Monday, 27 April 2015

Normal Not Normal

A #MatExp post

N is for Normal

Today we reached N in the #MatExp ABC and that brings me to "Normal" birth. Regular readers of this blog will have noted that I tend to put normal in " " and may also have guessed that that is because I'm not very keen on the the phrase.

One of the things often discussed using the #MatExp hashtag on twitter is the power of the language used when talking about birth. For example, I know that a lot of Mums and some medical professionals dislike the term "failure to progress". It's a technical term and intends no judgement on the mother's efforts, but the word failure is of course very emotive. That one didn't personally bother me, perhaps because I work in medical research and am used to there being lots of words and phrases that mean one thing to those in the field and something different to everyone else. But I appreciate that language is important and one phrase that I find really problematic is "normal birth".

For those who aren't familiar with the term, a "normal" birth as defined in the Birth Place study is a birth without induction, forceps, ventouse, caesarean, episiotomy or epidural, spinal or general anaesthetic  I have a number of issues with that:

1- Conforming to a standard; usualtypical, or expected:
1.1 - (Of a person) free from physical or mental disorders:

If This Is Normal - What Is Abnormal?

The main problem is, if you declare that a birth is only normal if it meets a strict and specific set of criteria then, by default, any birth that falls outside those criteria is not normal, it is therefore abnormal. Clearly forceps and epidurals etc are not natural parts of birth but are they really abnormal?  I find this hardest to reconcile where pain relief is concerned. As I've said many times on this blog, I see nothing inherently wrong with making an informed decision to want pharmacological pain relief in labour. For many women, giving birth is extremely painful and I struggle to understand how wanting pain relief for something very painful is an abnormal action.

Nudging Normal

Normal also implies that this is how the majority of births happen, i.e. how the majority of women give birth. Telling people that "that's what everyone else does" is a powerful way to influence their decisions and one that is utalised by advertisers and government agencies. For example, it may be more effective to tell people that most others in their area have already done their tax returns, than to just threaten individuals with fines if they don't. Suggesting to women that most other mothers, normal mothers, have unmedicated vaginal births applies subtle pressure on them to conform to this ideal.

Is "Normal" actually Normal?

I'm not even sure if most women are having "normal" births.  If anyone has better stats on this please let me know but going on the Birth Place Study data it seems like "normal" births aren't the clear majority. It found that for every 1000 low risk births in hospital, only 460 will be classed as normal. The majority of those planning homebirths do achieve the "normal" classification but that is still relatively few women so may not do much to alter the national average and, significantly, this data excludes all high risk births, which are presumably more likely to involve drugs or interventions. Essentially as far as I can tell, "normal" birth, isn't actually the norm.

***Update - many thanks to BirthChoiceUK who have confirmed that for England only around 40% of births meet the Birth Place Study definition of normal.***

What Is Normal Anyway?

Finally, I wonder about the criteria for normal. I can appreciate that syntocinon drips, instrumental deliveries and emergency caesareans should only happen in the event of medical need, ie. when something unexpected / not normal has happened. But then I come back to the pain relief issue. Why is it abnormal to have have a well researched and highly effective form of pain relief with known, minimal side effects (an epidural) but it's entirely "normal" to strap a small electronic device to your back and get it to give you regular electric shocks, even though there is little evidence that it's actually effective (a TENS machine)? Similarly if a "normal" birth is one that avoids any modern interventions why is it "normal" to labour and/or give birth in a recently invented, specialised pool of warm water? I'm not saying there is anything wrong with waterbirth by the way, I spent hours in the pool during my first labour and found it very helpful and calming, but clearly for most of human history women didn't have access to large quantities of clean warm water. Finally (actually I'm sure there are more but I think you get my drift) why is it abnormal for a birth to involve surgical incisions in the abdomen but a vaginal birth that results in the mother needing stitches, or even surgery under general anesthetic is still "normal"?

Of course sitting here and criticising from the comfort of my own blog is easy enough, I have no better word than "normal" for the type of birth described. I slightly prefer "natural" as normal birth is essentialy that - a birth which needs no help from modern medicine, and personally I would rather be unnatural than abnormal. But I appreciate that natural comes with it's own problematic connotations.

But do we even need a word to classify this? Doing so, and placing the emphasis on getting more women to have this particular kind of birth worries me. What about those who can't meet this standard due to medical reasons? What about those who can't or don't want to endure the pain? It seems to me worryingly patriarchal to hold up one kind of birth as the ideal for all women at a time in our history when there have never been so many good, safe, options available. I am all for supporting women who want this kind of birth but I worry about just where support and encouragement turn into persuasion and coercion.

For me, "normal" is a mother who wants to ensure the well being of her baby and who will make huge personal sacrifices to achieve that. Whether that means enduring the pain of a natural birth, the risks and indignities of interventions or the arduous recovery from a C section. There are so many different kinds of birth, none is inherently better or more valuable than the others, and none can claim the title "normal" by shear weight of numbers. The only thing that is genuinely Normal about birth is the everyday, ordinary heroism of mothers everywhere, bringing their babies into the world the best way they can.

Tuesday, 21 April 2015

H is for Hospital, Home and Genuine Choice

This is another #MatExp ABC post. Today we have reached H and when I went on twitter this morning the first suggestion I saw was H is for Homebirth. That got me thinking and, as usual, 140 characters wasn't really enough. So my H is for Hospital birth, Home birth and genuine choice.

To be clear I am not at all against home birth. I support the idea of making it available to more women and of giving them accurate information about how safe and beneficial it can be. But, especially online and in social media, I hear a great many voices, mothers, midwives, doula's etc. all championing that cause. I stand with them, but I also have some concerns.

I'll be honest, when I read stories of high risk mothers having home births it does worry me, ultimately I support the ideal that it's her body her choice, but as a mum who saw her straightforward natural birth become anything but, I can't help but worry about what might happen. That however isn't what troubles me most about the current advocacy for homebirth. I have two main concerns:

1-Avoiding the problems

The birthplace study led to many calls for all low risk women to be encouraged to give birth at home. It found that those who did were less likely to end up with interventions such as c sections and and epidurals. But what few commentators seemed to ask was - why are there so many more interventions in hospital and if they are unnecessary - how can we stop them? The consensus seemed to be that it was better just to convince women to have home births so they could avoid the problem. But where does that leave those who want to be in hospital? A lot of mums actively choose to have an epidural and you can't get that at home. What about the mums who would have loved a straightforward home birth but who's pregnancies have become too complex for them to feel safe at home? What about those whose home environment isn't safe and comforting?

1- Equality of care

My NCT teacher was a staunch advocate of homebirth. At our first class she advised us all to have one or to at least pretend we wanted one (then fake chickening out at the last minute). It might seem a bit bizarre to pretend to want a homebirth if you don't, but (on this at least), she had a point. In our area, planning a homebirth means you have a named midwife working with a small caseload team. That small team will all get to know you and care for you before, during and after the birth. Each midwife has a carefully limited number of women to ensure she has enough time for all of them. In a cash strapped NHS it's an amazing service. But it's only available to those choosing a homebirth.

I worry that these two aspects could combine to create a two tier maternity service within the NHS. Excellent, consistent care, a nice environment, time to discuss options and fears, no unnecessary interventions - but only if you are willing and able to have a homebirth.

Clearly the losers here are those many women who need to be in hospital. Who, in many cases will be those most in need of kind and consistent care. It effectively says you can either have modern medicine or compassion, but not both. Fall from that narrow pedestal of "low risk" and you may have to accept that the demon doctors will be waiting for you.

That said, I don't think this dichotomy is good for anyone. I am all for women making informed choices about where and how they give birth, but that choice should be between giving birth at home, in their own, familiar environment or giving birth in a modern hospital with every possible form of medical assistance and pain relief close at hand. If we simply wash our hands of the problems in hospitals and instead tell people to go home to avoid them, then that is not the choice that's being made. Instead we are asking women who think they will want an epidural to chose between between good care or pain relief. It means women who develop complications in pregnancy will have to decide between compassion or safety. That's not making the best choice for yourself, it's going with the least worst option.

Women should be able to chose hospital birth because it's what they want, not because they have over inflated fears of homebirth. But they should also be able to chose homebirth because it's what they want, not because the alternative is terrifying and those whose choices are limited by their medical or social situation should never be forced to accept sub standard care because no one was shouting loudly enough for them.


Friday, 17 April 2015

D Is For Demons

A #MatExp ABC post

For those who don't know what the #MatExp ABC is:

Each day over on twitter, midwives, mothers, obstetricians and anyone else who wants to join in are sharing a word which is important to them and which relates to maternity care. I've been joining in and also trying to link my words to old blog posts, to give a more detailed explanation of my thoughts for anyone interested (some people seem to be so that's nice!). Today though I've struggled to find a post that puts it succinctly enough so I'm writing something new.


D is for Demonising

My NCT teacher had some pretty strong opinions about childbirth. She was a retired midwife and, understandably had a great deal of love and respect for her profession. Those feelings did not extend to her former colleagues with medical degrees.

We were taught that "normal", natural, ideally home birth was a wonderful thing and that it was achievable by almost anyone so long as we kept mobile, banished our fears and were helped only by midwives and doulas. But stray from her principles and horrors awaited us. There were doctors just desperate to turn our births into cold, medical procedures, soley to speed it up for their own benefit. Or because they were terrified of the minute chance that something would go wrong and they would be sued. If we allowed fear to creep in and agreed to pain relief or that first intervention, then we would surely be stepping off a cliff into an inevitable cascade of worsening tortures.

At most times I am quite pragmatic and rational, but I challenge anyone to maintain that after 24 hours of labour. With hindsight it made perfect sense to transfer from the birthing pool in the midwife led unit to the obstetric unit so I could let modern medicine help things along and get some pain relief and rest. But at the time it felt like an utter defeat, like I was surrendering my body and my will to whatever my sinister new masters dictated. I hadn't been afraid when I went into labour, as I moved along that corridor, towards the doctors and their machines, I was utterly terrified.

Being unafraid didn't prevent problems in my case, perhaps it does help others. However, those who seem in a position of authority, who present themselves as knowledgeable on the subject, should never try to remove the fear from one kind of birth by piling it onto all others. Most low risk pregnant women won't have to deal with doctors unless and until something goes wrong. So they have only other people's opinions of them to go on. If those opinions lump all doctors and all interventions together to be demonised - what does that do to the woman waiting for her first encounter with the obstetrician?

Wanting a "normal" birth, even if you have everything seemingly in your favour, can never entirely guarantee one. How much worse, then, is the fear of all those women who unexpectedly find they will need those demon doctors and tortuous medical acts?


D is for Demons

For a long time after MissE was born I carried my own demons. The ones who kept telling me I'd failed by having an emergency Casearean. Who suggested perhaps I just didn't try hard enough, that perhaps it wasn't really as necessary as I wanted to believe. For a long time I thought the only way to be free from them was to prove that I could do better next time. That I could give birth naturally and have one of those wonderful, empowering, birth experiences they were telling me I had thrown away. But those demons are gone now, and when it came to it, that wasn't what drove them out at all.

I didn't placate them by passing their test. My Demons were vanquished when I lay, calm and determined, on an operating table. My body was cut open by a man I had only just met, but I was not afraid or submissive. I had looked at all the evidence and all the options and I had chosen this. I had been taught that a woman's power in childbirth came from nature. But nature can be random and cruel, last time she would have casually watched me and my baby die. This time I decided not to leave it to her whims, I found power in the human creations of science and modern medicine and in myself choosing the safest way to protect my baby girl on her short trip into this world. As she arrived, the bright winter sun poured in through the window and I sent my demons flying out into it.


Saturday, 11 April 2015

The WHO Recommended Caesarean Section Rate (2015 Edition)

Yesterday the World Health Organisation (WHO) issued a statement about Caesarean sections- the title was:

Caesarean sections should only be performed when medically necessary

This was, of course, picked up by the press, with The Guardian pretty much copy-pasting the headline. So, does the WHO have some striking new evidence that there are far too many unnecessary C sections going on and it's endangering women and babies?

Well, no.

The statement comes with the publication of an article in the medical journal The Lancet. This looked at two studies into Caesarean section rates in 21 countries around the world. It found that overall the C- section rate was increasing everywhere (other than Japan for some reason). One of the main observations was that in countries where the Caesarean rate had been very low, maternal and infant mortality dropped as that rate rose towards 10%.  Here's a quote from the press release:

“These conclusions highlight the value of caesarean section in saving the lives of mothers and newborns,” says Dr Marleen Temmerman, Director of WHO’s Department of Reproductive Health and Research. “They also illustrate how important it is to ensure a caesarean section is provided to the women in need - and to not just focus on achieving any specific rate.”

But isn't there a WHO recommended C section rate? 

I've lost count of how many times on this blog I've used the phrase:

There is no WHO recommended caesarean section rate!!!

It is a much loved "fact" dragged up by every journalist writing anything about Cesareans (and in the press release and Guardian article) that the WHO recommends all countries should aim for a C section rate no higher than 10- 15%. Much less than in many developed countries including the UK and USA. It's true that the WHO used to recommend this, but they quietly dropped that in 2010 after they admitted the figure was based on no real evidence. It pretty much just seemed like a good enough number to someone so he went with it.

This hasn't stopped journalists continuing to drag it out at every opportunity though. Want to say women are choosing C sections because they are too posh to push, because they think it's an easy option, or because they are worried about their sex lives? Drag out that 15% figure to show how unnecessary all those caesareans are. Want to say that all these surgical deliveries are making babies stupid or fat  or costing the NHS a fortune? Be sure to mention that the WHO thinks a lot of C section mums are just being selfish!

So what does this new study really tell us?

Rather than setting a maximum C section rate, all this study can actually do is set a minimum. It shows that when a country's caesarean rate is below 10% then women and children will die needlessly. It also found that that once the C section rate got above 10% there was no further decrease in maternal or infant mortality. However, that doesn't necessarily mean that 10% is the optimum number (as suggested by the Guardian). The Lancet team only had information on mortality but death isn't the only possible serious outcome of a difficult birth. My family knows first hand the life long effects of a baby being deprived of oxygen during a difficult birth and, while it's almost unheard of in countries with good access to modern medicine, there are many women around the world living with horrendous obstetric fistulas. Is a 10% C section rate enough to prevent these? We simply do not have the data and without it, setting an arbitrary target figure is potentially very harmful. Which is why the press release, the Lancet article and this interview with one of the authors all make the point that the focus should be on ensuring every women who needs a caesarean has access to one and not on achieving some specific national figure.

But all this must of course be balanced against the risks of potentially unnecessary major surgery. The paper doesn't tell us anything new about these but the press release makes some general comments about risks and also highlights the lack of data on the social and psychological effects of a mother having a caesarean as well as the cost implications. The latter being particularly important for weak health systems where increasing the number of C sections draws resources away from other vital services.

The WHO has a very difficult job here. It is, after all, the WORLD Health Organisation and, as with so many health issues, there is enormous variation in the caesarean rate around the world. This is evident in the data from the 21 countries in this report. Among the poorest, C section rates are generally low, in Niger the rate rose from 5.3 - 9.8% over the period covered. In some of the wealthier parts of central and south America the C section rate is very high. In Mexico, by the end of the study period, it had reached 47.5%. Clearly not all of those Mexican C sections will have saved a life or prevented long term harm and I've heard from women in other countries with very high C section rates who felt they were coerced or forced into the surgery without a good reason. I have no doubt that this is wrong and should be acted on. But at the other end of the scale the WHO is also dealing with countries where women and babies die because of too few C sections. We simply don't have the evidence to set an optimum caesarean section rate that applies to every country in the world.

The Lancet review seems reasonably useful. It looked at a variety of factors and how they influenced C section rates in 21 quite varied countries (although I notice that no European countries were in the list). But I find the WHO statement and the Guardian regurgitation of it troubling; if Caesareans should only be done when medically necessary, then how to we define "medically necessary"? When the risk of someone dying is 50%? 10%? 0.001%?  Is a C section "medically necessary" if it won't save a life but will prevent a long term disability? What about a minor short term problem? What if the medical need isn't physical? Vaginal birth with all the attendant examinations and indignities can have serious mental health implications for women who've experienced sexual abuse. Then there are the women who've already had traumatic births or who are just plain scared.

That's a lot of questions and the Lancet publication can not possibly answer them. It doesn't even try to. So I find it worrying and bizarre that an organisation as important and influential as the WHO should extrapolate so wildly from a specific and limited data set. It looks like an attempt to shoe horn in something controversial in order to gain column inches. If so it's been successful.

But that still leaves me with another question - even if we could define and predict which Caesareans are medically necessary - should they be the only kind?

Don't get me wrong there are some pretty major downsides to surgical birth. It may avoid the pain of labour but the recovery can be long and agonising and it's major surgery. Things can go wrong. But according to NICE (the UK National Institute for Health and Care Excellence) the overall risks of caesarean section aren't much greater than for vaginal birth. It recommends that if a woman with no medical indication wants a C section she should receive counselling to explore her reasons but if she still wants a Caesarean birth she should get one.

In the UK where most of us have the luxury of taking it for granted that we and our babies will survive childbirth this seems like a reasonable position. I've had two caesareans, the second was my choice but I wouldn't recommend it to anyone with a good chance of a straightforward vaginal birth. However,  It's not for me or anyone else to make that decision about another woman's body. I don't think it's a great idea to have a C section without a pretty good reason. I really don't think it's sensible to have a home birth after multiple caesareans but women do make these choices and so long as she has made it herself, based on accurate information, then ultimately it's her body her choice. 

It's also worth remembering that all these percentages are describing national averages. They can say nothing about any of the scenarios an individual woman may face. Just because your country has a worryingly high C section rate, it doesn't mean your placenta previa didn't really require surgery. Just because your country's rate is so low it's costing lives it doesn't mean you won't have a straightforward natural birth.

There is no WHO recommended caesarean section rate and there shouldn't be. The Lancet article demonstrates this but the media have once again twisted the limited conclusions of a piece of research into an opportunity to attack women's bodily autonomy. Bizarrely in this case, aided by a WHO press release.

Statistics are useful and interesting for those in the relevant field. Numerical targets may or may not be helpful at the national level. But individual mothers and babies are far more important than any numbers generated from them.