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.

The only think I learnt from that article is that the quality of science journalism in this country is worse than I thought.

As you were.

I've just waded through some of the stuff on Birthchoices.

Trouble is a lot of it is starting to really date now. The Healthcare Commission data is from 2007. Since then there have been a lot of updates in various areas in NICE guidance. Some of which has been taken up, some of which less so.

I focussed on the CS rates as a) its what I'm personally most interested in and b) its what everyone like to point to as an indicator of success and failure. I've not looked at all - just a random selection from the NW and London.

The average rate for VBACs for England was 32% at the time of publication. Yet South Manchester had a rate of 1.2% according to this data! Guys & St Thomas had 6.7%. And loads of Trusts didn't supply any data at all. Now the NICE guidelines have been updated since this report so it would be interesting to see what, if any, changes have happened since 2007.

Then you have EMCS undertaken within 30mins. English average 92.8%. Yet a significant number didn't supply data, and of those that did I've seen a significant percentage at around 65 - 70%. One or two fell far below that.

The percentage of women over 35 having a CS ranged between 26.2% and 43.4% at the ones I looked at. English average was 33.3%.

The ethnically and age adjusted figures were interesting. C&W which has been mentioned on this thread had an overall figure of 30.1% - the highest I've seen. But when adjusted this came out at 25.7%. Which was at the higher end, but not the highest. Conversely, St Helens and Knowsleys base figure was 23.2% but adjusted came out at 24.1%. The England average being 22.2%.

So actually, I really do not think that C&W is nearly as bad as it is being reported. (The lowest one I've spotted of the ones I looked at, was ironically Lewisham adjusted to 16.8% from 22.5%).

The other figure that jumped out at me, was the staggering 27.4% of CS done by GA at Mid Cheshire. The English average was 9.9%.

It really does seem to me, that what the base CS rate is, probably should be one of our lesser concerns. Not when you look at some of the other figures popping up all over the place. I really, really wish that the newspapers started looking at some of this, as its far more revealing.

From browsing, I could have easily looked at a bunch of other issues other than CS and painted a similar pattern. It just daft. And it annoys me more and more, when its constantly about the same old shit in the newspapers.

As mentioned before, I read the article as bland and a wasted opportunity. Yes, it's about her choices, but with power comes responsibility, and it's important to recognise that not everyone has the same level of choice or care available.

And I agree that choice in labour is an illusion to an extent - however, there are choices that you can make along the way. Induction or monitoring, what pain relief options you want to to pursue, constant VEs or not, what plans you want in place if everything goes horribly wrong... while in some circumstances choices will be limited, there are often some elements of choice still available. Even if it's 'sod my health, save the baby at all costs'.

The issue is that it's difficult to make informed choices about such decisions when so much evidence is skewed by wonky data or biased reporting (by pro and anti-VB/CS camps, consultants, midwives and the mothers club down the road).

To me at least, it's a shame that such a useful platform to create a discussion around evidence-based childbirth misses this opportunity when it's a discussion that really needs to be had on a national scale.

"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"

Oh come on - you can't control the position of your baby (usually), or the rate at which your cervix dilates, or the shape of your pelvis, but you can often have some control over:

• what you do with your body in response to the contractions,
• how you mentally respond to the experience of labour,
• how you are treated by the people looking after you.

And I know this because I felt in control of myself through most of my second two labours, once I'd organised to be looked for by someone who shaped the care she gave me according to my specific needs, rather than the organisational needs and protocols of the NHS.

And there will be other women on this board who will tell you the same.

"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."

Nobody in their right mind would say or suggest that it's reasonable to lead women to feel that they can avoid all problems in labour if they plan it right, or have care from someone they trust. But it DOES make a difference to the majority. And that difference is reflected in the better clinical outcomes for low risk women cared for by independent midwives.

Really - it doesn't make sense to take that sort of fatalistic attitude, to insist that because you can't control some aspects of labour, you therefore can't control anything at all about the birth. It's also not true, as many women on this board will tell you in relation to their personal experiences.

Re: PND - actually I've got some research on this, one of the very few studies on expectations of birth and how they impact on women's feelings after birth. They show that women who go into birth with high expectations of being treated well, and an expectation that they will find it a positive experience (albeit with a realistic expectation that anything can happen), have the best psychological outcomes afterwards, independent of what actually happens during labour. Which of course runs pretty much counter to the stereotype bandied about on mumsnet.

"and the main thing that will put you in one camp or the other is genetics and you have no control over it".

If the POB figures are to be believed the single most influential thing when it comes to what sort of birth you have is WHERE you have your baby. You are a healthy mum, you appear to be really very much more likely to have an uncomplicated birth if you stay the hell away from a CLU to have your baby, and either head for a MLU or stay at home.

Redtoothbrush

I'm warning you - those tables on BirthChoice can suck the life out of you. I've spent hours goggling at them, saying, 'What? No! Eh? WTF!'

An uncomplicated birth .... But with double the risk of adverse outcomes for your baby. We can all spin statistics...

Mode of delivery is not the be all and end all. And by that I don't mean "as long as we are both alive that's OK".

I had a fantastic experience with DS's labour and delivery. Yes, you read that right. I was well supported, and the eventual forceps and PPH were all managed very well and efficiently. I was treated with respect and kindness throughout. The way he eventually exited my body is way, way down my wishlist after compassionate, caring, competent treatment.

(Btw I delivered somewhere I hadn't worked, where noone knew me as a Dr, so certainly didn't get preferential treatment).

I find terms like "twice as risky" "more than double the risk" "three times safer" unhelpful because there's no comparator.

A risk of 1:20,000 vs 1:10,000 is pretty unlikely in either circumstance. 1:4 or 1:2 both very likely in either circumstance and yet both show "double the risk" stats.

I want to be given data straight up (evidence) and then adjusted for my personal circumstances (subjective) so I can make better informed decisions.

Until we get information like this women cannot make informed decisions about their care.

Haha I've figured that already. I think I'd be more interested in whats changed since they were published now though. 2007 is a lot time and the face of healthcare has changed a great deal since then. I like to know whether making that data public got rid of some of those glaring anomalies or not. If collecting all that data has done nothing, then its a absolute travesty - and the fact it has been so ignored would owe quite a lot to the unintelligent and backwards media coverage of the whole subject in my mind.

Interesting thread.

There seems to be an idea here that HB means you are all Ina May Gaskin hippy and NCT.

That's really not always the case.

I had a hb because I didn't have childcare within an hour's travel and I was warned my birth would be fast based on history.

Had I even tried to get to hospital DS4 would have been born in the Tesco Express car park at 12.35 am on a cold April night attended by DH, 2 autistic sons (hence the childcare issues- can hardly drop with a neighbour and as I have AS myself I really needed Dh to advocate for me).. instead he was born in a warm home after a 35 minute labour with a MW in attendance (just) and another arriving just afterwards, also with a doula there to help out.
The GP told me to drop my hippy ways and go to hospital when I asked about HB; he refused to do the post birth visit as well so I had to go to hospital for that. A MW at the hospital told me similar, and then argued with me about the number of children I already had (3) because one was born at a different hospital and she didn't have the notes in front of her so she proclaimed I must be wrong and only had 2. you will understand my confidence in that, new to us, hospital plummeted immediately!

And a day or two after ds4's joyous but rapid birth the hospital unit was closed as a risk to women due to two maternal deaths. My instincts were bang on.

But primarily it was the childcare / sn kids issue, and absolutely I would have transferred if needed- hence the doula to accompany me whilst DH drove to England to drop children with only childcare we had.

I wish people would not make assumptions, people and their reasons are all very different. I am neither under educated (think almost completed MA in Autism) nor anti NHS or medical care, I am just a normal person with a complex life who researched, read, and made the decisions right for her.

And yes I did feel much more in control than my previous birth: and healthier too, but that might be because I couldn't eat after ds3 was born until I went home, the maternity unit being unable to provide the dairy free diet I rely on. Toast with butter ('sorry it's buttered when it comes'), cereal with milk, those were the options.

long time ago even*

Exactly Katie, hence my comment about spin.

Well I haven't read much of this thread or related links as yet, but I think it's a shame there can't be a smoother continuum between different kinds of care offered to women in labour.

For example there is talk of "having to throw out your birth plan when it doesn't go according to plan" whereas I very much felt I wanted to cover all bases.

A shame there is such a divide between midwife led care and obsetrician led care.
I'd like to see everyone coming together more to provide women with the care they need in sometimes unknown and changing circumstances.

I had a hospital birth for my first, was advised by the director of midwifery to have a homebirth for my second and didn't even see an obstetrician for my third. At the time it was much safer for me to keep away from the local obstetricians who thought women should be designed with a zip. I wasn't prepared to accept the risk of interventions that would have followed a hospital booking at the time.

lol peachy arguing with you about how many children you have

Btw, I'm not anti hospital birth, I was very happy with my hospital induction and waterbirth but I moved house between ds and dd1 and the new hospital was run by scalpel happy obs.

Alice Roberts annoyed me because if she had read the Place of Birth study which she is purporting to quote she would know that it talks about planned place of birth at the start of labour. It shouldn't be too difficult to work out that the forceps and epidurals happen in a CLU after transfer, hence my comments that her statements about forceps and epidurals are silly.

She then pays credence to the ACOG source which she admits is hard line "choosing to deliver a baby at home? is to show preference for the process of giving birth over the goal of having a healthy baby", This is an opinion from a biased source which has a vested interest in hospital births. It can't be directly compared to the UK because the systems are so different. It isn't backed up by good quality UK research, nor do I believe is it a viewpoint backed up by our own RCOG.

Ultimately it's her choice. At present no one is saying that she can't have a CLU birth so really what is she going on about? Why bother with the swipe at home births and NCT?

Still, ?not something I want, even though it's a safe option for the baby with proven benefits for the mother. End of." doesn't fill a two page article, does it?

How do you define "a safe option"? It certainly isn't the safest option according to the POB study.

What do you see as the 'safest option' for a second time mum like Alice Roberts Vinegar? Factoring in the doubling of the risk of major surgery that comes with a hospital birth?

For multiparous women, there were no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units.

The bolding is mine. That would be good enough for me.

For multiparous women, birth in a non-obstetric unit setting significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy. That would be another bonus factor.

Btw, I hope it is obvious I am not anti HBs. I am anti people being uninformed about the true difference in risk profile. Which goes both ways for sure, I think in general we (MWs and Drs) are really bad at being honest about the unpredictable risks of childbirth in a non scary way. And the lobby groups do often get very emotionally involved in their way being the Right Way, hence the difficulty with getting hold of pure facts (the limited ones we do have).

Ah the multip bit I agree with, I didn't realise you were talking about her case specifically.

Homebirth is a safe option in the same way that hospital birth is a safe option. Neither is guaranteed. But you chose your own risks and personally I would never book with an obstetrician again. They can undermine your confidence in your ability to birth vaginally, and increase your anxiety. Whereas a good midwife will stand back and only coach you through the process if you need help. Of course doctors have their place but they should not be let loose to influence women's decisions at the booking in appointment...

Also to say - you have to look at the risks to the woman and the baby separately if at all possible imho. Risks to women : much more common but to many people usually less "serious" (in terms of life changing). Risks to baby, much rarer but potentially devastating. (Oversimplification for sure!)

The use of episiotomy as an adverse outcome is an interesting one. I think of them as fairly value neutral - obviously unnecessary ones are Bad but they have their place and I certainly didn't give mine a second thought.

jchoc are you in the UK? You don't generally choose to be under Consultant care if you are low risk. It isn't offered as an option. And Drs don't do booking appointments here either.

Studiously ignoring the rest of your generalisations and insults

They did do the hospital booking in appointment, they did tell me I needed a pelvic xray. That is my experience, personally I would never book with an obstetrician again. no insult intended.