Wednesday, 25 November 2015

Don't Fear Sunday's Child - A Look At Today's Headlines On Weekend Births

If  I was pregnant at the moment I suspect I'd find today's headlines pretty scary. They report that giving birth at the weekend, something most women can not control or predict, puts babies lives at risk.

It would be great if we could dismiss this as yet another case of media hype, a rouge press release or even (as has been suggested) a conspiracy theory aiming to turn the public against junior doctors.  But having read the stories, the press release and the paper they are all based on, I think it's all a bit more complicated than that.

The first thing I want to say though, to any readers who are pregnant and scared  by this news is please, don't be.

The headline story that there is a binary difference between weekend and weekdays simply isn't true. Take a look at the data below, taken from the BMJ paper this is all based on. The death rate is highest for babies born on a Thursday. In fact the most notable trend isn't a peak at the weekend but a drop on Mondays and Tuesdays. This trough drags down the average across all weekdays, making the weekend average seem much higher  by comparison.  This data doesn't tell us that lives would be saved if weekends were more like weekdays. It shows we'd be better off if every day was more like Tuesday (this may be the only time in all of human history when that sentence has been true!)

Plot taken (axis adapted for clarity) from the BMJ paper 

So should we instead  be terrified of giving birth on a Thursday?  The paper doesn't really address this issue. It merely speculates  (unconvincingly in my opinion) that babies born on a Thursday may be more likely to die a few days later because of the care they receive over the weekend.

This study also doesn't prove that weekends are more dangerous because the consultants are all off playing golf or something. It found no difference in death rates between units that met the recommended consultant levels and those that didn't. In fact of all the outcomes looked at, including injuries, infections and hospital re-admissions, the only one where weekend consultant numbers were important was the number of perineal tears. Yet even this isn't necessarily an indicator of poorer care when consultants aren't around. It is quite widely believed that obstetricians are more risk averse than midwives and more likely to recommend emergency caesareans. The decreased number of tears when there are more consultants may be due to an increase in possibly avoidable C sections. I expect many mums will have an opinion on which is the lesser of those particular evils!

I am, by the way, just speculating on the fewer tears means more C-sections thing. But that brings me to the fundamental flaws in this paper and how it's being reported to the public. The news stories and (unusually) the paper itself all seem determined that there is indeed a "weekend effect". They gloss over or ignore the data showing that this effect starts on Wednesday, and, having shown that consultant cover isn't an issue, offer only speculation on potential causes. Much of these seems to have been thought up to make the data fit the hypothesis. For example, while it may be the case that outcomes for babies born on Thursday are influenced by their care the following weekend, there is no real evidence for that. The data doesn't tell us how long babies were in hospital after the birth. Similarly it doesn't tell us how long the mother was in labour (and in the hospital) prior to birth, a period where good care is crucial. A large proportion of the women giving birth on a Monday and even Tuesday will have been receiving weekend care during labour, yet these are actually the days with the lowest death rates. Why? We don't know, but perhaps the question of why babies born at the weekend fare worst should be re-framed so we're asking what we can learn from the Monday and Tuesday births.

This study is fascinating and will certainly be a valuable contribution to the academic literature on the subject, but it generates more questions than it answers.

For example, the birth rate is 21% lower at weekends. Even if elective c sections (which are very low risk and almost always done on weekdays) are removed, it is still 11% lower. Why? Could a reduction in the number of Inductions (IOL) at the weekend be involved? There is increasing evidence that IOL for overdue babies improves a number of outcomes, but this isn't covered int he paper so we don't know.

If consultant cover makes no difference what about the number of midwives, junior doctors, pediatricians etc.? What about their work patterns and moral?

What about dozens of other factors that we just haven't thought of? The simple answer is we don't know.

What we do know, if we actually look at the data not the headlines, is that there is no reason for women to be afraid of going into labour on the weekend. I've heard several health care professionals today express concern that women who start to get contractions, who's waters break or who feel a reduction in their baby's movements could delay going to hospital to avoid the weekend effect and in so doing risk something worse. The prospect of giving birth can be scary enough as it is, women need real evidence not hype. I find myself saying this over and over again, we are grown up adult human beings - why are we so rarely treated like it when there are column inches up for grabs (and perhaps in this case academic impact factors)?

Clearly more research is needed on the questions raised by this paper, it could be the starting point for something really useful, maybe lifesaving. But right now, it and the media response to it, only risk causing yet more fear and confusion.

If you are pregnant and reading this, just take this one thing away: The NHS is flawed and under funded, sometimes it makes mistakes, sometimes it just doesn't do things as well as it should, but if things get difficult in childbirth it has your back. The vast majority of women will take home wonderful, healthy babies, whatever day of the week they decide to turn up on. I, and my babies, wouldn't be here without it.


In case you missed the other links - the original paper including the full version of the diagram above can be found HERE

EDITED TO ADD (26.11.15) I've just seen this response  from the RCOG it raises a few additional and important points that I didn't include in this post and is well worth a read (I'm neither an obstetrician or a statistician and didn't want to include anything I wasn't sure I had right!) An important one is that for 86% of still births the baby dies before birth, often several days before so the day they are actually born doesn't tell us what happened or when.

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