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Childbirth

Share experiences and get support around labour, birth and recovery.

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

260 replies

VinegarDrinker · 10/03/2013 13:30

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.

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Shagmundfreud · 12/03/2013 09:18

An interesting lecture on place of birth by Professor Peter Brocklehurst UCL Director of Women's Health. FYI.

Vinegar - the point I was making was about FMU's. The findings of the POB study don't suggest that ALL out of hospital birth is associated with poorer outcomes for the babies of first time mums, only that home birth is. Would you address this point? I do accept that you are not making a case for low risk women to give birth on a CLU. However, you are making a case that primips should give birth in hospital.

Perhaps you have not recognised that when I'm talking about 'out of hospital birth' I'm not simply referring to home birth, but to the other out of hospital setting - free standing midwife led units. Perhaps this is what's causing the confusion.

VinegarDrinker · 12/03/2013 09:34

No I'm not! You are putting words in my mouth. We have a freestanding MLU where I work now, I have no issues whatsoever with them, and all our low risk women are automatically offered FMU or attached MLU by their midwives, by definition they don't see me anyway.

I just didn't choose one myself, which should be neither here nor there. (In fact where I delivered it wasn't an option!)

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LaVolcan · 12/03/2013 09:43

It's often said on threads like this and in childbirth discussions that an MLU is no better equipped than the midwives would be at a home birth, so if you are considered OK for MLU you would be equally OK for a homebirth.

The PoB's finding that the freestanding MLUs were the safest place for mother and baby for a primip is an interesting one. So if it's not equipment, what is it that gives it the edge? Staffing, or staff being more familiar and hence confident in a known environment? Ease of transfer if there is a problem with the ambulance being more familiar with the MLU? It's something which needs further research.

Shagmundfreud · 12/03/2013 10:02

"We have a freestanding MLU where I work now, I have no issues whatsoever with them"

Vinegar, it seems your primary concern about home birth for first time mothers is the lack of immediate medical input in the case of a severe obstetric emergency and the possible impact of this on the baby.

Why do you not have the same concerns about FMU's as women in these units also need to transfer for obstetric input?

LaVolcan - I'm convinced it's down to the experience of the staff working in FMU's. This would obviously impact on all areas of labour management, including those surrounding how transfer is handled.

TBH it's very frustrating that the response of many medics to the POB's findings about primips and home birth hasn't been to question why this disparity between outcomes in out of hospital settings exists and to consider how to address it, considering the considerable advantages of having a home birth in relation to the very much reduced rates of intervention. It's not fair to say that women can simply go to a birth centre to access these benefits - FMU's are few and far between in the UK, and alongside birth centres simply don't at the moment have the capacity to deal with all the women who would be considered suitable to use them.

Shagmundfreud · 12/03/2013 10:07

Can I urge anyone on this thread who is interested in this topic to the discussion I posted a link to earlier?

It really does answer many of the questions about the POB study which have cropped up here.

It also shows Alice Roberts article up in a very poor light, particularly her comments about the ACOG stance of home birth. ( 5 or 6 minutes towards the end for the speakers reference to this).

VinegarDrinker · 12/03/2013 10:26

Are we talking about my personal concerns or my professional concerns? Professionally I think women should deliver where they want. I think they should be aware of the comparative risks to mum and baby and make their own decisions. I would always emphasise to anyone the absolute risks of adverse outcomes are extremely low.

Personally I've seen enough unexpected unpredictable emergencies in low risk women that I felt more comfortable (and therefore probably laboured more quickly) in an attached MLU with an obstetric/anaesthetic/neonatal team a crash bleep away. From a purely personal POV the stats actually become quite meaningless - I know I personally would not have wanted to be the one in XXX where being near a theatre/anaesthetist/neonatalogist would have made a difference to the outcome in a life changing way.

I do think there are interesting questions about FMUs vs HBs stats. I have mentioned and agreed with this several times so I have no idea why you think I am uninterested. I think FMUs are actually better equipped, and also have more hands on deck in an emergency. But as I'm not a MW the amount of time I spend either at HBs or FMUs is limited, therefore I don't feel qualified to comment further. Furthermore, medics have zero input into commissioning and running midwifery led maternity services, so quite why you think doctors should or could be looking at FMUs vs HBs is beyond me. I am interested of course but I have no more influence over any of it than any other MNer. Maybe mayhew will come back to add her expert opinion?

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LaVolcan · 12/03/2013 10:49

Excellent link shagmund - thanks for posting it.

TBH it's very frustrating that the response of many medics to the POB's findings about primips and home birth hasn't been to question why this disparity between outcomes in out of hospital settings exists and to consider how to address it, .............. It's not fair to say that women can simply go to a birth centre to access these benefits - FMU's are few and far between in the UK,.......

I fully agree with your statement above.

I was annoyed by the biased reporting of the PoB study by the Daily Mail and others. For me the big story was that for multips CLUs are significantly less safe for her, without offering a compensating advantage for the baby. There was hardly a peep about this in the press and yet this potentially effects a majority of childbearing women in this country.

On a personal level the PoB was a revelation to me. I had often noticed women/partners saying that they had a homebirth/MLU birth but they were lucky it all went well. I'd noticed CLU births very rarely occured without some sort of intervention, with EMCS becoming increasingly common. As they say, anecdote is not data, so this study put some flesh onto the bones of my personal observations. It wasn't a matter of luck, outcomes really were better at home or MLUs.

LaVolcan · 12/03/2013 11:20

I know I personally would not have wanted to be the one in XXX where being near a theatre/anaesthetist/neonatalogist would have made a difference to the outcome in a life changing way.

Which just goes to show that we are all different. My choice was: do I take pot luck in the CLU and get a share of a probably newishly qualified midwife who I have never met before, who has to scrabble through my notes to find the first thing about me, and then has to keep popping in and out to the next room? Or do I go with a midwife I have got to know over six months, who has twenty years experience, whose judgement I trust?

VinegarDrinker · 12/03/2013 11:41

It is a bit of an oversimplification to say community MWs are all very experienced and those in MLUs/CLUs are newly qualified!. I do appreciate the attraction of having a MW you know, though. However, whilst the quality of midwifery is undoubtedly very important, it won't precent those rare but devastating complications where minutes matter.

I can't see why those complaints aren't better dealing with by campaigning for proper one to one midwifery in all settings rather than just campaigning for HB. It seems a very odd way of going about things.

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VinegarDrinker · 12/03/2013 11:44

Btw as clarified above, these are my personal reasons for choosing an attached MLU, completely separate to what I think anyone else should do.

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LaVolcan · 12/03/2013 12:03

I wasn't saying that all midwives in the CLU were newly qualified - just basing it on what was likely to be the experience for me. Others having a homebirth wouldn't have a caseloading midwife so for them the choices might be different.

Many people are campaigning for one to one midwifery in whatever setting. I think there are actually precious few specifically campaigning for homebirth.

lrichmondgabber · 12/03/2013 12:05

Sorry thought it was politics

VisualiseAHorse · 12/03/2013 12:17

I haven't had time yet to read through the thread, but have just read the article.

Knowledge is always power - women should always be aware of their local POB, transfer rates, intervention rates etc.

It's often said on threads like this and in childbirth discussions that an MLU is no better equipped than the midwives would be at a home birth, so if you are considered OK for MLU you would be equally OK for a homebirth.
I would've been ok for a homebirth, but the MLU was already 40 minutes (that's at top speed on a windy rural road that is often closed during the winter due to snow) away, so I never would've risked a homebirth. The hospital itself is 2 hours away from home, so we felt the MLU was a happy medium. Having had all the information from the MW's, I was able to make the best decision for us both, which was the MLU.

I would prefer a campaign for proper one to one MW care using 'birth centers', rather than a campaign for HB.

LaVolcan · 12/03/2013 12:25

I think we took the wrong direction when we started concentrating on the place of birth rather than the quality of care, and hence the present mess where one midwife is covering two or three women in strong labour. Professor Peter Brocklehurst, in the discussion above, was an accidental home birth when his mother was sent home because she was deemed not to be in labour. He didn't say whether she was able to get hold of a midwife or not, but who was attending her later stages of labour in the car home? At a guess, no-one.

I would prefer a campaign centred round one to one care from a known and appropriate attendant. It's just as bad for someone who needs consultant care not to get it.

KatieMiddleton · 12/03/2013 12:27

I would prefer a campaign for proper one to one MW care using 'birth centers', rather than a campaign for HB.

Well obviously, because that is what you would prefer! A campaign for proper one-to-one care for all would be better and I could support that. I couldn't support something that takes away a choice (that for many women is a good option and saves the NHS money) any more than I could support something that takes away MLU or CLU care.

Shagmundfreud · 12/03/2013 12:36

"I would prefer a campaign for proper one to one MW care using 'birth centers', rather than a campaign for HB."

Do you not feel that home birth should be an option for women?

Because if you do then there DOES need to be a campaign to make sure the homebirth service is a) safe b) available in all areas and b) that women aren't subject to misinformation about it.

Shagmundfreud · 12/03/2013 12:41

I think we need a campaign for one to one care for all women in labour.

And a campaign to make sure that women have a free choice as to where they have their baby.

Some women need an epidural to have a birth they can cope with emotionally and physically. Some women need not to go to hospital. If you feel it's reasonable to raise your voice against misinformation regarding epidurals, and covert restriction of their use because of funding issues, then it's also reasonable to raise your voice in support of women having the right to access a good quality home birth service, the appropriately presented information to make an informed choice.

VisualiseAHorse · 12/03/2013 12:43

HB should always be an option, alongside MLU and hospitals....so maybe I should've written 'I would like a campaign for one-to-one care' fullstop. I agree that maybe stopping concentrating so much on the place of birth, and thinking more about the actual human support during pregnancy and labour is the way forward.

Are there figures for how many women actually prefer or want to have a MLU/Hospital birth? I personally don't ever want a homebirth (unless I'm lucky enough to live next-door to the MLU!).

VinegarDrinker · 12/03/2013 12:44

" I think we took the wrong direction when we started concentrating on the place of birth rather than the quality of care"

Yes absolutely. I also feel for those women who have to deliver in CLUs for valid medical reasons - it often seems they get forgotten in the sea of lobbying. They often end up with a raw deal both in terms of midwifery staffing, and in terms of making their environment more pleasant to deliver and labour in (private postnatal rooms, flat screen TV etc) .

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VinegarDrinker · 12/03/2013 12:47

And actually I think the polarisation of birth and emphasis on moving low risk women out of hospitals is deskilling midwives and undermining their confidence in managing normal labours.

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KatieMiddleton · 12/03/2013 12:53

I don't think there are figures because that is considered to be the norm. What is still not thought of as the norm is homebirth so there is more data about that abd you could argue that everyone else wants care in a hospital/MLU by default.

I wonder if there's a difference in unplanned interventions (ie those agreed to and planned prior to labour) for those who receive one-to-one care and those who do not?

Shagmundfreud · 12/03/2013 12:54

I disagree.

I think we took a wrong turn when we started ignoring the hormonal physiology of mammalian birth when deciding how we were going to organise maternity care for women.

IMO it doesn't matter how nice hospitals or birth centres are - going to one still involves moving a woman in labour to an environment she's pretty much unfamiliar with, and putting her care in the hands of people she's unlikely to see again.

I know some people think these things are irrelevant or unimportant, but IMO they're not.

"on moving low risk women out of hospitals is deskilling midwives and undermining their confidence in managing normal labours."

The biggest barrier to encouraging midwives to learn how to support normal physiological birth is their working in a highly risk averse environment where practice is primarily driven by protocol and a fear of litigation, and where epidural is seen as the only humane and sensible response to a challenging labour.

Shagmundfreud · 12/03/2013 12:56

Part of what causes a polarisation of opinion are biased, poorly written and inadequately researched articles like the one you praise as being 'balanced' in your OP.

Hmm
Shagmundfreud · 12/03/2013 12:59

"I wonder if there's a difference in unplanned interventions (ie those agreed to and planned prior to labour) for those who receive one-to-one care and those who do not?"

From the Cochrane Pregnancy and Birth reviews:

"The review of studies included 23 trials (22 providing data), from 16 countries, involving more than 15,000 women in a wide range of settings and circumstances. The continuous support was provided either by hospital staff (such as nurses or midwives), women who were not hospital employees and had no personal relationship to the labouring woman (such as doulas or women who were provided with a modest amount of guidance), or by companions of the woman's choice from her social network (such as her husband, partner, mother, or friend). Women who received continuous labour support were more likely to give birth 'spontaneously', i.e. give birth with neither caesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. Their babies were less likely to have low five-minute Apgar scores. No adverse effects were identified. We conclude that all women should have continuous support during labour. Continuous support from a person who is present solely to provide support, is not a member of the woman's social network, is experienced in providing labour support, and has at least a modest amount of training, appears to be most beneficial.

KatieMiddleton · 12/03/2013 12:59

I think what is deskilling midwives is not having the opportunity to use their skills. Any midwife who is mainly doing antenatal and postnatal checks and the odd homebirth every month or so is going to be more rusty than one delivering 3 babies a day.

So I would take issue with the assertion the problem is moving low risk women out of hospitals; imo the issue is one of protocol and organisational fragmentation making it impossible to deliver an optimum service.