For some time now I’ve notice a promoted tweet from Which appearing on my timeline linking to a ‘Birth-choice Tool’. The tool is supported by the Royal College of Midwives (RCM), with the Chief Executive of the RCM Cathy Warwick saying that it will “…go a long way towards helping them [pregnant women] make an informed choice and to decide what is the best place for them to give birth.”
The tool has also been endorsed by Julie Cumberlege, the Chair of the National Maternity Review who (see tweet below) also makes a link with Personal Maternity Care Budgets. (This was a pre decided recommendation of the National Maternity Review).
Providing unbiased information to women and their families so that they can make informed choices about birth-place is clearly important and positive. This is something I can’t see anyone objecting to. But the emphasis here must be on accurate and unbiased information. To this end, I got a bit of a shock when I used the tool and entered various scenarios.
I’ll go through a worked example here.
The first question the tool asks is under the heading ‘Your birth experience’ and asks the question ‘Do you think you will want to use a birthing pool during labour?’.
Of note, the tool cites the benefits of a birthing pool as being coping with pain and being less likely to need an epidural. There is no discussion around published studies around potential risk and benefit.
The next question is ‘Do you think you will want an epidural?’.
My only comment here is that I can imagine for some first time mums they won’t know what to expect or how they will experience pain. Would a better question be ‘do you want to keep the option of having an epidural open’?
On to the next question… ‘How do you see birth’?
I have to say this is the point at which I began to feel really concerned. The tool gives two options.
- As a natural event that should take place in a relaxed and private setting.
- As a clinical event that needs medical equipment and staff on hand.
It seems to me that the language here is very loaded; ‘natural, relaxed and private’ vs ‘clinical, medical and equipment.’
Is it the case for example that birth in an obstetric led unit can not be ‘relaxed, natural and private’?
The tool then asks the question ‘Are you willing to plan for the possibility of transfer during labour’?
The explanation note does point out that if you plan to give birth at home or in a birth centre you may have to be transferred. It highlights that that such a choice ‘can reduce your chance of needing medical interventions.’ There is however no mention that for first time mums the transfer rate nationally is 36-40% and there is no discussion about the implications for the safety of mother or baby in the case of a complication arising that necessitates obstetric intervention.
The tool then asks for your age, if it’s your first birth and what your post code is.
In some scenarios, before coming up with the recommended options, the tool will ask an additional question:
‘Do you actively want to avoid the need for medical intervention’?
I have to admit to surprise when I read this. No matter what choice a woman and her family make about place of birth it surely isn’t possible to ‘avoid the need for medical intervention’. It might be possible to make choices that reduce the chance of experiencing an intervention that may not have been necessary. However, this is complex and in reality, many lives are saved by virtue of mothers giving birth in a setting where risks are carefully monitored and midwives and doctors train and work together to respond to obstetric emergencies promptly. For example, the obstetric unit at Southmead is regarded as one of the safest places anywhere in the world to have a baby.
Nowhere in the tool are the risks associated with childbirth quantified. For example, in 1999 the World Health Organisation (WHO) published research that showed that globally around 15% of all births are complicated by a potentially fatal condition that requires emergency care.
Academic research also that shows that your risk of death is greater on the day you are born, than any other day of your life until you reach the age of 92.
The things that can go wrong in childbirth (for example sepsis, amniotic fluid embolism, haemorrhage, placental abruption, pre-eclampsia) are not things that can be controlled by making a choice about birthplace. They are complications that on rare occasions, women and babies sadly continue to die from unnecessarily because interventions (sometimes as simple as a single of dose of antibiotics) were denied.
What did the Birthchoice tool recommended in my imagined scenario?
I live approximately 2 miles from Furness General Hospital (FGH). This is a unit that has recently been through a period of significant change and improvement. In many ways, the unit at FGH is now a leading one in terms of safety, quality and experience.
I completed the Birthchoice tool as a young first time mum, 19 years of age with my postcode. I answered all the questions leaving the slider in the middle (in reality I think the language in the questions is so loaded that I can’t see how it wouldn’t influence the responses). These are the recommendations the Birthchoice tool made:
In my scenario, the tool recommended a freestanding midwifery unit in Penrith, 62.8 miles from my home as a better choice than the unit at Furness General Hospital (FGH) which is just 2 miles away. This recommendation is made for a 19-year-old first time mother.
I always find it interesting to observe the wider context when I come across things like this.
Last week HSJ covered this story stating that there will be a doubling of ‘midwife-led births share by 2020’.
A week earlier, I noticed the following tweets from a midwifery conference attended by senior NHS and RCM midwifery leaders.
The tweet says “Obstetric violence, we have all seen it…” and shows what seems to be a video with a male doctor (presumably an obstetrician) and the words ‘No, no, no. Stay there quietly’. Someone comments that the phrase is worrying and the response is, ‘it’s very worrying… & exists’.
Last week I also took the time to watch a presentation from Bill Kirkup about events at Morecambe Bay where 16 babies and 3 mothers lost their lives. If you have the time, please watch it also. It is hard for me to reconcile the messages in Dr Kirkup’s report with some of the observations I’ve highlighted in this blog.
I know that there are many fantastic people working hard to ensure safer maternity care is a priority, but is it now time that we saw some national leadership in challenging these issues? If so, would a good place to start be by providing a resource for women and families that really did provide unbiased and accurate information to enable informed choice? Instead of conferences that promote ‘normality’ in childbirth and appear to promote negative messages relating to obstetricians that must be very frightening for women to see, shouldn’t we be holding conferences attended by all professionals involved in delivering maternity care, where we celebrate teamwork, discuss and learn from poor outcomes, listen to all voices and agree actions we can take together to make maternity care safer and better for everyone.
James Titcombe – 8th Jan 2017