Choice

On Thursday, obstetrician Maggie Blott, from the Royal College of Obstetricains and Gynecologists (RCOG) spoke on BBC Radio 4's Woman's Hour in a feature on pregnancy and birth, she stated that some women do not have a choice in where (and one must assume, how) they give birth.

The feature was generally very good and well balanced, I have no complaint with the BBC over this. The host, Jenni Murray was her usual calm and collected self, giving equal floor time to all of her guests. Sheila Kitzinger, founder of NCT and Birth Crisis, author and all around birth activist was interviewed and was asked about choice, birth plans and even orgasmic birth. A woman who had had a home birth recently was interviewed with her midwife and they both talked about how wonderful the experience was. The midwife was enthusiastic about home birth and talked about how rewarding her job was, which was refreshing coming from an NHS midwife, who are so often beaten down and jaded by the hideous system within which they have to work.

The issue of maternity services commissioning came up, following the Royal College of Midwives (RCM) recent conference, at which general secretary Cathy Warwick criticised the government for their U-turn on this topic. In the White Paper released in the summer, it was announced that while much commissioning would go to GPs to be determined on a local level (quite rightly so), maternity services would be commissioned by a national body. The reasoning for this is that maternity services is not generally dealing with people who are unwell, so is therefore outside of a GP's field of expertise. It is also something best looked at on a national level, because where complications do exist in small numbers not every local authority is going to have the resources to fund expensive facilities for very rare cases. It needs to be looked at on a larger scale so that the best provisions for those who need more care can be made in a sensible fashion. For example, not every local hospital needs a maternity unit and Special Care Baby Unit (SCBU), but at least one major hospital per region does need this. If commissioning is local then how will these facilities be funded?

However, some GPs inexplicably came out against this decision and have lobbied the government with such spurious arguments as "this is stupid". Hmm, helpful and how professional.

Cathy Warwick appeared on Woman's Hour and presented the case against GP commissioning. Health Minister, Anne Milton was also interviewed and she stated that no decision has yet been reached and that all sides were being considered. The general feeling among those in the know is that the government is going to come down in favour of the GPs. Why are the GPs even interested in this? What is in it for them? What does it mean for women and their families if their GP practice decides to reduce funding? The whole ethos of choice and quality care is under threat. It will become a postcode lottery as to whether a woman and her family can enjoy the essential quality of care that she needs. Women may end up having to travel large distances to receive their antenatal care if community midwives are made redundant by GP practices and the choice of where to give birth flies swiftly out of the window.

Which brings me back to the opening of this post. In the UK we are lucky to be able to exercise our fundamental human rights without fear from the government. Mostly. We are much better off than some countries. The Universal Declaration of Human Rights (UDHR) stipulates in Article 3 that "Everyone has the right to life, liberty and security of person." Security of person relates to the body and the mind, so basically every person has the right to bodily autonomy; they decide what happens to their physical body, and has the right to protect their emotional and mental wellbeing and no one has any right to override that autonomy. It would be under this fundamental human right that choice in birth comes. Every woman has the right to choose how and where they give birth. It may be that she has certain risk factors that may incline her care givers to recommend one place over another, but ultimately it is the woman's choice to take or leave that recommendation. For instance, an intense phobia of hospitals may mean that a woman chooses an elective caesarian in order to be able to plan the date and time of her birth and to control the amount of the time spent in that environment. Or it may mean that she chooses to give birth at home, perhaps even on her own with no midwife present if her phobia extends to hospital staff. That is her right.

During my first pregnancy I had no "risk factors". I was totally free from any medical-based prejudice towards one location or another for my birth. I was lucky enough too, to live in an area that nominally supports and encourages home birth. Unfortunately, there are so few women in this area choosing to birth at home that the midwives are not as skilled and experienced in normal, un-medical birth as they ought to be and as such, I was given a medical birth at home, which was never going to end well. Now I do have "risk factors". Next time I am pregnant, the NHS will "advise" me to have my baby at hospital. Not because it is what is statistically safest for me and my baby, but because their protocols are set out by a team of lawyers with the paralysing fear of being sued forever at the forefront of their minds. They want to control and manage all risk, rather than simply dealing with problems on the rare occasions that they do occur, so that they can say "we knew this was a risk and we tried to avoid it".

However, what many women genuinely do not realise is that they still have their fundamental human rights, as protected by the UDHR. They can decide for themselves whether to take the advice they are given or not. Because I am well-informed and have taken a great deal of time and effort to research the risks for myself and to analyse the reasons for protocols and guidelines to be in place, I know for myself that not only can I still have my next baby at home if I want to, but that there is even an official guideline that tells maternity personnel that I can make that choice. There is a NICE Guideline that states that women with one previous c-section should be treated no differently from any nulliparious woman (someone expecting their first child).

So, when I hear an obstetrician from RCOG on national radio stating that women with a previous c-section, for this was one of several specific examples that she gave, "do not have a choice in where they give birth" I am furious. Not only is she stating that some women do not have their fundamental human rights for the sole reason that they are pregnant, she is also going against the guidelines she is otherwise so tied to!

Midwife Cathy Warwick was wonderful at this point in the interview and did intercede to state that women do still have a choice and should be supported in that choice even if she has risks that her obstetrician is unhappy with. However, my fear is that Maggie Blott has given a green light to her colleagues to lie to women in their care. I know that the practices of lying and coercion are already very common in maternity care, from my own experience and those of other women I know, but to hear it on national radio from a member of RCOG has had quite an impact on me.

I urge women and birth activists everywhere to not let this go by without comment. Tell your friends, relatives, strangers in the waiting room, that being pregnant does not strip a woman of her human rights! Write to RCOG and demand a formal public apology for Maggie Blott's comments. I will be doing just that.

And on the subject of maternity services commissioning, please write to your MP as a matter of urgency and demand that the government stand by its commitment in July. The final decision on this is due in just a few weeks so there is no time to lose. You can find contact details for your local representatives here: http://www.writetothem.com/

Guess the Weight

Guess how many sweets are in the jar, or better yet, guess how much the sweets inside the jar weigh. Not including the jar itself but including all the sweets you can't actually see in the photo....

I'll give you a little help, you see that green one near the top left? Well the distance from the highest tip of that sweet to the lowest tip of the red stripy one down the bottom is... let's say 25cm. NOW tell me how much the contents of the jar weigh.

What? You mean you can't work it out?

No, I couldn't either, neither can my mathematically gifted husband. Although he does argue that he is familiar with these kinds of sweet jars and would therefore be able to estimate that the sweets weigh 1kg. But he is missing my point a bit.

From looking at this picture alone, with one arbitrary measurement and without being able to see maybe 80% of the sweets in the jar, there is absolutely no way that with this information alone anyone would be able to estimate with any degree of accuracy how much the sweets weigh. My husband is right though, using his life experience, he can guess the weight fairly accurately. But we do know with some degree of certainty that these exact sweets were weighed before putting them in the jar prior to sale. The same cannot be said of a baby in the womb.

So why do so many people believe a sonographer when they say that their unborn baby weighs xlbs in utero? It's the same sort of equation. An ultrasound gives the sonographer a view of a small section of the uterus at any one time and gradually builds up a picture as the transducer is moved across the abdomen. Three measurements are taken during a growth scan, the biparietal diameter (distance between the 2 sides of the head), femur length and the abdominal circumference. These measurements are entered into a computer program which then calculates the estimated weight based on charts created by researchers. You would think it would be fairly accurate. All that science.

The problem is that for one, the scan is only as good as the sonographer. All humans are capable of error. What one sonographer measures one day may be totally different to what another sonographer measures the next (on the same woman and baby). I have even heard of one sonographer giving a woman and her obstetrician quite a fright by writing down measurements that implied that her baby had SHRUNK! That was human error, babies don't shrink, as the obstetrician quite rightly pointed out, and later apologised to her and admitted that a mistake had been made.

But also, who made these charts and from what research? My best guess is that researchers have measured aborted and miscarried fetuses in order to establish average lengths, diameters and circumferences at different gestational ages. I wonder how many samples they looked at before coming up with these charts? From how many different ethnicities? Did they account for growth abnormalities in unhealthy fetuses?

There is a wonderful bit of research that demonstrates the complete unreliability of growth scans in late pregnancy:

Pregnancy outcome following ultrasound diagnosis of macrosomia.
AUTHORS: Delpapa EH; Mueller-Heubach E
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Pittsburgh, Magee-Women's Hospital, Pennsylvania.
SOURCE: Obstet Gynecol 1991 Sep;78(3 Pt 1):340-3
Extract: "In 66 of 86 women (77%) delivering within 3 days of ultrasound examination, estimated fetal weight (EFW) exceeded birth weight. In only 41 of these 86 women (48%) were the EFWs within the corresponding 500-g category of birth weight."

So basically, this study (admittedly only a small one), found that 77% of growth scans predicted a higher birth weight three days BEFORE birth, so if these scans really are as accurate as we are led to believe then 77% of babies shrink in the last days of pregnancy. See above. More alarming is that 48% of scans, i.e. less than half, were accurate to within 500g, which is more than 1lb. What a large margin for error! The difference between a 9lb baby and a 10lb baby can be a HUGE difference to the mother and her care providers both psychologically and in terms of her care during late pregnancy and birth. To look at it the other way, more than half of scans were LESS accurate than that. 52% of women scanned were expecting either much bigger or much smaller babies than they got.

Why does it matter?

Because if a midwife sends a woman for a growth scan because of concerns late in pregnancy, and the obstetrician that the woman sees after her scan decides that, based on this one scan, her baby is too big or too small, then interventions may be advised that are simply not necessary. For example, if a baby is suspected to be too big, early induction or c-section will be advised. Except in the current NHS system the woman will come away thinking that it is not advice that she has been given, but an order to comply with.

Why does it matter?

Because interventions without clinical need are a waste of resources and may have long-lasting negative effects on the mother and baby. Caesarian sections are known to leave babies with more breathing problems, greater risk of diabetes and cause risk factors for the woman in future pregnancies, never mind the risk of post operative infection and post traumatic stress disorder.

Why put women through that? Why subject a woman at the end of her pregnancy to fears about the wellbeing of her baby? Even when the prediction of a too big or too small baby is accurate, how often does it actually mean ill health for the newborn? According to one study, "Our ability to predict macrosomia is poor. Our management policy of suspected macrosomic pregnancies raises induction of labor and cesarean delivery rates without improving maternal or fetal outcome." (My emphasis).

The Delpapa and Mueller-Heubach study above also concludes that "A trial of labor resulted in vaginal delivery in 76 of 106 women (72%). There were five cases of shoulder dystocia but no birth trauma. Estimated fetal weights and birth weights were not significantly different between the women who had a trial of labor and those who did not. Our results do not support cesarean delivery or early induction as a means of preventing infant morbidity when fetal macrosomia (weight of 4000 g or more or the 90th percentile for gestational age) is diagnosed by ultrasound."

So ultrasound is NOT an accurate estimate of fetal weight and even when a baby is genuinely large (4000g+), spontaneous labour and vaginal birth are still the safest option.