Childbirth risks: best overview I've found

[thomasstockmann]

I've found this overview of the risks involved in giving birth. The document comes from the Childbirth connection organisation in the US (they look like a more powerful equivalent of NCT here-any American mums to confirm/shed light?)
www.pqcnc.org/documents/sivbdoc/sivbeb/8ChildbirthConnectionVaginalBirthandCesareanBirthRiskComparison.pdf
In my view, a must read before writing a birth plan. If anyone knows of other gems like this one (reliable info put together in a concise way), could you share please?

I'm not, to be honest, sure that this is all that great. It does look to be coming from a very NCT type angle. It really skims over the risks of an unassisted delivery - surely there are far more than it lists, even if many are straightforward. It seems overly simplistic; you can't analyse whether a c-section, assisted delivery or unassisted delivery is better unless and until you have all of the facts, which are individual to each birth (and some of the relevant facts will never truly be established, but will have to be judged on the basis of guess work in labour). You don't always get to make a choice in advance - it's good to be armed with information, but if your baby gets distressed or stuck in labour, it's probably not the time to be worrying about the risks of intervention in isolation from the risks of not intervening. If I'm being honest, it looks like an anti c-section / anti-intervention publication, rather than a full and frank assessment of the risks.

I have always found RCOG guidelines good for more UK evidence-based evaluation.

The risks differ in the US from the risks in the UK for more reasons than I care to mention.

Take with a huge pinch of salt for that reason.

I agree that this doesn't look great. I also think practice is so different in the states that info from there needs to be treated with some caution. Rcog better from British info.

SomeSunnyDay I also thought RCOG was a good source of information but realised that
1-the information for the general public is in my view not always complete
For example, the leaflet about assisted vaginal delivery does not explain you are at higher risk of urinary and/or faecal incontinence. Why is that?
www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-an-assisted-vaginal-birth-ventouse-or-forceps.pdf
2-the guidelines aimed at obstetricians are complex to read and understand
www.rcog.org.uk/globalassets/documents/guidelines/gtg26.pdf
The information is long and as far as I can see they never explicitly mention faecal incontinence. Why is that?

I take your point that there probably are more risks linked to a straight forward vaginal delivery (postnatal depression?) than mentioned in the Childbirth connection doc. However I have not seen a summary like this anywhere else.

Thanks thomasstockmann - that's interesting and helpful, at least to US mothers.

What makes it a bit less useful for UK mothers is that the risks/benefits in the UK will be different as we have much lower rates of induction at term, and lower rates of epidural use (about half). That will alter outcomes for vaginal birth, which tend to be worse if there is epidural/induction involved.

"It really skims over the risks of an unassisted delivery - surely there are far more than it lists, even if many are straightforward"

Actually I think you'll find the 'risks' for a straightforward, unassisted, unaugmented vaginal birth are very low.

Sorry O p but I am not very impressed by this document. It should differentiate between EL and EM C a as they carry some very different risks and the likelihood of risks occurring is not the only factor in assessing them, the severity of the risk is also crucial.

I understand that, Root, but it doesn't even address the risks - even just to rate them as "Low". Things like tearing, infection, PPH, psychological trauma, just to give a few examples, are still a possibility after an unassisted, unaugmented, straightforward delivery and this document doesn't even acknowledge that.

It would be more useful (albeit still American) if in analysed the same risks in the context of different types of deliveries.

someSunnyDay "It would be more useful (albeit still American) if it analysed the same risks in the context of different types of different deliveries"

Agree. I wish someone in the UK did that. Anyone? :-)

It should be looking at planned ELCS verses planned VBs (which include EMCS). The vast majority of research does not do this, and therefore only has limited usefulness. Its not useless but it can only really be used in certain contexts.

NICE, however, did look at this for first time mothers when redoing the guidance for CS in 2011. However there is nothing for subsequent pregnancies and this does not take into account any subsequent risks for future pregnancies, nor does it show how unbalanced risk is and how much it is stacked for certain groups of women, such as women over 35 or women who are obese.

Having spent a lot of time looking at the research available and what gaps there currently are, I think you are looking for something that would be frankly impossible to do because of the complexity of it. You have complained that the RCOG stuff was difficult to read and understand, but that's really the point. You can not break this down into simplistic stuff accessible to all because of its very nature. There has to be some generalisation in there somewhere even for clinicians. Just about any data you get will be flawed in someway, and that's part of the point. You need several different sources and methods to draw from and to be used in conjunction with each other rather than just 'facts' which really aren't 'facts' anyway.

Besides which if this was done, we would be in serious danger of ending up being dictated by these statistics with women in certain groups being effectively forced down certain routes, because the issue is not with the information available but more with the attitudes of health care staff. Routes which for various reasons they may not be happy with and would prefer the alternative. We wouldn't be any better off than we currently we are.

The NHS is driven and run by targets and policies rather than on women centred care sadly. And that's your issue more than the actual risks themselves tbh. We do need more discussion on the subject and more focus on how women end up with long term complications which are a largely taboo subject. But I don't think this is the way forward. You simply end up confusing women and making them unnecessarily fearful in many cases. Women fall into two groups; women who want as much information as possible to make an informed decision and to control their anxieties and women who control their anxieties by deliberately avoiding this information and just getting on with things. How you balance the need of both groups without ignoring the other is something of an enigma.

I understand that you had a particularly difficult birth, and ended up in a situation which you were unaware could happen. That's not a good state of affairs, but in trying to come to terms with it, you are projecting onto others which is equally not informing women in a balanced way. You can not approach this, with a certain agenda without understanding the limitations of the system, how statistics work properly and how your own bias will drive discussion a certain way because of the emotion you have invested in it. Put simply, you need to resolve some of your own issues before you can campaign effectively on this, as its blinding you to certain things. I have every sympathy for you, and hope that you can find the peace you are looking for, but anger is only useful if it is channelled properly.

RedToothBrush I'm not entirely sure why you're shifting the conversation to my own story (of which you know next to nothing). I thought the conversation was interesting and I hope it carries on being so despite your comments.
I personally found this document interesting. It gives an overview which pregnancy books and healthcare professionals do not give. It can certainly be improved (mainly the point of this thread) but it is I think very relevant.

[A side note on your comments. Even when the care is supposed to be individual I'm afraid risks are not explained to women. A friend of mine was followed by a consultant because she is over forty (so very individual care). She was offered an induction or an ELCS. She choose the induction. Which failed and therefore asked for an ELCS. She has since very clearly expressed the fact that she was not informed of the balance of risks between the two procedures. This is of course only one example but looking at Mumsnet generally it is not uncommon at all.
So I'm interested to know where you got your information from before you gave birth?]

Anyway this is not about you nor me. It's about a document I thought was worth looking at and discussing, which we are doing. I hope I understand your view on this document: you don't think synthesised information can be achieved and you don't think it would be relevant anyway. We disagree then.

Thomas, you've posted several times very biased or misleading information that's doesn't help women with informed decisions anymore than the current situation. You just drown them in more and more information. I do feel your experience is clouding what you are judging, which is why I mentioned it.

If you want women to be able to make informed decisions you need to be unemotional about it and critical about what stats are actually showing you. As part of posting them, its always worth pointing out where their flaws are rather than expecting others to highlight them. Firstly to stop yourself looking like you are being too militant and biased in what you are posting yourself (and based on your previous postings, I do think you are at risk of doing) and also to ensure that women are conscious of the weaknesses in data and if they are not used to understanding the data available here and elsewhere, show them the type of things they should look out for when presented with it.

Teaching women to question the face value of what they are told is far more valuable than giving them 'overview' of the risks, because the nature of risk means its a very personal thing that really you can only assess based on your personal circumstances, your personal judgement on what constitutes an acceptable level of risk and in conjunction with the clinical expertise of those caring for you.

In terms of where I have learnt information, its less about numbers and more about things like understanding how we are biased before we even look at studies, how we are influenced by how figures are presented to us, having a good understanding of methodology, and knowing our legal rights within childbirth and encouraging women to assert those rights.

Ben Goldacre is a good read for many of these principles within healthcare, as is Margaret McCartney. Focusing more on the VB v CS debate Pauline Hull's book on Choosing Caesarean is also good, provided you learn the principles she outlines and then apply them back on many of the things she says (there is a touch of hypocrisy in what she tries to achieve unfortunately, but the book is a very good counterbalance to most other published thought on the subject of childbirth in the UK).

As for debate. You can start a debate on MN about what ever you choose, but don't expect everyone to take conversation in the direction you want to take it. It just doesn't work like that.

This is now completely off topic.

RedToothBrush Pardon me for not knowing that as well as reading pregnancy books, going to antenatal classes, going to see my midwives and talking to friends who had given birth I had to read non-pregnancy-related books, scroll through pages of obstetric literature aimed at doctors and read a book about choosing to have an ELCS when I didn't need one in order to prepare for birth.
I was also unaware that posting links on MN to get views different to mine included a covert rule to highlight flaws so others didn't have to highlight anything.
I must be a very average person with very average friends.

Its not off topic though! I think it very much is on topic to say that some sort of overview isn't really possible and that there are reasons why we shouldn't go down that route too much. You just don't want that debate as it disagrees with your point of view...

In terms of preparing for birth, I do think in the majority of cases, a VB should be the default because the alternative is major surgery which does carry its own risks and isn't a magic alternative here. The problem is that complications happen for both. When you get pregnant you are taking a risk however you eventually give birth. I do think that there should be more discussion over complicated deliveries - if women want that - but every time this debate comes up, there are a number of women who say that they were glad they didn't get bombarded with negative thoughts about complications as they wanted to go into the experience with a positive attitude and more relaxed about the whole thing. Which does make it very difficult to know where the point is where too much information may actually be counter productive in creating anxiety which in turn may actually have a negative impact on labour.

I personally do not think that issues over continence are that unknown and aren't talked about in 2014. I think in the past it was much more taboo, but the internet really has revolutionised that.

And yes, I do think its partly up to women to be responsible for their own health to a degree. I don't think that putting complete unquestioning blind faith in doctors is a good think, even though I think for the most part they do try and do what is in our best interests, purely because they are human. We should have a general interest in the politics of healthcare on a wider level, not just when it comes to when we actually need to use it.

There are certain things that I do think need to be talked about more - poor care that results in complications, long term complications, mental health complications... but I don't think that statistics for a 'general overview' are what we need to be aiming for. Its wholesale changes in attitude by policy makers and more emphasis on women as individuals rather than statistics that need to be focused on.

The document is shit

I found the overview helpful.

The main factor in deciding whether to go VBAC or EL was the risk and consequences of an assisted vaginal delivery. Whilst the NHS was at pains to explain the risks of a CS, it was rubbish at setting out the risks of a vaginal birth, particularly an assisted one, which this document has addressed.

Thank you, OP

buttercupbear You think this doc is shit. Ok but why? Not enough info? Wrong info? General but not individualised risks? Missing info?
I agree it's not perfect. Other posters have pointed at flaws (missing risks for VB, biased data, impossibility to synthesise so much info in an helpful way, some find it helpful). What's your experience and how does it inform your view?
RedToothBrush You raise a lot of points I can't all address I'm afraid. I'll just take a couple. If too much information can be counterproductive then why wouldn't an overview have its place in prenatal care? Women can then look at more reliable sources for risks they want to know about?
I agree some women would rather not know much. They can choose not to look at the childbirth forum on MN for example and not go to antenatal classes (although I think it's better to go, I at least learnt about TENS machines-a godsend).
blueshoes Glad this is useful.

I also think that the document is inherently misleading - it means absolutely nothing to compare VB risks to CS (both planned and unplanned! ridiculous!) to instrumental, because by definition most births that end up with "natural" vaginal deliveries are the textbook births that went well. So, OF COURSE the outcomes for both mothers and baby will be better!

I guess my main gripe here is that the document seems to present the three types of birth as three independent options, as if women were somehow choosing between the three - but, in the overwhelming majority of cases they don't! Yes, in some cases a choice needs to be made between forceps and EMCS, but mostly it's just a matter of doing what needs to be done to come out with a living baby and mother.

So you end up with women setting their hearts on a natural VB because it's the "best" birth, and when need forceps or a life-saving EMCS, they feel cheated or feel like they somehow failed.

All incredibly misleading and very biased!

If too much information can be counterproductive then why wouldn't an overview have its place in prenatal care? Women can then look at more reliable sources for risks they want to know about?

Precisely because an overview in its own right is wholly misleading. A overview is of no practical use to women, because of the way risk is spread. There are no single reliable sources, only a number of resources that can be used together in conjunction to build up a tapestry of patterns rather than definitive 'truths'.

If you give the same information to a woman in her early twenties and to a woman who is 39, then that woman's actually risks may be over or under stated depending on a huge variety of factors, age being the most obvious, but just being one of the variables.

Equally, you can look at something like place of birth, for low risk women and find that risk differs purely because of where women give birth. Which does point more to environment, standards of care and women's involvement in the care they receive being as important as any other factor.

You say, I raise a lot of point you can't address. Please, please consider that and give thought to some of them, before you start advertising 'facts' that you consider give 'a good overview' when you don't properly understand what you are promoting.

Oh and I meant to say that too much information can be counter productive unless you are equipped with the skills and teach how to question multiple sources.

RedToothBrush Ok so when do you suggest individual risks are assessed? And by whom? (You seem to have a very authoritative voice on the matter. What do you work as?)

You are missing the point. Somewhat deliberately.

OP I understand the desire to better inform women, and I agree with it to an extent, but I think just giving information as bald facts and expecting that to be helpful is very optimistic. I agree with RedToothBrush on the reliability of sources and the difficulty of applying statistical risks at a population level to individual women.

I would also debate whether better information on risks always leads to better decision making. There is a growing amount of behavioural research into risk assessment/risk management, and it is simply not the case that more information = better decisions. If it were, nobody would ever smoke! Or get fat!

I'm not arguing for keeping people in the dark, but assessing and explaining risk at an individual level is actually hugely complex and I don't believe that in our overstretched antenatal system there is the time or the expertise to cover every possible risk in detail with every woman.

We're going round in circles. So where do you get your information from? And who assesses your individual risks?

As for facts, the Childbirth connection website is very well documented.

Its very well documented but is fuck all use to women giving birth in the UK. If you don't know why the information is not comparable and not relevant then you aren't going to get very far with looking at other data.

If you want information, plow through NHS statistics and research, RCOG information and NICE documentation. Learn how to 'read' statistics and research. It can be difficult to understand unfortunately.

The problem in essence is you want a 'newspaper story' type explanation where everything s simplified and dumbed down rather than a text book discussion which proposes various theories and hypothesis and does necessarily draw definitive conclusions.

If you really want to understand it, you do need to do a lot of background reading and have the ability to understand research, methodology and statistics.

Coming up with an overview does not educate women. It actually treats them as stupid in many respects.

And yes we will go round in circles if you don't understand why some data is weak and some is good. You are picking and choosing stuff that suits your agenda, not whats actually worthwhile.