Wednesday, 3 December 2014

Home Birth, Hospital Birth and Not So NICE Advice



I've written previously here and here about the draft guidance from NICE on where women should give birth, but (as you'll have noticed if you were anywhere near UK media this morning) the final version is now out. The headlines mostly read something like this (From the Mirror):

Mums-To-Be Warned "Have Your Baby At Home, It's Safer" By Health Chiefs


An awful lot has been written on this subject today but, having looked at much of it and at what the new guidelines actually say I think there is a fair bit of confusion and a lot that annoys me too. What follow is long, be warned, but I hope it will clarify things for people or at least vent my frustrations. (Also fyi, it's not as well checked over as normal because I also have a sad, snotty two year old on my arm).

The Confusing Stuff


It's not all Mums
Firstly, this advice doesn't apply to all Mums-to-be. It is solely for low risk mothers who have already had at least one baby. The guidance also covers low risk first time mums but it does not say that home birth is safer than hospital for this group as there is a slight increase in risk to the baby with home birth. I'll be coming back to this.

The Meaning of "Safer"
What do you think of when you hear that word related to child birth? Is a safer birth one where mother and baby are less likely to die or suffer lasting harm? Well yes but these reports also consider a birth safer if there are no interventions such as emergency caesareans, forceps deliveries (so far so sensible) and epidural pain relief. I'll be coming back to this too.

There is no, single "right" place to give birth
Crucially, the NICE guidance itself doesn't actually say that there is a single best option for where women should give birth. Here's what it actually says midwives and doctors should do:

  • Explain to both multiparous and first-time mothers that they may choose any birth setting (home, FMU, AMU or hospital obstetric unit), and support them in their choice of setting wherever they choose to give birth.

This is the first point in the "Key Priorities" section of the document, and it doesn't say "tell all women to have home births" it says, tell those who are low risk that they have choices, then respect those choices.

Here's my fantasy headline:

NHS Told "Women are Intelligent Individuals, Facilitate Their Informed Decision" By Health Chiefs

Well, I can dream.


The stuff I'm coming back to


To be clear, I am not against home birth. I am certainly not against birth in a midwife led unit - it's what I chose myself first time around. The thing that is bugging me is the headlines which suggest there is one, best, safest, correct way to give birth. I just don't believe that. No two women are the same, our, bodies, minds, life experiences and social situations make each and every birth utterly unique. 

What about the "other" women?
The fact that this guidance doesn't apply to all mums anyway is very important and it's something the media has pretty much overlooked. What about all those women who aren't low risk? Who are told that for them, the best/safest/correct way to give birth isn't an option, they have to be in the dangerous hospital with it's terrifying interventions. Firstly, these stories only add to the fear and stress of those whose situations are the most difficult to start with. Then, after the birth there is the lingering guilt that many feel for having failed to give birth properly. For more on this see this post over at Headspace Perspective

My safe or your safe?
The recommendations published today are based mostly on the Birth Place Study, which I covered in  (much) more detail here. It looks at how likely it is a baby will suffer one of a list of adverse outcomes and how often women have a range of interventions but (as I say in the post) how you interpret that risk is a very personal matter. What is more worrying a very small chance of something dreadful happening to the baby at home or a greater chance of having to endure interventions in hospital? There is no right or wrong answer to that. It's a personal, individual choice.

One thing that really bugs me is the inclusion of epidurals in the intervention list. While I doubt that anyone would want a forceps delivery or an episiotomy, there are perfectly good, intelligent, valid, reasons for choosing an epidural, - it's the best way to make the very hurty thing stop hurting being the main one and the risks are very low. So I don't think having one should be a measure of a bad or unsafe birth. 


The Stuff That Just Makes Me Cross

In a home birth no one can hear you scream give you an epidural
This is a real biggy for me and I say this as someone who didn't want an epidural and, were I magically a low risk pregnant mum again, still wouldn't want one: 

There is nothing wrong with wanting pain relief in labour.

You can't have an epidural at home or in a midwife led unit. If you plan to have one in advance then your only choice on place of birth is an obstetric unit. Women need to be made aware of this.


Transfer Rates
Something else that very few of the media reports mention is the transfer rates. The Birth Place study grouped women according to where they planned to give birth, not where the birth actually happened in the end. For first time Mums, a whopping 45% of those who planned a home birth ended up in hospital (It's only 12% for those who've done it all before). Again, it is vital that Mums have this information and are realistic about the possibility of a transfer. How would that feel? - Is it worse to be surrounded by the trappings of medical birth all along or to be bundled into an ambulance in the full throws of labour? No right answer, personal choice.


Why Are there more interventions in hospital anyway?
There is no clear answer to this, it's generally supposed that women are more relaxed at home or in a midwife only unit and that this helps labour progress better, though the evidence for that is sketchy. and of course some women find it reassuring to have modern medicine on hand. Another possibility is that doctors are overly keen on interventions, they see the rare cases that go bad and so over medicalise everyone to avoid them (and the ensuing law suits). I suspect it's also likely that most women having home births (only 2% of UK births) are very committed to it. So they are less likely to agree to eg. a drip to speed up labour if it comes with an unplanned ride to the hospital and the abandonment of all their carefully worked out plans. If many more low risk mums started out at home, would it always be the same story?

It's probably a combinatinon of many reasons, but whatever it is we should be finding out and doing something about it. Simply telling women to give up and go home is fine for some but it does nothing to improve care for the many women who want or need to be in an obstetric unit.

The Care Factor
Where I live there is already a two tier system for midwife care. If you are lucky enough to be in a certain area, be low risk, planning a home birth and well enough informed to contact them early, then you can have a caseload midwife. She will look after you throughout pregnancy birth and the postnatal period. She'll come to your home for some of your appointments and take time to get to know you. She'll also ensure that you have chance to meet the other members of her small team in case they are on call when you go into labour. If you aren't so lucky you may see a different person every time for rushed appointments and give birth with complete strangers then be looked after by whoever turns up, if they turn up. Why shouldn't women going to hospital have this standard of care too? It's probably one of the reasons why there are fewer interventions at home - women are supported. You shouldn't have to choose between an epidural or good care.

Midwife Units
The media and admittedly me too, keep talking about this as home v hospital, but what the NICE press release actually says is that Midwife led units are safest for straightforward births. They offer both the low risk to the baby that comes with hospital birth and the reduced intervention rate of home birth, so why aren't we cheering these on more?

Well for one thing,  not everyone has access to one and when there is so little money about do NICE really think NHS trusts will put in the massive capital outlay to build them? 


 Women's bodies


But what's the other reason why the media aren't talking about midwife units? It's because no one is all that passionate about them. Women choosing them aren't  ****ing hippies risking their babies for bragging rights about their orgasmic home births. They aren't cold, too posh to push bitches, so removed from what is right and natural for a mother that they have their poor babies surgically removed at a convenient time. They aren't even the terrified masses, strapped to a bed by an unfeeling doctor because they watched Eastenders too many times and were afraid to be anywhere other than hospital. In short (which will be a first for this post) they are women making reasonable, informed decisions about their own bodies* not caricatures to be judged and vilified, and for some reason, that is something our society and the media that reflects and feeds it, still struggles with. 

I'm going to shut up soon, I promise.
What the NICE guidelines actually say is that low risk women should have a choice of home, hospital or midwife unit. They should be informed of the pros and cons of each choice and they should be supported, whatever their decision. Well done NICE, now can the rest of the country catch up please?

SBx

*as indeed are the vast majority of women who choose, home, hospital or even C sections!

4 comments:

  1. >here are perfectly good, intelligent, valid, reasons for choosing an epidural,
    agree with everything. but just want to give an idea why maybe epidurals where in the list.

    In my wifes case as soon as the epidural was put in place not only the pain stopped .. the contractions stopped too which then triggered lots of other interventions (which rightfully are on the risk list) and ended in a C section. I am not saying this is always the case (it might be just a sample of one.. but the doctors/midwifes told us that this is normal.. is this true?) , but might have contributed why epidurals also considered to evaluate safty ... not sure ... just a guess

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  2. Gah the comment gremlin has struck again - reposting this from "Luke" which I was notified of by email but it doesn't seem to be here:

    >here are perfectly good, intelligent, valid, reasons for choosing an epidural,
    agree with everything. but just want to give an idea why maybe epidurals where in the list.

    In my wifes case as soon as the epidural was put in place not only the pain stopped .. the contractions stopped too which then triggered lots of other interventions (which rightfully are on the risk list) and ended in a C section. I am not saying this is always the case (it might be just a sample of one.. but the doctors/midwifes told us that this is normal.. is this true?) , but might have contributed why epidurals also considered to evaluate safty ... not sure ... just a guess

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  3. Thanks Leigh, yes I think it's really important that women aren't scared off having a home/midwife unit birth if they are low risk and it's what they want, but this shouldn't be achieved by increasing the fear of those women who want or have to give birth in hospital. Surely we don't have to be so polarised?

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  4. Thanks for commenting Luke,
    There certainly are pros and cons to having an epidural or not and it is well established that they increase the risk of instrumental deliveries and can slow the progress of the labour. I didn't want to go into lots of detail on this as the post was already rather long! But it is certainly something women should be warned about and take into consideration when deciding if they want access to an epidural in labour.


    My point was really that all the other "interventions" mentioned are things that I can't imagine anyone wanting unless completely unavaoidable, but I think it would be a perfectly reasonable choice to say that - "yes it may increase the risk forceps and a longer labour, but the removal of pain is more important to me." Therefore having an epidural isn't a "bad outcome" if it was what the woman wanted. So, if no other interventions were involved you could have births which were classed as bad or dangerous solely because of the epidural when in fact the woman had exactly the birth she wanted!


    I'm afraid I can't really comment on your wife, it's not something I've come across before though. Overall epidurals don't increase the c section rate but of course every woman and every birth is unique so anything is possible. I wonder slightly though - if this happened as soon as the epidrual was in place could something else have been involved too as usually (and I speak from bitter personal experience here) it takes about 20 minutes for the drugs to actually do anything.


    I hope your wife is well recovered from the c section now and all is well with you and your baby

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