Why the UK is still a-okay for childbirth a mother s view.

Transcription

1 Why the UK is still a-okay for childbirth a mother s view. I have been reading a lot recently about childbirth practices in the developed world and have come to the conclusion that here in the UK we are doing pretty well (in a humble, very British self-deprecating way). Okay, so the system s not perfect: the NHS is still short of some 5,000 midwives, independent midwifery is under threat due to prohibitively expensive insurance, and with a birth-rate that has grown by a fifth in the last decate, one-to-one midwifery for all is still a distant dream. On the upside however, the UK is still one of the safest places to have a baby, and because our NHS system is funded by the tax-payer, there is no financial incentive for hospitals to favour expensive interventions and unneccesary c-sections. Not so in countries such as Brazil, the USA and the white population of South Africa, where convenience and financial gain can often seem to take precedence over what is in the best interests of the mother. In a private medical system, inductions are often scheduled no later than a Wednesday or Thursday (so the baby is born before the weekend?). The healthcare system in some countries has created its own delivery schedule, rather than operating in the way nature intended, and it is common to give nature a little helping hand. In the UK, the vast majority of women may not have the little luxuries that private medical insurance can buy (for example a hotel-like room or a la carte dining). To have your baby in a private hospital in the UK costs in the region of 10,000, and if complications do occur in the newborn, you could end up being transferred to an NHS neo-natal unit, which has the specialist care your baby would require. For the majority of women in the UK who receive maternity services through the NHS, if a mother has had a straightforward vaginal delivery she will be sent home after 6-24 hours. (Compare this to the 1970s when women in the UK having their first baby were generally in hospital for 10 days). My own mother was quite horrified when I told her I d been sent home 6 hours after giving birth, but really, there is much evidence to suggest that the best place for a mother to be post-natally, provided she is seen by a community midwife on her return from hospital, is at home. She is more likely to get more rest in the comfort of her own home than in hospital, and since childbirth is a life event, not a sickness, there is an argument to say that she should be as far away from a hospital as is practically possible. So is our system so flawed? Another plus for living in the UK: a woman can decide, and be fully supported in her decision as to where she will have her baby. Whilst homebirth rates are still low (at around 2%), there is much anecdotal evidence to suggest that the tide is turning back towards a more community-based model of midwifery (perhaps fed by the success of TV programmes such as Call the Midwife, or the recent documentary following an independent midwife: Home Delivery). However, we still have a long way

2 to go before we have such high homebirth rates as Holland (currently around 30%), and often touted as the model of progressive maternity care. One area where the UK could possibly do better is in the contentious area of inductions. The World Health organisation recommends that inductions should account for only around 10% of all labours and should only be carried out where there is a medical reason for doing so. However, in most hospitals in the UK, the rate is around about 20%. Many inductions are undertaken because the woman is supposedly late (inductions are offered routinely at 40 weeks plus 10 days), failing to accept that baby knows best, and will more likely than not put in an appearance when it is ready and when the mother s body is ready. What constitutes full-term is also open to interpretation. In France for example, pregnancies are calculated at 41 weeks in length. It can also be difficult to pinpoint with certainty exactly how many weeks or days a woman is pregnant. We all have different lengths of menstrual cycle, so how can we know for sure that a woman has reached that critical time? Even scans cannot determine due date with 100% accuracy. The argument for inducing at 40 plus 10 days is often cited as fear of placental failure or stillbirth, however these risks are still very small. With stillbirth for example, the risk of stillbirth does go up slightly with a longer pregnancy, but only once the pregnancy has reached 42 weeks. Modern statistics show an almost flate rate of stillbirth from 40 weeks to 42 at around 2/1000, with a slight rise at 43 weeks (4-7/1000)* Nonetheless, it has not been proven that it is the longer pregnancy itself that is the cause. If you wish to avoid artificial induction, it is quite feasible to monitor fetal heartbeat, levels of amniotic fluid and your blood pressure on a regular basis, and this is a good option to propose. As long as these three measures are deemed to be normal then there should be no reason to induce for the sake of it. Obviously there are some very valid medical reasons why an induction may be necessary, eg. for pre-eclampsia or obstetric cholestasis (a very rare liver disease), and in this case induction can be a life-saving procedure. For many women however, if they are still pregnant at approaching 42 weeks they may be offered a routine induction, which at the time can seem like an attractive option, yet often the repercussions of an induction are not fully explained: induced labour can be more intense, leading to increased use of epidurals, assisted deliveries and c-sections. Inductions also carry a greater risk of bleeding, uterine hyperstimulation and rupture, cord prolapse, meconium aspiration and neonatal jaundice. So we should think very carefully before interfering with the natural timing of birth. Even an uncomplicated induced labour needs to be monitored more carefully than a spontaneous labour, therefore it is common to be attached to a continuous monitor, which at the very least can limit movement. The other major circumstance where an induction is offered is when a woman s waters have broken but labour hasn t started within 24 hours. This window has been reduced over time. Originally the World Health Organisation stipulated the timeframe to not exceed 92 hours, then it came down to 48 hours and now it is set at 24 hours in the majority of hospitals. No wonder then that the rate of inductions has gone up. The main risk of leaving labour to start naturally once the amniotic fluid has been released is the danger the baby will pick up the Group Strep B virus, which can be fatal. High-risk categories for a baby contracting Group Strep B are premature labour, (esp before 35 weeks), having a previous baby with Group Strep B, or having a fever in labour. There is a slightly increased risk if you do not go into labour within 24 hours of waters breaking, but in fact this increased risk is actually quite small. An alternative to induction after 24 hours can be the administration of antibiotics, but like other drugs, we do not know the effect these may have on the baby. One argument against the use of intravenous anitbiotics in labour is that it makes your baby less vulnerable to Group Strep B, but more vulnerable to infection from antibiotic-resistant organisms due to antibiotics immune-depressing qualities. The good news is that 95% of labours will begin within 24 hours of waters breaking, so you

3 are very unlikely to find yourself in this position, and even if you do, you still have options. What happens if we do nothing is always a good question to have up your sleeves for your medical carers. At least when you are armed with all the information you can make informed decisions. I touched briefly on C-sections in the UK and abroad and I would like to revisit this point. The world health organisation, in a paper in 2010** (see sources) stated that countries with c-section rates under 10% showed underuse of the operation, whilst those with rates over 15% tended towards overuse. A total of 54 countries had C-section rates below 10%, whereas 69 showed rates above 15%. 14 countries had rates between 10 and 15%. In conclusion the report estimated that in 2008, 3.18 million additional CS were needed and 6.20 million unnecessary sections were performed. There are negative implications for both overuse and underuse in terms of maternal and neonatal morbidity and outcomes. In 2009, caesarean section rates were the lowest in the Netherlands (14% of all live births), and were relatively low also in many Nordic countries (Finland, Iceland, Norway and Sweden. We have also talked about how the Netherlands also has the highest rate of homebirths, so unsurprisingly there is a strong correlation here. Brazil and China have the highest rate of C-sections and between the two countries account for 50% of so-deemed unneccesary caesars. Figure 1. Caesarean rates per country ***Source: OECD Health Data 2011; WHO (2008a) Figure 2 Caesarean sections per 100 live births, (or nearest year)

4 Source: OECD Health Data 2011 The overall UK rates for c-sections were 23.7% in In some hospitals they are pushing 30%. Emergency c-sections tend to average around 15%, which is at the upper end of the healthy bracket. So in terms of emergency c-section rates we are pretty much where we should be. It is when we look at overall rates we fall down. This tends to be because in the UK one c-section leads to another, which doesn t have to be the case. In fact about 3-quarters of women who attempt a VBAC (vaginal birth after c-section) are successful. Luckily for us in the UK, VBAC births ARE well supported for women if they choose to go down that route. Many don t. The most worrying thing about the data fron the OECD is that all countries show an overall upward trend for caesarean-sections, quite significantly upon 1990 levels, as the risks to mother and baby from a caesarean are three times higher than a vaginal birth. Within the UK, caesarean rates vary from hospital to hospital. To see individual hospital c-section rates please visit the birthchoice website: Finally, as a mother of 2, I am pleased to report that my experiences of giving birth in the UK have been very positive. I had both my babies at Kingston Hospital once in the delivery suite, and secondtime around in the Malden suite (the midwife-led unit). On both occasions I had excellent midwifery care and relatively straightforward births (my second using hypnobirthing). I always found the care to be very professional and I was treated like a human being. I know there are some hospitals and circumstances where this isn t the case, but the turmoil surrounding the mid-staffs hospital shows that under-performing hospitals cannot carry on underperforming without actions being taken. Sadly, for some, this is too late and of limited consolation But it is worth mentioning that if you are NOT happy with your hospital, or indeed the midwife you are allocated you do have the right to change, or ask to speak to the consultant midwife in charge. All things considered, the UK is still one of the safest places to have a baby, with maternal and perinatal mortalities extremely low (source: Neonatal and Perinatal mortality country, regional and global estimates, WHO 2006). We are fortunate to have considerable choice over where and how we birth our babies, and by and large our system favours natural and normal birth. Conclusion: What the UK does well: a mother s view

5 Promoting natural and normal birth as the default position for low-risk pregnancies High standards of obstetric and midwifery care Acknowledgement of the benefits of midwife-led units Access to high-standards of medical care for complications or emergency situations Low rates of maternal and neo-natal morbidity Choice of care options What we could do better: a mother s view More investment into recruiting new midwives; the Royal College of midwives estimates we are still short of some 5,000 midwives. One-to-one midwifery for the duration of pregnancy. Promotion of the normality of homebirth. Sources: *Eden, R.D. et al, Perinatal characteristics of uncomplicated postdates pregnancies. ** The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage Luz Gibbons, José M. Belizán, Jeremy A Lauer, Ana P Betrán, Mario Merialdi and Fernando Althabe World Health Report (2010) *** OECD health data 2011 ENDS Copyright Simplyborn 2013.