Author Archives: Karen Hall

19 Jun

Book Review: Optimal Care in Childbirth, by Henci Goer and Amy Romano

This dense and fascinating book presents a huge amount of evidence and a highly articulate argument for a physiological model of birth, starting from the premise that pregnancy and birth are healthy, normal experiences for the majority of women, and only where risk exists, does medical management become appropriate.

This approach fits nicely with my own philosophy of pregnancy and birth, and is well-supported by short analyses of the research in each chapter. Other reviewers have pointed out that the evidence is somewhat cherry-picked, as is always the way in the context of books on birth. It seems to be categorically impossible to have a truly objective reading of the evidence on this subject, and few people with any real knowledge seem to occupy a middle ground on the spectrum from hardline birth skeptics who can only allow the medical model, and advocates of straightforward physiological birth. Both groups tend to be very blinkered about research that contradicts their point of view.

Optimal Care in Childbirth gives a good insight into the source of this deep opposition between the two philosophies. Within the medical model, pregnancy and birth are presented as intrinsically dangerous and difficult. The historical background to this assumption is well documented. In the 21st Century western world, overall levels of risk, particularly to the mother, are very low; and this results in a narrow focus where almost the sole positive outcome to be achieved is a live baby and mother. Strategies are therefore devised to minimise the maximum potential risks, and preventative procedures become routine. This leads to an assumption that the medical approach is the norm, which has a knock-on effect on the research available. The more women who give birth by caesarean section, for example, the greater the belief in the medical community that birth is difficult and dangerous, and the more deskilled midwifery becomes.

There is no doubt that childbirth is complex, variable, and human; and the outcomes of childbirth are soft, complex and variable too. Goer and Romano define the optimal outcome as:

“the highest probability of spontaneous birth of a healthy baby to a healthy mother who feels pleased with herself and her caregivers, ready for the challenges of motherhood, attached to her baby, and who goes on to breastfeed successfully.” [p21]

However since the language and thinking of research is based in the medical model, the basic assumption is that non-intervention in childbirth equals risk, rather than the other way around. Optimal Care in Childbirth recommends reserving medical intervention for those women who would genuinely face greater difficulty without it, rather than protocols that offer it routinely in order to reduce risks that are already small.

The chapters of the book cover all the main topics of relevance to anyone working in childbirth (it is probably not a book aimed at pregnant women, who might get similar but more accessible information from Ina May Gaskin’s books). The chapters cover caesarean birth, induction of labour, care during labour, birth, postnatal care, and midwifery practice. Each chapter includes a mini-review of research and strategies for optimal care. It is a very practical book and an important resource for midwives, obstetricians, doulas and antenatal educators.

20 May

Tropes about homebirth

I like Alice Roberts, she is interesting and clever. Some of the things she has written about birth have given me plenty to think about, and it’s good for me to think. This evening twitter drew my attention to an article in which she claims to take a “scientific approach to having a baby.” The article may be a year old, but it is relevant in the light of new guidance from NICE recommending that more women should give birth at home.

This of course has flushed all the extreme advocates of both hospital and homebirth right out of the woodwork, so here’s trope number one:

We all have to be for one thing and against the other.
Surely it’s a little more nuanced than that.

And it’s those nuances that make up the rest of the tropes.

Human birth is difficult and dangerous.
Except, not for everyone. Where does this information come from? What’s the evidence for that statement, as made by Roberts in the above article, and followed up by this statistic: “about five per 100,000 women die in childbirth and four per 1,000 babies” So, we’re not dropping like flies. And yes, in some cases that’s because modern medical intervention improves outcomes. But it’s also because in many cases, women’s bodies are apparently surprisingly good at giving birth. Up to date medical knowledge, high standards of midwifery training, and modern cleanliness are also factors, but these things are not exclusive to hospitals.

A healthy baby is the only important outcome.
Postnatal trauma is a real thing. Where the risk of a poor outcome to the baby is very small, maternal satisfaction with the birth process is actually highly relevant. The “healthy baby” trope buys into the patriarchal system where women must be compliant and put her unquestioning trust in the doctors; furthermore she should be grateful that they “deliver” her healthy live baby, no matter what they did to her, often without fully informed consent, in order to achieve that. The draft NICE guidelines acknowledge the importance of maternal satisfaction with the process; this is not the same as prioritising the process of birth over the goal of a healthy baby; it is simply stating that birth is a process. Giving birth is a huge physical and psychological event, and to reduce women to precious vessels whose only role is to produce live offspring is patronising at best.

A high proportion of women planning a homebirth end up transferring into hospital, so why bother?
Roberts quotes a 45% transfer rate for first time mothers, 12% for subsequent births. Of course, nobody goes into hospital before actually going into labour unless they’re suffering some severe condition such as pre-eclampsia. This is not an argument against labouring at home, and does not necessarily mean that those mothers who transfer in have less satisfaction. If we could take the value judgement out of home vs hospital, we could look at this as encouraging women to labour at home and only go in if necessary, rather than framing it as failure to birth at home.

If you need intervention, it’s instantly available in hospital.
Not true. You may have to wait a couple of hours for an anaesthetist to be available, or for the previous woman to move out of theatre. So plenty of time for that transfer.

Well duh, of course there’s a lower risk of intervention at home, because you can only carry out intervention in hospital.
This still isn’t an argument against homebirth, and it is one of the main reasons women might choose to birth at home. Yes, obviously, the tools are not available. If an intervention is necessary, then a transfer is going to be needed. But an intervention is less likely to be necessary where women give birth in a calm home-like environment. Statistics demonstrating a lower incidence of intervention in planned homebirths include those who transferred and then experienced intervention, because that happens.

Homebirth advocates present the research findings with the wrong priorities because they have An Agenda.
And by “wrong priorities,” we mean priorities that differ from hospital birth advocates. From Roberts’ article:

look up “home birth” on the National Childbirth Trust (NCT) website, […] the findings are laid out in exactly the opposite order to that in the original research paper and the RCOG’s statement: women having a home birth are more likely to have a “normal birth” without intervention; home births are safe for women having a second or subsequent baby; lastly: home birth increases the risk to the baby for first-time mums. The main outcome investigated by the study is the last to be mentioned.

What NCT are doing here is normalising straightforward birth. It’s all semantics, innit? If you do follow Roberts’ link to NCT, you will see that the risks are clearly mentioned. In fact, it took me several attempts to replicate Roberts’ results by searching NCT’s website; the first few articles I came up with were clearer, more accessible, and included links to relevant information from The Birthplace Study and the NHS.
I would argue that hospital birth advocates also have An Agenda.

Homebirth is unethical and dangerous
In January The Independent headline claimed that homebirth was “as dangerous as ‘driving without putting your child’s seatbelt on’.”
The always excellent NHS Choices website responded to this with the conclusion:

A case could be made that rather than discouraging home births, we should instead be improving the levels of support to women who choose to home birth and so reduce the risk of complications.

Perhaps that’s where we should leave it. This isn’t about our different choices making us good or bad people, or our different experiences making us successful or failures. It’s about informing and supporting families, even those whose priorities aren’t the same as yours.

Views expressed here are my own, and do not represent the views of NCT.

04 Apr

The science of birthplace

My work now includes talking to parents-to-be about where they choose to give birth, and so this subject is of increasing interest, particularly since the skeptics I hang out with suck their teeth a little when we get on to the subject. To be quite frank, I suck my own teeth. It’s very hard to weigh up the pros and cons of a subject in which even the most scientifically minded get rather emotionally invested. I will conclude, perhaps, that we all give different weight to different outcomes, and that’s parenting for you, which means that I am as usual chasing my tail and asking “why can’t we all just get along?”

This is a complex and emotive topic, and few people seem able to write about it without their passion leaking through. So let’s state upfront that my passion is to support parents to make their own informed decisions, decisions they will have to live through, and live with, about an event that is in many cases earthshattering in the experience itself, and in its ramifications. Giving birth is a very big deal. Yes, it’s a normal physiological process and women’s bodies are well-adapted to perform it; but let’s bear in mind two very important provisos here:

  • It’s 2014. We give birth in very different conditions than those to which our bodies are adapted; and
  • Birth is safer in England than it has ever been, and this is down to a range of factors including modern techonology and hygiene.

But giving birth is not simply a physiological process. It is a profound life event affecting our bodies and our view of our bodies, affecting our families and other relationships, affecting us in social, financial and psychological ways that cannot possibly be accounted for in a simple birthplace study. Therefore birthplace studies tend to base their conclusions on measurable outcomes, usually neonatal death, injury, or oxygen deprivation to the baby. Some studies also consider some physical outcomes for the mothers, such as whether she experienced medical interventions or whether she went on to breastfeed. Very few studies consider birth trauma as an outcome.

Which? Birth Choice has a very clear set of tables comparing outcomes for hospital obstetric units, midwife-led birth centres, and homebirth. This is based on the 2011 study Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study BMJ 2011;343:d7400. If you click through to the tables in the report you find risks for ALL births reported as 4.3 adverse outcomes per 1000 births. This is then broken down to show the differences for first births (5.3/1000) compared with second or subsequent births (3.1/1000), and broken down still further to show risks according to place of birth. As has been reported, the risk of an adverse outcome at a planned homebirth for a first baby shoots up to 9.3/1000. As has not been reported, the risk of an adverse outcome at a planned homebirth for second or subsequent baby drops to 2.3/1000. The study concludes that “The incidence of adverse perinatal outcomes was low in all settings.” The headlines, meanwhile, focus on the relative risk: 9.3/1000 is more than twice as high as 4.3/1000, therefore homebirth is twice as dangerous as hospital birth.

Parents need to be given these numbers along with a little bit of information about how to make sense of them, which is where the Which? page is useful. But they also need the opportunity to consider what other outcomes are important to them, given that the absolute risk of adverse outcomes is so low. The Which? page gives information about the likelihood of intervention in various settings, and parents may want to consider this as a factor in their decision making.

Meanwhile, all this pitting of hospital birth against homebirth results in Birth Centres being overlooked. Birth Centres are intended to offer a home-like setting, with midwife-led care. They are often located within hospital settings, so the obstetric facilities are on hand. Our birthplace study referenced above shows that the risk of adverse outcomes is comparable to an obstetric unit, while the likelihood of intervention such as instrumental birth or caesarean birth is lower. A 2012 Cochrane Review of Home-like versus conventional institutional settings for birth by Hodnett et al supports this:

Home-like institutional birth settings reduce the chances of medical interventions and increase maternal satisfaction, but it is important to watch for signs of complications.

One thing that is important to beware of is using data originating in the US, since the model of midwifery care in the US is very different to the UK. This perhaps is a subject for a later post, and probably not by me.

Finally I want to come back to the definition of an adverse outcome, where once again women are reduced to the precious vessels, solely charged with but not entirely trusted to bring this baby to the world unharmed and perfect in every way. What about outcomes for mothers? I have heard Sheila Kitzinger speak on the subject and read some harrowing accounts of childbirth:

one reason why many women have low self-esteem and cannot enjoy their babies is that care in childbirth often denies them honest information, the possibility of choice, and simple human respect…..

Studies from 2003 and 2004 found that up to 6% of women show full PTSD symptoms following an experience of birth where they felt scared, helpless and vulnerable. While all the focus is on outcomes for the baby, women’s lived experience is belittled and ignored as a decision-making factor. This is why parents need to be given all the information, and not frightened into seeing hospital birth as the only safe choice for their babies, regardless of how it will feel for them; and the information given needs to include more than just the risk of adverse outcomes for the baby.

14 Jan

Firstborn by Katherine Gallagher

For years I dreamt you
my lost child, a face unpromised.
I gather you in, gambling,
making maps over your head.
You were the beginning of wish
and when I finally held you,
like some mother-cat I looked you over –
my dozy lone-traveller set down at last.

So much for maps,
I tried to etch you in, little stranger
wrapped like a Japanese doll.

You opened your fish-eyes and stared,
slowly bunching your fists bracing on air.

With kind permission from Katherine Gallagher

12 Nov

Incentivising Breastfeeding

Much excitement this afternoon when I was asked to speak to Anne Diamond on BBC Radio Berkshire, with a response to the news that researchers from the University of Sheffield are running a study where 130 new mothers are offered £200 vouchers if they breastfeed their babies. This is aimed at mothers in communities where breastfeeding rates are low, with the intention of increasing initiation rates and reducing health inequalities. The Guardian has a good explanation of the project and some responses to it here. Read More →

22 Oct

Book Review: Birth Trauma by Kim Thomas

Birth Trauma: A Guide for You, Your Friends and Family to Coping with Post-Traumatic Stress Disorder Following Birth

A year ago I listened to Sheila Kitzinger talk about her Birth Crisis Network, which she set up to help women who had suffered a traumatic birth. She gave examples of some of the things said by women for whom childbirth was not a happy or straightforward event, and I was shocked at the language and strength of feeling expressed. Only in recent years has it been recognised that a traumatic birth experience can give rise to post-traumatic stress disorder (PTSD) in women, and there are still few accessible resources for them or the people supporting them. Read More →

30 Sep

Baby Weight Charts

A couple of weeks ago, The Times reported that the UK baby weight charts were “skewed to promote breastfeeding.” The Times article is behind a paywall, but I picked up on it on another website. According to these reports, using weight charts based on exclusively breastfed babies will make formula fed babies seem to be overweight; the overall impression was a rather paranoid assumption that this was being done in order to make mothers breastfeed. Read More →

19 Sep

Book Review: Theo Gallas Always Gets Her Man, by Kristen Panzer

Theo Gallas Always Gets Her Man – Kristen Panzer

This was a free download, in which a trainee lactation consultant juggles family, a neighbourhood mystery, and voluntary breastfeeding support of an unusually medicalised nature. It is not clear how or when she does her training, but she shares her knowledge readily and always carries a pair of latex gloves with her with which to do a quick mouth exam (not something a fully qualified and experienced NCT Breastfeeding Counsellor is likely to do). Read More →