.

Thats not to say that there probably isn't a lot in what Ina May says; far from it. But to look at her figures and be blinded by them also helps no one. It doesn't improve our understanding unless we look at the demographics properly.

In terms of the changes in CS rates in the UK since the 1950 we must not loose sight of the fact that the population of the 1950s is not directly comparable with the population of today. The figures tell a story, but what is the story? Thats the question - you don't just look at the black and white figures without understanding the bigger picture behind them. People tend to lack the knowledge to look at stats and ask these questions and simply take them at face value. Not just your average person but also people who are educated and work in science and should have been taught about stats.

Age and obesity are the obvious and best known changes when it comes to changes in the British demographic but they are by not means the only ones.

Women's bodies have changed, not just because they are unhealthier but also because they are more healthy! The skeletal frame of a British woman has got bigger, with the exception of her pelvis. Profound changes that have outstripped our evolutionary ability.

Babies who would previously not have survived to child bearing age, now do; in theory this might mean in fact that women who never would have been designed by nature to give birth because of various underlying health issues, now do. The NHS has a lot to answer for!

Birth weights and head sizes have increased significantly from better diets and vitamin supplements. (Lets note the use of folic acid which has a proven effect on spine and skull development)

And we should look at changing ethnic populations. Certain groups have more problems and mixed ethnic couples have been shown in a few studies to have problems and a greater rate of cephalic disproportion because of genetic mixes that haven't previously be as common.

Indeed, there was a study a couple of years ago, that I was looking at over the weekend because of a crap article in the Telegraph that looked at a 'north / south' divide in CS rates. The study looked closely at the differences and picked up that these regional differences owed far more to the varying demographics than to women's choice or CS-happy Obstetricians.

At the moment the questions that really need to be raised for me are about this level of transparency and understanding. Its clear that something is different between a home birth and a hospital birth; thats what we need to find out. But there is absolutely no point in becoming obsessed with low risk mothers only, because again that does women a disserve.

How many women are low risk and then become high risk.
How many women are being rejected from MLUs far earlier in the process.
How many women plan a homebirth but don't even get a shot at it for x, y or reason.

These are things that seem to repeatedly be missed from these studies and stats. They are important. They highlight that choice is more limited than we are lead to believe.

This is stuff that I wish Alice Roberts had thought to look at in her article, rather than 'taking a swipe at the NCT' as someone upthread put. TBH, I don't actually blame the NCT for promoting stuff in the way they have. I blame the fact that statistics is poorly taught and understood and the fact that people are not taught to question comparisons more.

[LaVolcan]

They are all good questions Red. They could go further. They could ask," since 90%+ of women give birth in CLUs, why are there such discrepancies between the outcomes for such hospitals?"

Just to take one example: I was looking at the stats for the Oxford region <a class="break-all" href="http://www.birthchoiceuk.com/BirthChoiceUKFrame.htm?www.birthchoiceuk.com/Access.htm" rel="nofollow noindex" target="_blank">www.birthchoiceuk.com/BirthChoiceUKFrame.htm?www.birthchoiceuk.com/Access.htm
You would expect the JR to have high rates of intervention because it's a regional centre of expertise, so women with problems are referred there from far and wide. I don't know the first thing about Kettering hospital, but they have a higher induction rate than the JR, a higher CS rate but lower instrumental delivery rate, but only have 38.3% of a normal birth rate as opposed to the JRs 37%. If they are not a regional centre with the higher proportion of high risk cases, why aren't their normal births higher? Maybe there is a reason which we don't know about until we dig deeper into the stats.

As you say, there is so much that Alice Roberts could have asked. She could have used her celebrity coupled with her medical knowledge to ask some hard hitting questions.

[VinegarDrinker]

Not all high risk cases are concentrated in central units, though. I've worked in many DGHs that have a higher risk profile than teaching hospitals, in terms of BMI, ethnicity, non English speaking, HIV, multiple previous uterine surgeries etc.

No idea about that particular area, but it is worth considering.

Juggling toddler so can't reply at more length but reading all replies with interest.

[VinegarDrinker]

Btw I don't think she (AR) is a practising Dr. Need Ben Goldacre on the case for a proper public dissection of the research and stats.

[RedToothBrush]

LaVolcan, The Telegraph article I saw this weekend was slamming 'wealthy' Chelsea and Westminster for having really high CS rates and this apparently 'supported the idea of too posh to push'.

TBF the journalist was an absolute moron when he picked up on the particularly high ELCS rate. He didn't know the difference between an ELCS and maternal request, and the way the article reads it seems that he is under the impression that most ELCS are for non-medical reasons! .

So he completely ignored the older demographic of wealthier women who have an increased risk of a medically needed ELCS, the wide disparity of wealth within the area which also has areas of high poverty as well as wealth and the diverse ethnic makeup of the area.

One of the comments below the article was very interesting, and something I would never have known. It turns out Chelsea and Westminster is home to rather large Somali population which has particularly complex needs; there is a specialist FGM clinic at the hospital...

This stuff is important. I think that perhaps there needs to be a modifier or indicator of these type of things on the data that is on NHS choices.

[BraveLilBear]

Reading this discussion with interest. As a former journalist who was particularly good on statistics, I was unimpressed with what reads as a bland feature with no real insight.

As to CLU units not accepting low-risk mothers or not wanting them, I am in an area where I have no choice. It's CLU or HB. The free-standing MLU was closed 18 months ago because they were incapable of safely staffing it - the hospital does > 6,000 births a year with a handful of HBs.

The Trust is supposed to be creating an AMU with, wait for it, 3 birth pools and a handful more delivery suites, but there is no sign of it as yet. It was supposed to open in January 2013. So currently there's an average of 17-18 births a day, in 20 delivery suites. It troubles me that my first-born is due in the middle of a baby-boom, where the next nearest facility is more than 40 miles away.

As I am so stricken for choice, I looked at the stats for the hospital, and was shocked to see a very high induction rate of nearly 25% - but fortunately coupled with low CS and instrumental birth rates. I can only imagine this is down to it being a MW teaching hospital, but will be discussing with my MW at my next appointment.

[RedToothBrush]

Welovegrapes, I honestly would be surprised if they weren't also affected by those things. I think they are really valid and interesting ideas that we should be exploring. It would be wrong to dismiss what she's doing, as it seems like she's got 'something'.

But even if that is the case, I don't think that it would be possible to expand that to the entire population; I think it would only help a certain percentage of the population due to the different approaches to life we have. You simply are not going to get universal rates of 95% across the country and that be good for women or children alike.

You can not forget that The Farm does not exist in isolation, and its my understanding that although they do take on some higher risk pregnancies such as breech, twins and women who have had 5 or more children already, they do reject some women with more complex medical histories.

Like Edgeware.

[Shagmundfreud]

Redtooth - Ina May's stats really aren't that exceptional for a low risk, healthy population of young mothers.

And you have to remember that women who have case loading care (which is what Ina May provides) really do have better outcomes than women who have the normal type of NHS midwifery care.

There was a study on outcomes associated with independent midwifery care in the UK a few years ago. 77.9% of women in the study who had independent midwifery care had a completely normal delivery, despite the fact that 21% had previous obstetric complications (including c/s) and 3.1% were carrying twins. When high risk cases were excluded, the neonatal outcomes were similar to those found in low risk women having NHS midwifery care.

Redtoothbrush - my concern about C&W is why they have a 33% c/s rate, whereas nearby St Georges in Tooting, which is also serving a high risk population (it's only about 3 miles from C&W) has a 26% c/s rate. St Georges attracts a lot of high risk cases because of its top notch neonatal unit.

I don't honestly think it's that complicated. We know what patterns of care and what features are associated with an increase in the normal birth rate:

• case-loading midwifery care
  
• one to one care in labour
  
• consultant input when a labour becomes complicated
  
• a healthy BMI at booking
  
• maternal age under 30
  

and there's a growing body of evidence suggesting that doula care in labour is associated with a significant raising of the likelihood of a normal birth.

If I was a first time mum thinking about where and how to have my baby, I'd be looking at this information on BirthChoice UK (which comes from the Quality Care Commission Survey) -

• 'how many midwives looked after you in labour?',
  

• 'Did you get the pain relief you wanted?',
  

• 'Were you (and/or your husband, partner or a companion) left alone by midwives or doctors at a time when it worried you?',
  

• 'Were you treated with respect and kindness?'
  

• 'Overall, thinking about your care during labour and birth, were you involved enough in decisions about your care?'
  

And maybe look at the number of births per midwife at the hospitals you can choose from and compare them to the number suggested by the RCM which allows for 'optimal' care.

Really - it amazes me that people aren't more interested in this type of information. Some of the information on BirthChoice UK is absolutely MIND BOGGLING!

• Some hospitals have episiotomy rates which are DOUBLE that of other hospitals (Ealing Hospital 40%, West Suffolk, 14%),
  
• What about birth positions? 44% of women giving birth at Barts in London give birth with their legs in stirrups, compared to only 14% at Kings in London!
  

I mean, seriously, WTF is going on here?

[Shagmundfreud]

Case-loading domino care for all mothers who want it I say! That would bring the C-section rate down.

here

[LeBFG]

Such an interesting thread to read. One that is long overdue imo. Particularly interesting is the point that these out-of-hospital births are clearly not a random sample of 'low-risk' women - for one thing, these women are, for one reason or another, pretty determined to birth naturally.

Just a small point. In the Netherlands the referral rate for HB is lower than in the UK even though HB are at 30%. Plus I read that midwifery techniques (particularly for a natural 3rd stage) are very important to outcome (delivery of placenta, pph etc). I would like to see more comparative sort of research - what are the Netherlands doing to make HB so safe? Should we be revising MW techniques in the UK?

Hospitals certainly should be safer places for higher risk births. I would expect that to be the case - if they aren't, questions need to be asked. I can see how low-risk women in hospital situations however may be more likely to have interventions etc because the professionals in charge are used to seeing more high-risk births, some with poor outcomes. I would expect these people to act in a precautionary way to limit events spiralling. As these people have been 'enlisted' by the women to overlook their births, should it really come to a surprise to anyone that they intervene perhaps a little too hastily in low-risk births?

[LaVolcan]

Red I take it this was the Telegraph article:
www.telegraph.co.uk/health/healthnews/9918384/Caesarian-rates-support-too-posh-to-push-theory.html

I haven't had time to read all the comments - some are sensible, some are the usual sorts of rants that you get on these sites. I was interested in the comment that it was a teaching hospital and therefore they wanted to give medical students hands on experience. I have a suspicion that there may be some truth in this.

The presence of the Somali community was interesting, but I doubt whether they are the cause of the high CS rates - which would link with shagmund's comment about St George's also serving a high risk population but with lower intervention rates.

[Shagmundfreud]

"I would like to see more comparative sort of research - what are the Netherlands doing to make HB so safe? Should we be revising MW techniques in the UK?"

In the UK there are areas where only 1% of babies are born at home. In other areas it's more than 10%. Some areas have dedicated home birth teams who provide case loading care for all home birth mothers. In other areas women booking a home birth may end up being looked after by a midwife who's done very, very few home births, and who they've never met before.

I think you'll find that this might account for some of the differences, as well as the fact that mothers having homebirths in the UK are probably on average much older and fatter than their counterparts in the Netherlands.

It puts me in mind of an editorial in the BJM a few years back discussing how midwives used to work and train in the days when many many more women in the UK had homebirths (1950's and beginning of the 1960's). Midwives either focused on a career delivering babies in hospital, or a career working in the community. It was acknowledged that to some extent they needed a different focus and skill set for these two jobs. I think this is very much the case now, when some midwives working in hospital hardly ever see a completely normal labour that doesn't involve some sort of intervention or other.

LeBFG - I don't think doctors and midwives are cavalier about interventions. I think labours are more likely to go shit shaped in hospital and it's this that leads to higher rates of c/s and other interventions.