Breech training in Paris, November 30 & December 1. Places still available. Download complete poster for more information.
This story about a woman’s home birth after 3 caesarean sections (HBA3C) caused a bit of a Twitter storm earlier this year. OB Prof Jim Thornton has written about his involvement here – his post and the comments below it will give you a sense of what the outrage was all about. What they won’t tell you is that a significant number of maternity service users and professional advocates active in the #matexp campaign called for an end to the storm, just as they are calling for an end to disrepectful care and divided professional camps. Their work is very worthy of your attention.
What interests and concerns me is that criticism and debate around this woman’s story seems to centre on:
Conspicuously absent is discussion about the woman’s description of care leading to her first 3 caesarean sections .. “As I was naive I thought I had to do what they said” .. “I was determined to have my VBAC. Until the doctor told me I was going to kill myself and my baby. So a scheduled CS was made for 38+4.” In my experience of working with women requesting support for what some might call extreme birth choices, disrespectful, coercive and often non-evidence based experiences of maternity care usually precede such apparently extreme decisions. Moderate risk-taking behaviour by a woman keen to collaborate with her care providers has been over-ruled by someone who feels they know best.
Strictly speaking, her midwives were correct: a woman CAN have a natural birth no matter how many sections she has had .. or she can try. This descriptive statement says nothing about the risk/benefit balance of such a choice, which her caregivers would certainly have discussed in detail. Women are supported to choose the mode of birth which is best for them, or they aren’t. Women are supported to choose the location of their birth, or they aren’t. ‘Risking out’ is an entirely different model of decision-making. And supporting women to exercise their own power and autonomy in low- to moderate-risk situations will potentially create fewer high-risk situations further compromised by lack of trust and respect between women and caregivers.
I would like to see more professional discussion around how we counsel women making very complex birth choices. This conversation is often difficult for health professionals because it requires an admission of vulnerability. The nature of complexity means several things could be going on at once, some of which may be new and unfamiliar and thus require more time and consideration for an appropriate response. But the nature of birth is that a crisis can emerge very quickly, and that time may not available. Experience helps. But who has a hefty bulk of experience supporting VBA3Cs? Experience of complications is particularly valuable in such work – but how many midwives who have actually experienced a uterine rupture at home are still practising? Professionals in these situations are always out on a limb.
Does this mean health professionals should never support women making choices which increase the complexity of caring for them in labour? What should professionals’ attitudes be to such choices? One tweeter opined that the NHS should not support VBAC’s at home, because brain damaged babies cost the NHS a fortune and, “There is a limit to what you can do with other people’s money.” What exactly did the woman in question do with ‘other people’s money,’ except use the minimum required for such a birth? Should a woman be forced to have surgery because otherwise her baby might cost the health system too much? Is this really a route we want to go down as a society?
All of the outrage about women making apparently ‘risky’ birth choices contrasts with societal reactions when men make make similarly risky lifestyle choices. Stories about mountain climbers always send a chill up my spine, and one that particularly affected me was the disappearance of Jean-Christophe Lafaille during his ill-fated winter climb up Makalu in 2006. I casually stumbled upon an article in some large-circulation magazine, containing a haunting photo of his wife and 4-year-old son. I was struck by the look of loss and longing in their eyes, probably because in 2006 I had two sons of my own of a similar age. I often wonder how his wife and son are doing now.
While mountain climbers are not immune to criticism from their own community as well as those outside it, they are also glorified and funded by large companies. They usually climb with teams of people, so it is not just their own lives they are responsible for (although in the case of J-C L it was). The captivating stories of their exploits are used to promote merchandise. Even people who would never dream of scaling Makalu find their tales inspiring. The makers of the film Everest, due to be released this week, are banking on it.
Perhaps Jean-Christophe Lafaille can help shed some light on the essential humanness of risk-taking and some women’s deep desire for contact with their most basic – and essential – self:
“I find it fascinating that our planet still has areas where no modern technology can save you, where you are reduced to your most basic – and essential – self. This natural space creates demanding situations that can lead to suffering and death, but also generate a wild interior richness. Ultimately, there is no way of reconciling these contradictions. All I can do it try to live within their margins, in the narrow boundary between joy and horror. Everything on this earth is a balancing act.” (reference)
While maternity services are about safety, they should never be about enforcing some presumed collective version of what is safe onto everyone, suppressing in the process the inherently creative and often risk-taking human spirit, as well as the potential discovery of benefits in these non-mainstream choices. Nations have mountain rescue services because people will continue to climb mountains. And women will continue to want to birth their babies, sometimes in extreme circumstances. I am comfortable with my role ‘on the ground,’ so to speak, providing the standardised care which institutional systems offer and most women are happy with. I am also comfortable supporting women who metaphorically want to scale a mountain, and I will continue trying to find what sort of equipment, sustenance, maps and guidance will help them be as safe as possible while being boundary-testing humans in all their glory. I hope that maternity services can find a way through which enables more women to ‘be themselves’ in birth, as safely as possible, with an open acceptance by women and health professionals that in some instances, this may in fact come with some greater risk. I hope that maternity services can provide care which meets women’s spiritual as well as physical needs, and that judgements and coercion can recede into the past. Every woman who gives birth – however she does it – is a hero.
(Originally written on 12 April 2015. Publication postponed due to professional blizzards.)
Related resources –
You may be interested in this article, co-written with Mariamni Plested. Plested M, Walker S (2014) Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9):13-16 – (Archived at City Research Online)
See also the Mama Sherpas film
Two weeks, two inspirational obstetric colleagues, two very welcoming UK cities. So much commitment to improve the system for breech babies and their mothers.
On the 20th of March, Dr Elie Azria of the Hôpital Paris Saint Joseph and Descartes University, joined me in Dundee, Scotland, to teach through the eclipse! The French and Belgians have continued to support breech births in the last 15 years, responding to the Term Breech Trial (TBT) with a prospective observational study (PREMODA, 2006) which involved over twice the number of planned breech births (VBB) than the TBT, and demonstrated no statistically significant difference in outcomes between those who planned a VBB and those who planned a caesarean section (CS). Azria was the lead author on a follow-up analysis of the data examining factors associated with adverse perinatal outcomes in the PREMODA data.
In our Breech Birth Network study day, Azria presented new research concerning whether breech presentation is an independent risk factor in preterm breech birth, with interesting results which we hope to see published soon. He also gave an inspiring presentation on the “Traps of Evidence Based Medicine,” using the example of term breech delivery, building on his work to reconcile the need for maternal autonomy and medical responsibility in shared decision-making about mode of childbirth.
I always enjoy teaching with experienced practitioners who come from a different practice culture. Practice constantly improves and evolves from sharing these different ways, if we are open to learning from each other. Azria pointed out that, sadly, even within a culture where support for VBB has remained standard, the use of CS is on the rise. As he described, “Breech delivery is a craftsman’s job,” an art as well as a science. Learning breech skills requires commitment, dedication and practice, which not everyone is willing to offer. Nor are many people keen to take the risk of learning in the current risk-averse climate of maternity care.
Read more about How singleton breech babies are born in France, from the AUDIPOG network (Lansac et al 2015).
On the 27th March, I was joined by Miss Nicola Lack, Consultant Obstetrician from University College London Hospital NHS Trust. Lack gave a fantastic presentation on the research base for counselling about mode of childbirth with a breech presenting baby. One of the problems with a decimated skills base is that, while we may have a strict set of inclusion criteria for what constitutes ‘normal’ for a VBB, it may be quite difficult to find someone who can actually assess those criteria at a moment’s notice on labour ward, eg. a hyperextended neck on ultrasound. Breech skills are not just the manoeuvres which may be used around the time of birth. Skilled practice also involves the ability to provide detailed individualised counselling and make relevant antenatal assessments, as well as on-going interpretation throughout pregnancy and labour.
Lack’s presentation drew extensively from her own experience of working in the UK and Africa, as well as her understanding of medico-legal issues and constraints caused by a litigious practice culture. She explained how, when counselling, we really need to talk about the potential benefits of VBB as well as the risks. For example, she reflected on how, when she first qualified as an obstetrician in 1999, placenta percreta was relatively rare. Now, she and her colleagues encounter it approximately once a week or fortnight, due to the increase in CS rate. That’s very concerning. Lack also facilitates a postnatal birth reflections clinic, where she has had the opportunity to learn how women feel about breech childbirth experiences, both CS and VBB, after the event.
My one sadness on both days was that, despite the best efforts of the organisers and the high calibre of the obstetric speakers at the events, so few obstetric colleagues attended the study days. This is a real problem. Midwives are increasingly advocating for women to have the realistic option of a well-supported VBB if that is their informed choice, but this needs to be a collaborative effort. I urge our obstetric colleagues to come to the table to learn and work with us, so that the women and babies we care for, and we as professionals, can benefit from the best possible support of the wider multi-disciplinary team.
Thank you to Consultant Midwife Phyllis Winters of the Montrose Maternity Unit and Julie Woodman of the Queen Alexandra Hospital in Portsmouth for organising the study days.