Taken from:
http://www.timesonline.co.uk/tol/life_and_style/health/article4628324.eceThe proper approach to maternity care has long caused philosophical differences. More than one baby in five is now delivered by Caesarean section and many midwives and natural birth campaigners think this is too high.
Childbirth, they argue, is a natural process that has become over-medicalised, with obstetricians too quick to whip out the scalpel at the first sign of difficulty. Many doctors, by contrast, think women face too much pressure to have natural births. Some, they say, are made to feel like failures if they have a Caesarean, or even an epidural.
There is great medical scepticism about home births: while most pass off fine, the mother is in the wrong place should there be an emergency. And female obstetricians are voting with their feet: almost a third have Caesareans themselves, a much higher rate than for non-doctors. It is no wonder that the chairman of the Healthcare Commission, Sir Ian Kennedy, complained last month of a “tribal” turf war between rival professionals.
New research from Australia this week has shed interesting light on the issue. It assessed how the risks of childbirth were assessed by five groups: pregnant women, midwives, obstetricians, and two other types of doctor, urogynaecologists and colorectal surgeons.
The patients, it turned out, were prepared to accept higher risks to have a natural delivery than the professionals. Midwives were closest in their judgment to the women, while the urogynaecologists and surgeons were the most risk-averse.
The findings suggest that medical staff overestimate the risks of natural delivery because of their own experiences. The human mind is very good at remembering unusual events and inflating the probability of them happening again. It's one reason why so many more people are scared of flying than of getting into a car.
The same phenomenon seems to be affecting views of the labour ward.
Because they witness thousands of births, medical professionals see more difficult cases, which they are apt to remember.
Midwives deal with the fewest severe complications, thus consider the risks to be lower. Urogynaecologists and colorectal surgeons see the extreme outcomes of complicated childbirth, such as intractable a**l incontinence, and thus show the greatest concern.
This is certainly something that doctors should consider when advising on the risks of vaginal delivery. Caesareans also have risks, such as haemorrhage, infection and impaired fertility, and this week a study suggested an association with diabetes.
It is important that doctors' bad experiences do not cause them to practise defensive medicine. That said, this long medical memory for adverse events is not wholly negative. It is only professional for doctors to consider everything that might go wrong. Childbirth might be natural, but it is also naturally dangerous. While the UK maternal death rate is only 14 per 100,000 births, the average in the developing world is 440 per 100,000. Many factors explain this difference, but prompt emergency Caesareans are certainly among them.
Doctors should, of course, consider that they might be prone to overestimating risk. But patients and midwives must also take an adaptable view of birth plans. These can undoubtedly be beneficial, helping women who want a natural delivery to achieve one. Doctors, however, often complain of a feeling among some women that they can plan a birth as precisely as they might a dinner party. These patients can then be reluctant to depart from the script, even when medical circumstances dictate a Caesarean or forceps.
A middle way can surely be found. But it requires flexibility on both sides if safety and patient choice are to be properly balanced.
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