Why forceps can be dangerous

 

Forceps deliveries and Ventouse deliveries are significantly more dangerous for both mother and baby than a caesarean section, according to new research published in the Canadian Medical Association Journal. The risk of severe complications to the baby is 80% higher.

The study looked at 187,234 births. The main finding was that “among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery.” To put it more simply, more babies died or were injured during an instrumental delivery than during a caesarean section. Although the study found that maternal mortality was no higher during an instrumental delivery, “rates of obstetric trauma” (this refers mainly to tearing) were higher.

This matters because in the UK, as in many other countries, there are moves to reduce the caesarean section rate, partly because caesareans are expensive, and partly because of the risks attached to abdominal surgery. The caesarean rate in this country is one in four, which many experts think is too high – and as a result, many hospitals now have “normal birth” targets.

The findings of the new research suggest that this drive is misguided. There have been a number of well-publicised cases over the past five years of babies dying after the mother was refused a caesarean section.

But there is a risk to the mother too. The Australian obstetrician Hans Peter Dietz has been outspoken about the target to reduce caesarean section rates in New South Wales, which has resulted in a huge increase in forceps deliveries, but also far more cases of women with severe pelvic floor and anal sphincter damage – something that can be absolutely devastating for women. Dr Dietz found that 81% of women who had forceps deliveries suffered internal damage.

Obviously there are caveats. A response to the research article by obstetrician Nicholas Pairaudeau argues that the decision to use or not use forceps should depend on factors such as the size of the woman’s pelvis and the positioning of the baby. He writes: “Even though I have used forceps for nearly 50 years I have, in my own practice, reduced many of the complications quoted, by careful selection of the patient, forceps, and type of pelvis. C-section is not a simple option in many cases, and is associated with major complications too.”

The question of risk in childbirth is never a simple one: often it’s a case of having to decide which is the lesser of two risky options. The worry is, however, that by setting a target to reduce caesareans, hospitals then become focused on the process rather than outcomes. A caesarean in itself is not a bad outcome: a dead or injured mother or baby is. Doctors’ decisions should be based entirely on whether they will lead to a healthy mother and baby – not on they meet an arbitrary external target.

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More mothers are dying in America. Why?

Throughout the developed world, the number of women dying in pregnancy or childbirth is going down.

The big drop happened in the 20th century, but even in the last 20 years, it’s continued to fall. Except, that is, in America.

A striking graphic in the Economist shows how, on average in developed countries, the rate has halved between 1990 and 2013 from 25 maternal deaths per 100,000 live births to 12. (In some countries, the rate is even lower: in Britain, there are six maternal deaths for every 100,000 live births.)

But in the US the reverse has happened. In the same 23 years the rate increased from 12 to 18.5.

Why? The Economist article posits various explanations: one is that the country has got better at counting the data, though it says that this can account for only a small part of the increase.

Another is that women are having their first child at an older age, which increases risk. But this also applies in other developed countries, where rates are falling.

It also considers that possibility that a rise in caesarean sections is to blame. Although caesareans are risky, again it seems unlikely that this accounts for such a dramatic rise.

The explanation favoured by the Economist is that American women are in poorer health when they become pregnant:

“Chronic health conditions, such as obesity, hypertension, diabetes and heart disease, are increasingly common among pregnant women, and they make delivery more dangerous.”

Shockingly, the maternal mortality rate among black women is roughly three times that of white women, because black women on average are more likely to suffer from these health conditions.

Chronic health conditions on their own don’t account for the difference between the US and other countries – British women also have problems of obesity, diabetes and so on but Britain has a much lower maternal mortality rate.

Perhaps the biggest problem still is the historic lack of universal healthcare.

“Medicaid already pays for almost half of all births in America, but millions of new mothers lost coverage 60 days after delivery, with the result that many entered their next pregnancy in bad shape,” the article says.

Obama’s Affordable Care Act may help to change things. But it’s scandalous that, in one of the richest countries in the world, pregnant and labouring women are still dying unnecessarily.

The shocking abuse of women worldwide during childbirth

The World Health Organisation has published a remarkable study that documents the abuse women worldwide experience during childbirth.

Published in a scholarly journal, it hasn’t yet received very much attention – which is a shame, because the treatment it highlights is deeply shocking.

The study is a systematic review, which means that it looks at research already published on this topic. It looks at 65 studies undertaken in 34 countries looking at the mistreatment of women during childbirth. The authors identify seven categories of abuse: physical abuse; sexual abuse; verbal abuse; stigma and discrimination like age or race; failure to meet professional standards of care; poor rapport between women and their healthcare providers; and health system conditions such as lack of privacy.

This is what the study says about the first of these – physical abuse:

“Physical abuse during childbirth was perpetrated by nurses and doctors. Women sometimes reported specific acts of violence, but often referred to these experiences more generally, describing beatings, aggression, physical abuse, a ‘rough touch,’ and the use of extreme force. Hitting and slapping, with an open hand or an instrument, were the most commonly reported specific acts of physical violence. Women also reported being pinched, particularly on the thighs and kicked. Some women were physically restrained during labor with bed restraints and mouth gags.”

It’s difficult to understand how anyone can imagine that this might be the appropriate way to treat a woman giving birth. Elsewhere, the study paints a picture of women having their babies in filthy conditions, being shouted at or threatened by health workers or having procedures forced on them without their consent.

Most of this abuse occurs in low- to middle-income countries – though we know that some categories (such as verbal abuse or consent not being sought for certain procedures) can occur in wealthier countries too.

The findings exist against a backdrop in which nearly 300,000 women, 99% them living in low- and middle-income countries, die each year from pregnancy- or childbirth-related complications. These deaths are almost all preventable with proper care. But there are other long-term consequences of poor care, including physical damage (such as obstetric fistula) and mental ill-health, such as depression or post-traumatic stress disorder. These – to put it at its mildest – have a lasting impact on women’s ability to look after or provide for their children.

Depressing though the study is, we should welcome this recognition by the WHO that abuse of women in childbirth is a problem that needs dealing with. Its identification of seven categories of abuse provides a framework for future research and policy-making.

And the message it sends out is one that policymakers everywhere – not just in the developing world – should take notice of:

“A woman’s autonomy and dignity during childbirth must be respected, and her health care providers should promote positive birth experiences through respectful, dignified, supportive care, as well as by ensuring high-quality clinical care.”

The 24th best place to be a mother?

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net
Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

Save the Children’s latest State of the World’s Mothers report has received a lot of media attention. In particular, the news that the United Kingdom comes only 24th in its Mothers’ Index Rankings (in other words, the list of the best and worse places in the world to be a mother) has been greeted with much dismay and finger-pointing.

While there are many admirable things in the report – particularly its focus on the shocking conditions in which women experience pregnancy and birth in many developing countries – the rankings themselves should be taken with a pinch of salt.

The rankings are drawn from five indicators:

  • Maternal health (by which is meant the lifetime risk of maternal death, ie dying during pregnancy or childbirth, or shortly afterwards)
  • Children’s well-being (the under-5 mortality rate)
  • Educational status (expected years of formal schooling)
  • Economic status (gross national income per capita)
  • Political status (participation of women in national government)

Each of these indicators is given an equal weighting.

All are interesting in their own right. But adding them together doesn’t really tell you anything useful about what it’s like to be a mother in each of those countries. Take the political status indicator. The report says that:

“When women have a voice in politics, issues that are important to mothers and their children are more likely to surface on the national agenda and emerge as national priorities.”

This is probably true, but in itself it doesn’t tell us anything about the experience of being a mother. It’s essentially a proxy indicator. If women are well represented politically, then they’re more likely to receive better healthcare, better education and better job opportunities. But there are already indicators for those things, so the political status indicator is just reinforcing the others.

Maternal mortality – a cause for concern?

More problematic is the maternal health indicator: the lifetime risk of maternal death. It’s a useful way of highlighting the difference between a country such as Norway, where the lifetime chance of dying in pregnancy or childbirth is about one in 15,000, and Somalia, where the chance is, shockingly, one in 18. But it’s not necessarily helpful to know that the lifetime chance in the UK is one in 6,900, compared to Greece (one in 12,000) or Iceland (one in 11,500).

That’s because there could be any number of reasons for this variation, such as the size of the ethnic minority population (women from ethnic minorities often have more difficulty in accessing good obstetric care), or the number of pregnancies a woman has in her lifetime, or the age at which she gives birth or her general health. Between 2006 and 2008, 261 women in the UK died of causes directly or indirectly related to pregnancy: half were overweight or obese, and 53 (20%) had problems with substance abuse.

More significantly, some of the variation may just be down to the way data is collected. The country that does best on this indicator is Belarus, where a woman has a lifetime risk of dying in pregnancy or childbirth of one in 45,200: which is more likely – that Belarus provides exceptional healthcare for mothers, or that its method of counting maternal deaths is rather more slapdash?

It’s not an argument for complacency – a figure of one in 6,900 is still too high. But we shouldn’t rush to the conclusion, as some have done, that the UK offers a poorer quality of care for pregnant women and new mothers than other Western countries.