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.

[BraveLilBear]

God that Telegraph article is even worse...

[LeBFG]

"I think labours are more likely to go shit shaped in hospital" why so? because women are less relaxed? or the effect of epidurals on labour?

[VinegarDrinker]

shag I was so surprised by the lithotomy figures you quoted I checked the study and it was 26% - a 44% increase - NOT 44% of all women! (though I agree, oddly high)

[LaVolcan]

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.

In many areas this must be true, in that the only women who get home births are ones which specifically ask for them. Other areas, Torbay used to be one, did set up their services to offer home births, so that would include women who hadn't previously thought about having a home birth. In those cases it probably could be said to be a random sample.

I would be interested to know how many women get a straight choice: hospital pros/cons, homebirth pros/cons, MLU (if available) pros/cons. I would also question whether it's a choice based on actual conditions or ideal conditions. It's a fat lot of good having wonderful facilities if they can't be accessed because the unit is closed because of staffing issues, or because it's heaving and is closed to new admissions, but no one tells you that this might happen.

[RedToothBrush]

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?

Might be that these women WANT intervention sooner - or at least give the impression that they need it. The act of choosing a CLU so that you have this 'safety net' might mean you have lower tolerances and seek intervention sooner than others. It might be harder to decline this pressure, if you are working in a CLU as a result.

In answer to the Tooting / C&W difference, I think there's a lot of possible answers to that.

The ones I can are:
Does Tooting have the same specialisms as C&S? Even if they serve a similar population, it doesn't mean they would also have something like an FGM clinic; so women might be being referred to one rather than the other?

C&W has a private ward. Tooting does not. I think I'm right in saying that the figures for private wards are included in HES figures, which does distort them.

So again you are having women from outside the local area - who usually fit into a higher risk group - actively self selecting to a greater extent and further distorting the natural demographic of the area, making the figures less comparible.

Further still, when I've seen stuff about C&W I've heard it has a more pro-ELCS policy than perhaps Tooting has. If I lived equal distance from both and had a choice of the two hospitals, maybe this reputation would affect my decision based on my own personal opinion. Again, more self selection that fuels a difference in rates. If policies between hospitals were less variable and more consistent, maybe we would see less of this type of thing occurring.

I'm speculating here, but I think its worth doing. I don't think that even though Tooting and C&W initially look similar areas, that necessarily explains things fully. Thats what we need to fully explore; who exactly is being rejected and admitted into which hospitals (and why) rather than speculating on it too much.

I do think you raise some very important questions - that list you mentioned is now on NHS Choices too and would be high on my list of considerations (though its worth noting that patients in one area might naturally have higher expectations and standards than another, so patient scores can also be a little misleading too!). I do note the ratio of midwives to births is not on NHS Choices though. I think I know the reason why it isn't. Pure politics. Only Scotland and NI have a rate below the recommended 28 midwives to one birth according to this BBC article from 2011.

LaVolcan I've actually just looked at the data that you can download at the bottom of that BBC article too, which I find highly interesting. It gives details about the number of times a maternity unit has been closed and the number of women who have been diverted.

I think I'd like to see more made of this, as I've not seen this information anywhere else before. Knowing that Barnet and Chase Farm closed 140 times in 2010 alone would give me nightmares if it lived locally. I'd be re-mortgaging and going private faced with that as a possibility. No question. Its a simply scandalous figure. I haven't been able to find more up to date figures than 2010 though unfortunately.

Shag you are also dead right about stuff about episiotomy and birth positions. I think I've mentioned about similar concerns about those episiotomies figures before too.

[RedToothBrush]

BraveLilBear, that Telegraph article made me want to strangle the man who wrote it. He clearly was way out of his depth with it.

Funnily enough its got over 240 comments and Kirsty Allsop wrote in to complain about it. The article about Kirsty's criticism published today had about 6 comments last time I checked.

I think it shows up the Telegraph for how it makes money. It generates more interest from an article which is monumentally piss poor and full of deliberately provokative judgementalness than one that has just a touch of intelligence and common sense.

So what hope do we have of evidence based childbirth with that?

[Shagmundfreud]

Vinegar - I'm talking about the figures on the BirthChoice UK site - the results of the Quality Care Commission survey.

You are wrong about the 44% figure indicating a percentage increase. That figure represents the number of women who had their baby in the lithotomy position. The arrow doesn't mean 44% higher. It means 44% of women gave birth in the lithotomy position and the double arrow indicates that this is much higher than the national average.

[VinegarDrinker]

C&W and St George's may be geographically close but that means nothing! They have totally different demographics - look at the ethnic makeup for a start.

And yes, St George's definitely are more pro normal delivery - eg they use STAN monitoring. (Although initial results don't appear to show a significant reduction in CS rates, having worked in units with and without STAN I am sure it makes a difference).

I do think the BirthChoices data is interesting but certainly doesn't tell the whole story.

[VinegarDrinker]

Yes, my error, on phone and trying to do too many things at the same time.

One point - It isn't Barts though, it's the Royal London. Barts haven't had maternity services for years. Same Trust but a very different population amongst many other things.

[Shagmundfreud]

My local hospital has a very high normal birth rate, despite serving one of the biggest African/Caribbean populations the the country.

I find it interesting that Epsom, which serves a very affluent, white population has an incredibly low normal birth rate.

There's probably some formula which would help you work it all out which would involve average age, divided by bmi, times ethnicity and smoking status. If someone gets to the bottom of it, can they let the rest of us know?

[Shagmundfreud]

A population with very rigid perineums, or an enthusiasm for epidurals by the looks of things! (or very scissor happy midwives!)

[Phineyj]

I booked a home birth (with independent midwife) so I could get one to one care, not because I wanted a home birth. I was alarmed by the regular stories in our local press about women giving birth in car parks etc because they had been sent away by the labour ward (I see it happened to someone on a train last week). In the discussions about place of birth, this issue of being sent away by hospital, possibly leading to an adverse outcome, does not get enough attention, imo. I think is it is going to get more common because of concentration of services in larger centres. I ended up transferring into hospital but having a MW with me the whole time was much more reassuring for me and DH than the alternative. I hadn't heard of 'Domino care' until seeing the post above, but that seems to be what I put in place for myself. Rather unfair if yo can only get it in some areas by paying for it!

[VinegarDrinker]

Ethnicity doesn't tell the whole story either though - obviously it affects things like GDM, but I tend to look at % who don't speak English as a better marker of "soft" risk factors, such as late access to antenatal care, barriers to understanding what is "normal" (eg in terms of reduced fetal movements), attendance at AN classes and ability/wish to push for a certain outcome (eg normal delivery)..

[LaVolcan]

Red I had never seen the BBC figures either, and they do make most interesting and depressing reading. I noticed that for Oxford Radcliffe Trust that there were only 5 midwifery vacanies, or 1.8%, but that the ratio of births to midwives was 36.38. On the face of it this sounds as though someone has set the staffing levels too low. A quick back of the envelope type calculation shows that it needs another 50 midwives to bring the ratio down to 28.

[VinegarDrinker]

White and affluent could also mean older women, higher IVF rates, higher twins, more pressure from patients for CS, higher epidural rates etc though.... Swings and roundabouts!

[Shagmundfreud]

I still don't think that it's reasonable to feel that big variations in emergency c/s between hospitals very close together in London can always be explained away by demographics.

[LaVolcan]

Link for Kirsty Allsop's response:

www.telegraph.co.uk/health/healthnews/9920709/Kirstie-Allsopp-Too-posh-to-push-caesarean-label-unfair.html

i am not surprised that Kirsty has responded because she is the sort of woman that the writer probably had in mind. For once I agree with her. I did note though that she had an EMCS the first time round. These are some of the least safe births and I do think that why these are happening, to whom and whether some hospitals have higher rates than their apparent risk populations would lead you to expect, are all questions which should be asked.

I am a bit surprised at The Telegraph in the case of the original article: I usually find that their birth articles are straightforward and factual.

[brettgirl2]

Where is the evidence that environment is what makes the difference? The fact is it could be any number of things. I thought the original study showed for subsequent births low risk mothers were at greatest risk in hospital?

[Kendodd]

I'm not a medic or NCT cheerleader and haven't read the whole thread.

But, I do think mothers sometimes focus too much on the birth process and not enough on the outcome. Birth is not hearts and flowers, it's blood and guts, personally I was just grateful that we both got through it alive and well. I do think it's a bit silly being upset if you didn't get to give birth in the pool with your plinky-plonky music on.

I didn't make a birth plan with any of my children because from what I could see it just goes straight out the window as soon as the birth gets going and just sets women up for failure.

[LaVolcan]

I think it's obvious that you haven't read the thread Kendodd - we are not talking about "pools and plinky-plonky music".

We are talking about a couple of articles, one of which, The Telegraph one we, I think all, agree is badly written, and doesn't say anything but peddles a weary 'too posh to push mantra'. The other article by Alice Roberts, we have varying opinions on, but many of us feel that she ducked the opportunity of highlighting some major problems with the maternity systems in this country which could and should be addressed. I personally, and I don't think I am alone, think that she made some comments about a report which illustrates the fact that she can't have read it and therefore were ignorant and silly.

Personally, I do think it's worth getting upset if you gave birth in the car park, because your hospital was too busy to admit you, or you had an EMCS which might have been avoided with better care. I wish women would get more angry.

[Shagmundfreud]

"I do think it's a bit silly being upset if you didn't get to give birth in the pool with your plinky-plonky music on"

I think that's quite insulting.

Birth is one of the hardest and most dangerous things you're ever likely to do. What happens in labour and how you feel about it can make a difference to your peace of mind and your relationship with your child and your partner in the first few months and sometimes even years of parenthood. I put a lot of effort into planning my care for my second and third birth because of how unpleasant my first labour had been. And I had a great midwife who used my birth plans to shape how she cared for me, even though neither of my labours progressed normally. It was fantastic to feel my feelings and wishes were important to her, and contributed to my feeling very positive afterwards about what was in essence a very difficult experience.

It's not about wanting a 'perfect birth'. It's about wanting to be listened to, and not be treated in such a way as to make a hard experience even harder.

If women want to give birth in a pool and that makes something that is really intrinsically very challenging more bearable, then who are you to sneer and ridicule it? Do you do the same to women who want epidurals?

[BraveLilBear]

Thanks for the Tel link LaVolcan - fair play to them for publishing it, they must have realised how far wide of the mark the original was - and thanks to Kirstie for having the wherewithal and cajones to use her celebrity to fashion such a response.

The BBC piece linked upthread is indeed fascinating, but yet again, incomplete. My Trust is one of those for which 'no data is available' - despite more than 6,000 births a year!

I think it's wrong that some Tusts can hide behind their figures like this.

Kendodd I think it's worth pointing out that the birth process can have a significant outcome on mother and baby's health going forwards, not lease in terms of the mental health of the mother. There are also very real mental health issues connected to the perception of control - choice can have a big influence on that, the more choices you have, the more in control you feel.

Take away control and mum is more likely to have PND which can lead to bonding issues and other problems for the pair of them growing up. It is incredibly important, and not a flippant luxury, as some would have you believe, to choose the most appropriate setting for your circumstances in which to give birth.

[BraveLilBear]

x post shagmund

[HoldMeCloserTonyDanza]

I really don't see the evidence in the quotes given that she hasn't read the full studies she refers to. TBH in an article all about why she wants to educate herself with full studies I find the suggestion she didn't actually read them pretty far-fetched.

Her point about epidurals makes sense to me.

Be honest, folks - did you read the (gentle) swipe at NCT/natural birth/etc, and scour the article for SOMETHING, however small, to disagree with? Because that's kind of how it looks.

(I do that, btw, it's crappy and I try not to but I do do it ).

[HoldMeCloserTonyDanza]

But Bear - control in labour is an illusion - we are at the mercy of genetics/chance/unknown factors related to baby - there is no such thing as a labour a woman can control.

And I think the lie, that by subscribing to any set of beliefs - ESPECIALLY total faith in Ina May Gaskin or your consultant or whoever - you can have what you want, rather than what nature has in store - is just as big a contributor to PND.

There is a lot of money in saying "Oh do what I say, do X and you will microscopically increase your already quite tiny chance of Y". There is not a lot of money in telling people "honestly you will probably be fine but a not insignificant minority of people are not fine, and the main thing that will put you in one camp or the other is genetics and you have no control over it".