Five late summer studies to ponder…

5732924471_2069b0c90aI am taking my own advice on the subject of self-care and this will be my last post for a week or two, while I take a holiday and have a complete computer break, but in order to help you stay updated while I’m away I have made one of my semi-regular lists of the juiciest articles on my reading pile. Illustrated by beaches and holiday spots to help me get in the mood!

And just in case you’re wondering, no … my birth-related reading pile is not coming away with us! 😉


The first two articles are on the topic of home birth after caesarean (HBAC). To some people, planning a home birth after a previous caesarean section seems like a crazy idea. However, as I can attest from my own practice, this is quite often a very sane and measured decision made by a woman/family who may have been treated poorly by the maternity services. In some cases, they weigh up the risks of being at home and the risks of being in hospital and they decide that home is the safest decision for them. Safety, of course, is a complex and multifactoral notion. It is not just about the numbers; it is also (and among other things) about how one feels in a place or in the presence of a particular care provider. One would think that the fact that some women decide to birth at home might make more of us sit up and pay attention to the state of what is on offer within the system, but it would appear that it is easier to label women than to consider that the service itself might have a part to play in women’s decision-making. This is only one of the complex issues that relate to this area, but it’s really good to have some data on the actual outcomes, so I’m looking forward to reading the first paper in depth.


6956978481_cd7e84dc3f1. Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making

We do of course need to consider the differences which exist between care and care providers in different countries, and colleagues in the UK (or elsewhere, come to that) might be interested to compare the US data with the results of the Birthplace analysis of this area. But to my mind it’s much more helpful to at least make a start on getting some better information for women and families than to simply rant about HBAC being a terrible thing. Who knows: we might even learn how we can make the system better for those who do (or might, if it was nicer) want to give birth within it?

There’s an interview with one of the study authors here which offers some interesting insight and discusses how midwives might take the findings forward in discussing the issues with women.

Background: In the United States, the number of planned home vaginal births after cesarean (VBACs) has increased. This study describes the maternal and neonatal outcomes for women who planned a VBAC at home with midwives who were contributing data to the Midwives Alliance of North America Statistics Project 2.0 cohort during the years 2004–2009.
Method: Two subsamples were created from the parent cohort: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. Descriptive statistics were calculated for maternal and neonatal outcomes for both groups. Sensitivity analyses comparing women with a prior vaginal birth and those who were at the lowest risk with various subgroups in the parent cohort were also conducted.
Results: Women with a prior cesarean had a VBAC rate of 87 percent, although transfer rates were higher compared with women without a prior cesarean (18% vs 7%, p < 0.001). The most common indication for transfer was failure to progress. Women with a prior cesarean had higher proportions of blood loss, maternal postpartum infections, uterine rupture, and neonatal intensive care unit admissions than those without a prior cesarean. Five neonatal deaths (4.75/1,000) occurred in the prior cesarean group compared with 1.24/1,000 in multiparas without a history of cesarean (p = 0.015).
Conclusion: Although there is a high likelihood of a vaginal birth at home, women planning a home VBAC should be counseled regarding maternal transfer rates and potential for increased risk to the newborn, particularly if uterine rupture occurs in the home setting.
Cox KJ, Bovbjerg ML, Cheyney M et al (2015). Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making. Birth, online ahead of print, DOI: 10.1111/birt.12188


719833887_1b2e0d76bb2. Women’s reasons for, and experiences of, choosing a homebirth following a caesarean section

This second HBAC-related paper looks, as you can probably tell from the title, at the experiences of Australian women who decided that HBAC was right for them. Really, really important stuff, and I’m looking forward to finding out more. At first glance, some of the issues – particularly women’s negative feelings at the ways in which they were treated by the maternity services – seem to be similar to those shared by the women that I have talked to in certain other Western countries.

Background: Caesarean section is rising in the developed world and vaginal birth after caesarean (VBAC) is declining. There are increased reports of women seeking a homebirth following a caesarean section (HBAC) in Australia but little is known about the reasons for this study aimed to explore women’s reasons for and experiences of choosing a HBAC.
Methods: Twelve women participated in a semi-structured one-to-one interview. The interviews were digitally recorded, then transcribed verbatim. These data were analysed using thematic analysis.
Results: The overarching theme that emerged was ‘It’s never happening again’. Women clearly articulated why it [caesarean section] was never happening again under the following sub themes: ‘treated like a piece of meat’, ‘I was traumatised by it for years’, ‘you can smell the fear in the room’, ‘re-traumatised by the system’. They also described how it [caesarean section] was never happening again under the sub themes: ‘getting informed and gaining confidence’, ‘avoiding judgment through selective telling’, ‘preparing for birth’, ‘gathering support’ and ‘all about safety but I came first’. The women then identified the impact of their HBAC under the subthemes ‘I felt like superwoman’ and ‘there is just no comparison’.
Conclusions: Birth intervention may cause physical and emotional trauma that can have a significant impact on some women. Inflexible hospital systems and inflexible attitudes around policy and care led some women to seek other options. Women report that achieving a HBAC has benefits for the relationship with their baby. VBAC policies and practices in hospitals need to be flexible to enable women to negotiate the care that they wish to have.
Keedle H, Schmied V, Burns E et al (2015). Women’s reasons for, and experiences of, choosing a homebirth following a caesarean section. BMC Pregnancy and Childbirth 2015, 15:206  doi:10.1186/s12884-015-0639-4



3. The re-enactment of childhood sexual abuse in maternity care: a qualitative study

I didn’t promise it was all going to be easy reading, but this paper contains some really key messages. It’s not necessarily what we do but how we do it, and we need to take ‘universal precautions’; demonstrating respect and ensuring that women feel in control. It all sounds so simple, but it’s so often lacking, and it could make such a difference for the women in our care.

Background: The process of pregnancy and birth are profound events that can be particularly challenging for women with a history of childhood sexual abuse. The silence that surrounds childhood sexual abuse means that few women disclose it and those caring for them will often not be aware of their history. It is known from anecdotal accounts that distressing memories may be triggered by childbirth and maternity care but research data on the subject are rare. This paper explores aspects of a study on the maternity care experiences of women who were sexually abused in childhood that demonstrate ways that maternity care can be reminiscent of abuse. Its purpose is to inform those providing care for these women.
Methods: The experiences of women were explored through in-depth interviews in this feminist narrative study. The Voice-Centred Relational Method and thematic analysis were employed to examine interview data.
Results: Women sometimes experienced re-enactment of abuse through intimate procedures but these were not necessarily problematic in themselves. How they were conducted was important. Women also experienced re-enactment of abuse through pain, loss of control, encounters with strangers and unexpected triggers. Many of these experiences were specific to the woman, often unpredictable and not necessarily avoidable. Maternity care was reminiscent of abuse for women irrespective of whether they had disclosed to midwives and was not necessarily prevented by sensitive care. ‘Re-enactment of abuse’ occurred both as a result of events that involved the crossing of a woman’s body boundaries and more subjective internal factors that related to her sense of agency.
Conclusions: As staff may not know of a woman’s history, they must be alert to unspoken messages and employ ‘universal precautions’ to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.
Montgomery E, Pope C and Rogers J (2015). The re-enactment of childhood sexual abuse in maternity care: a qualitative study. BMC Pregnancy and Childbirth 2015, 15:194  doi:10.1186/s12884-015-0626-9



4. Recurrence rate and outcome of postterm pregnancy, a national cohort study

Here’s a study on one of my very favourite topics; induction of labour. I haven’t read this in full yet, so I might change my mind when I have, but just looking at the abstract has made me think. What I’m mainly thinking is how big a gap there is between those of us who see pregnancy and birth as normal, everyday life events (in which, yes, women occasionally need help, but most of the time our bodies pretty much know how to do this, thanks) and those who see the birth journey as something that needs to be tamed, controlled, measured, monitored and contained as much as possible.

But what also strikes me as really interesting is that papers such as this one are written from the perspective of those who see so-called prolonged pregnancy as pathological. (Spoiler: I don’t agree that the concept of prolonged pregnancy is as helpful as some people think. Individuals vary, and there’s far more to it than just what the calendar or the clock says). The finding that women who have had one prolonged pregnancy are more likely to have another could (from the ‘pregnancy is really quite dodgy and always on the verge of going wrong’ perspective) be seen as a good bit of knowledge, because now we can do more monitoring of those women and make sure it doesn’t happen again. Or, from another perspective, we could say, ‘Oh, that’s interesting. Maybe a longer-than average pregnancy is normal for some women?’ and then spend our time with the women who really need it.

Take your pick, and here’s the abstract if you’d like to start digging in deeper:

Objective: To assess the recurrence rate of postterm delivery (gestational age at or beyond 42 + 0 weeks or 294 days) and to describe maternal and perinatal outcomes after previous postterm delivery.
Study design: From the longitudinal linked Netherlands Perinatal Registry database, we selected all singleton primiparous women who delivered between 37 + 0 and 42 + 6 weeks with a subsequent singleton pregnancy from 1999 to 2007. We excluded congenital abnormalities. We compared the recurrence rate of postterm delivery and risk of antenatal fetal death in women with and without a postterm delivery in their first pregnancy. We compared perinatal outcome (composite of perinatal mortality, Apgar score <7 and birth injury) and adverse maternal outcome (composite of maternal death, abruptio placentae, PPH > 1000 ml and blood transfusions) between women with a recurrent and a de novo postterm second pregnancy.
Results: Our study population consisted of 233,327 women of whom 17,874 (7.7%) delivered postterm in the first pregnancy. In the second pregnancy, 2678 (15%) women had a recurrent postterm delivery compared to 8698 (4%) women with a de novo postterm delivery (odds ratio (OR) 4.2 95% confidence interval (CI) 4.0–4.4). Subgroup analysis in recurrent and de novo postterm delivery showed no differences in composite perinatal and composite maternal outcome (OR 1.0; CI 0.7–1.5, p = 0.90 and OR 1.1, CI 0.9–1.4, p = 0.16), adjusted for fetal position and mode of delivery).
Conclusions: Women with a postterm delivery in the first pregnancy have a higher risk of recurrent postterm delivery. Our data suggest that there is no difference in the composite adverse perinatal outcome between recurrent and de novo postterm delivery.
Kortekaasa JC, Kazemierb BM, Ravellid ACJ et al (2015). Recurrence rate and outcome of postterm pregnancy, a national cohort study.  European Journal of Obstetrics & Gynecology and Reproductive Biology 193: 70–74.


5673400667_3a6f52ceba5. Optimal fetal growth: a misconception?

The last offering on my bumper reading list is a paper that has been on my desktop for a while, and I’ve just not find time to write about it, so I’m going to share it anyway, because it is really interesting. I have done a lot of challenging of concepts like normal limits over the years and I’ve also written about the problems raised by having universal growth standards, so I’m delighted to see some of these concepts being challenged from a more holistic and considered perspective than has sometimes been taken.

Alterations in fetal growth trajectory, either in terms of individual organs or the fetal body, constitute part of a suite of adaptive responses that the fetus can make to a developmental challenge such as inadequate nutrition. Nonetheless, despite substantial changes in nutrition in many countries over recent centuries, mean birthweight has changed relatively little. Low birthweight is recognized as a risk factor for later noncommunicable disease, although the developmental origins of such risk are graded across the full range of fetal growth and birthweight. Many parental and environmental factors, some biological and some cultural, can influence fetal growth, and these should not be viewed as abnormal. We argue that the suggestion of establishing a universal standard for optimal fetal growth ignores the breadth of these normal fetal responses. It may influence practice adversely, through incorrect estimation of gestational age and unnecessary elective deliveries. It raises ethical as well as practical issues.
Hanson M, Kiserud T, Visser GH et al (2015) Optimal fetal growth: a misconception? Am J Obstet Gynecol. 213(3):332.e1-4. doi: 10.1016/j.ajog.2015.06.027


Well, I hope that some of those help you keep updated while I laze about by the pool … or maybe you’re off on holiday too?!  Either way, see you in October!

photo credits: Rhodos via photopin (license); Sunrise @ Myrtle Beach via photopin (license); Bondi via photopin (license); A Calm Summer Night in Vancouver via photopin (license); Beautiful beach at Elafonisi with pink sand via photopin (license); via photopin (license)

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