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.

She also has a nasty dog at the NCT for 'prioritising the birth experience over the health of the baby' while utterly ignoring the fact that the NCT's website is the only one aimed at parents which provides links to the evidence and a full discussion of the methodology of the POB study.

Yes that bit about NCT pissed me off. It doesn't even make sense. Anything that compromises the health of the baby is going to negatively impact the birth experience. Surely that's obvious?!

I can honestly say I have never met anyone who does not put the health of her baby as a key priority. I have read online people who use infant and maternal mortality rates as the only measure for successful outcomes. Health of the baby and maternal wellbeing, including birth experience, are not mutually exclusive. They are intrinsically linked and when we start suggesting they are separate that's when we allow women to be subjected to poor treatment.

Experience of MW for home births varies enormously; my CM had worked in a local PCT where the stats for Hbs are some of the highest in the UK, so she was very positive. OTOH I had to fight for mine so of course availability of Hb was a key factor for me to campaign on afterwards; unless of course the CMU (much further away anyhow) could look after a couple of autistic children whilst we waited for my husband to arrive from work. Now there was the risk of needing emergency transfer (and luckily the baby arrived when Dh had taken a day off) but for a 4th time mum that was a relatively low risk compared to relying on someone else- there was a paramedic neighbour who could help if needed but who knows where her shifts would have fallen? I just didn't want to be alone,, mainly due to a first experience that was pretty rotten.

So I will always back a wide diversity of facilities- ds1 wouldn''t be here without a CLU. DS2 was born in a MLU that was amazing, ds3 was due to be born in a MLU (a different one) but they changed their minds as I was 0.05 below my anaemia cut off point. DS4 was a HB. Each choice was made at the time, with the information and options available to me, in different sets of circumstances. And for a woman with a risk of precipative labour like me, who lives some distance from the CLU and further from the MLU a HB surely is a very valid option? The attending MW lived in my village. I had raised an induction as an option in hospital, but was refused as social- yet another women was given one because her husband was going away, my MW was bemused and angry. There are no protocols to deal with a family like mine though as we are pretty rare. I suggest families with additional needs being forced (or choosing in our case but same outcome) to move away from support networks will be a key factor with the imminent changes to social support howeve.

Apols for strange typing, annoying new keyboard with everything in the wrong place!

Excellent posts from Shagmund. I just wanted to add if it hasn't been said already (haven't read every post) that it shouldn't be just about mortality rates of babies and mothers. That quote from the ACOG is so snooty and completely misses the point. I despite the attitude that says "Well, your baby's healthy, you're still alive - stop making a fuss about the fact that you had umpteen interventions you didn't want and are now suffering from postnatal depression!" It's as if wanting a birth where you feel safe and looked-after rather than one where you're treated like a piece of meat is a completely unreasonable and prissy expectation.

I've read the article by Alice now and kind of think it's OK as far as it goes, but it's a bit simplistic. At least she acknowledges at the beginning that what you will hear as a potential new mother will depend on who you listen to. The same applies with what she has to say though, no-one is without some bias based on their experiences, both personal, and through the people they've listened to.

But that doesn't mean that it isn't utterly flawed to fail to mention in a discussion about HB that home is not a safe place for many pregnant women.

Chunderella, I wouldn't disagree, but at the moment the default option is hospital birth. Out of curiosity - has anyone who has recently been pregnant been told that they must have a home birth, and that hospital is not an option, as they probably would have been told in 1953?

Disabled women need to have choices too, which by the sound of it, they are not getting.

Bear in mind that the discussion started with Alice Roberts and as far as I know none of the above apply to her.

That's another important aspect of her arguments being a bit simplistic Chunderella.
Also a bit patronising - don't many women seek to weigh up the evidence in the light of their own circumstances to inform their decision making about birth choices ?

I've had another look at that article and it seems to me that what she's saying in relation to her own experience is this: I'm a low risk second time mum. I could give birth at home but the most important thing to consider in my view is the safety of the baby. Therefore I'll be giving birth in hospital.

I'll be reassured by knowing that there are obstetricians and neonatologists close by. For other women, home might seem like an enticing option. But surely the most important thing to consider when making this choice has to be the safety of both mother and baby.

She then has a good old laugh at people saying that one of the advantages of hb is that it's associated with lower rates of intervention - something she doesn't understand because, hey ho, you can't do c-sections on the kitchen table!

She refers to the POB study, which she describes as 'good, robust information'. Information which disproves her view that as a low risk second time mum you need to give birth in hospital to be safe. But she's not interested in the very striking findings of the study on rates of intervention in different settings, which the author describes as 'highly statistically significant'. No, she's not interested in discussing this. She's interested in pointing the finger at the NCT for mentioning the possible additional risks to the babies of first time mums only third in an article about home birth.

Actually the more I look at the article the worse it seems.

"But that doesn't mean that it isn't utterly flawed to fail to mention in a discussion about HB that home is not a safe place for many pregnant women"

I think all the discussions of home birth make the point that there is only evidence for it being a safe option for healthy mothers with uncomplicated pregnancies.

"And the suggestion that NCB is an or the ideal is utterly ableist because it entirely fails to consider all the disabled and ill women for whom it isn't."

You'd kind of hope that women and health professionals would use their common sense on this one, but you can never be sure. Personally I read the 'NCB is an ideal' I interpreted that as meaning 'NCB is ideal when it can be safely achieved'. Which of course it can't for everyone, and I'd assume all adults are aware of this fact.

To be fair to Alice Roberts, I probably wouldn't think of things like that, Chunderella - I think there is a reason for this - I think she's merely reflecting what is going on when it comes to promoting birth more generally.

There is currently a real focus and promotion on low risk women at the moment - for political and financial reasons. The idea of promoting choice looks, on paper, as a good move. It might be much more of an illusion than the reality out there, but promoting it is politically advantageous.

Its being pushed hugely by a number of groups. Its not just the NCT - its the RCM AND somewhat more surprisingly the RCOG. They put out a joint paper aimed at CCG commissioning some months ago about 'normalising' birth.

I happen to dislike terms like this; it puts anyone outside this box into the 'abnormal box' and whilst that might be being precious about terminology to some, I think numerous discussions on MN about terminology repeatedly show up how important this is to women and how it can affect their mindset. There must be a way to achieve similar purposes without using the same damaging phrases.

The thing is, whilst these groups are hugely publicising the options of low risk women, there is a tiny amount of discussion on any high risk women and their choices and what their actual risks are, even for groups that are significant in size. Its mentioned in passing, but then bypassed in discussion unless you end up finding yourself in one of these groups and facing these kind of discussions with your midwife or consultant. It means women don't know if there ARE other ways to do things other than what they are being told by the person treating them. And given that low risk women are being told things by professionals that reflect the professionals personal opinion rather than being balance and unbiased, it puts higher risk women in a very weak position indeed.

I think its up to these groups to be leading the way opening this area up for discussion. Being honest if journalists can't do a good job discussing the issue over what information is out there for low risk women, and don't hold high hopes for what they would add to the presently none existant debate. It does needs to be discussed, and I would like to see a journalist tackle the issue at some point in the future, but the driving force behind this needs to be someone with first hand experience or knowledge rather than repeating the cliches as its an even more sensitive area than perhaps low risk women are.

So in the context of what she was talking about - her own approaching birth as a low risk woman - then I think Alice Roberts can be let off it.

I think all the discussions of home birth make the point that there is only evidence for it being a safe option for healthy mothers with uncomplicated pregnancies.

I think we have already touched on the difficulty of being able to do research on higher risk cases, simply because there are relatively few going for home births and MLUs are usually closed to them. Maybe a comparison of outcomes for large teaching hospitals and more run of the mill CLUs would give some useful results? I don't know.

I think that Majorie Tew's research back in the 70s did show that for higher risk women things were not necessarily safer in hospital. I can't lay my hands on the research right now, and besides which, so much has changed over the last 50 years it's debatable to what extent the information would be useful.

Redtoothbrush - would 'physiological birth, be more acceptable and less loaded for you than 'normal birth?

In relation to bodily functions I do think the word 'normal' is useful and not discriminatory.

Re: 'high risk' - I had a high risk pregnancy (gestational diabetes and massive baby) but chose a home birth. I also chose not to be induced. I know only a small handful of women who have made choices like mine and all of them have found the experience very difficult.

Do you mean making the arrangements or the birth itself, shagmund?

Yes I think its a less loaded word.

No one wants to think they are 'abnormal' even if that happens to be a convenant description.

The fact is its something beyond the control of many if we are being completely accurate their bodily functions ARE behaving in a normal way in situations where intervention is needed.

It is normal to want pain to stop. It might be normal for labour to stall under certain conditions.

Death is a normal outcome of birth in humans afterall.

hospital is not necessarily a safe place for a labouring woman either. I posted about my experience earlier but there have been a succession of truly appalling cases at Queen's Hospital Romford, Morecambe Bay and probably other hospitals as well - let alone the more routine ones that never make it into a news story but cause considerable harm and distress to new mothers and babies.

We need a mature discussion that acknowledges that there is no completely 'safe' place, that you need to weigh up the likely risks to mother and baby and make the best judgement you can in an individual case with the individual's medical history, wants and needs. And that hospitals and health providers can do a hell of a lot more to make giving birth safe wherever you do it.

"I have a problem with the fact that DV and unsafe home environments generally are hardly mentioned in discussion of whether HB is safe or not. And they weren't in this thread, until I did it. The great big fuckoff elephant in the room is that the DV risk increases during pregnancy."

How is having a hospital birth safer in cases of DV if a mother may well be spending a good part of her labour alone with her dp in a room on the labour ward, and is then discharged to go home within 3 - 24 hours? Particularly if the mother ends up having surgery, which is more likely if she opts for a hospital birth, and which leaves her much more vulnerable and reliant on a possibly abusive partner for weeks after the birth.

"who make blanket suggestions that an uncomplicated vaginal delivery is an or the ideal"

But it is the optimal outcome in health terms for all women who can achieve it safely (and I use 'safe' in the widest possible sense to include emotional safety), for disabled women as well as the able bodied. Obviously it's not the best option for all women, able bodied and otherwise because it simply isn't viable for everyone.

Oh lord Chunderella - all midwives are supposed to consider DV and all other possible impediments (poor housing, aggressive animals, ease of access etc...,,) when they discuss birth options with mums who have shown an interest. I don't think it's reasonable to expect this to be detailed each and every time home birth is mentioned in the media.

Re: Alice Roberts - She probably didn't say it because she's trying not to state the bleeding obvious.

Chunderella. Most people do not advocate one thing or anothe but trying to support people to make their own decisions.

Chunderella - if there is a discussion of epidural in the media and someone is advocating for the wider availability of it, would you expect them to mention all the clinical conditions that render epidural unsuitable as an analgesic? No? Then why insist on the same for home birth?

There is no one specific 'group' of low risk mothers for whom home birth is categorically unsuitable or inaccessible and each woman needs to be assessed on a case by case basis. There are places for a discussion about widening access to home birth - that place is probably NOT Alice Roberts article.