Midwives would prefer a vaginal delivery
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7215.1008a (Published 09 October 1999) Cite this as: BMJ 1999;319:1008
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Editor
Dickson and Willett's survey of midwives provides an important
perspective on childbirth. However, although midwives have greater
experience of puerperal problems than obstetricians, their experience of
later complications may be in crucial respects more limited.
Urinary incontinence remains a significant problem for many women -
estimates range between 8% and 30%. In the UK, where obstetricians are
generally also gynaecologists, they will operate on many whose urinary
problems have not resolved in the months after the midwife has finished
her care. Faecal incontinence is rare though underrreported - but when
it occurs is devastating. Long term dysaesthesiae (vulvodynia) and sexual
dysfunction can also result from vaginal delivery, and will again be more
visible to the obstetrician than the midwife. These problems - all known
to be underreported to professionals - may perhaps account for more
postnatal depression than we think.
Prospective studies of the experiences of women - addressing quality
of life issues as they relate to obstetric complications - through and
well beyond the puerperium are necessary if women and professionals are to
understand what is at stake. The place of childbirth in any culture is
politically and emotionally charged, and will always be a focus of
strongly felt disagreement. However, the surveying of groups with vested
interests and a limited perspective - however worthy their motives - can
be of only limited interest in an era where the need to involve patients
is acknowledged.
Competing interests: No competing interests
Editor,
Dickson and Willett's limited survey of midwives just like
"obstetrician's" survey, do not prove any point nor are they persuasive.
If a proposal were made to group of deep level coal miners to close their
pit in favour of a nearby open cast mine or visa versa the results would
be predictable. These will not necessarily reflect a realistic appraisal
of the relative risk of the two ways of delivering coal; it merely
reflects a bias, which exists regardless of the real or perceived risk.
Risk remains an abstract statistical concept until it materialises at
which point it becomes a non-numerical reality. Our perception of risk is
affected by a complex multiplicity of factors, least of all our
experience. Midwives' experience barely last beyond their statutory period
of responsibility to the woman and her child, the peuperium, the short
term. Yes, most midwives are female and most do have children.
Obstetricians on the whole tend to also practice gynaecology. There are
real risks attached to a vaginal delivery, which are, with some overlap,
different to those of attached to a caesarean section delivery. The risks
of both have decreased dramatically this century and caesarean section is
a safe, be it more expensive, alternative to vaginal delivery. No one
knows whether this extra expense can be made up from the savings latter on
in life from a reduction in pelvic floor repairs. Whether the NHS can
afford it or not is a separate debate. Some of the effects are not easy to
quantify in numerical terms, such as the effect on sexual function.
We cannot talk of "informed choice". This, like "informed consent",
remains an illusive theoretical ideal beyond our grasp depending on how
one constructs "informed". There is a huge gap of knowledge amongst
obstetricians and midwives; there is a larger void of knowledge amongst
the patients who come to us for advice. In most cases patients want
guidance, a few have strongly held convictions and risk, which is often
expressed qualitatively despite its remoteness, carries moderate weight.
Midwives and female obstetricians are a highly select subset of the
gestating population with differing views on parturition. Their opinions
show the same distribution to be expected from any "interest group", this
is why midwives are midwives. A wider debate on the matter is desirable as
NICE will never address the matter.
Xavier Mmono
Higher Specialist Trainee
Department of Obstetrics and Gynaecology,
North Manchester General Hospital,
Manchester. M8
1. Dickson MJ, Willett M. Midwives would prefer a vaginal delivery.
BMJ 1999;319:1008
2. Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians' personal
preference and discretionary practice. Eur J Obstet Gynaecol Reprod Biol
1997;73:1-4.
3. Paterson-Brown S, Amu O, Rajendran S, Bolaji II. Should doctors
perform an elective caesarean section on request? BMJ 1998;319:462-5.
Competing interests: No competing interests
The results of the survey carried out by Drs. Dickson and Willett are
interesting to me because of my research, as an anthropologist, into
childbirth in Brazil. Here, where women can be broadly divided into two
groups, those with access to private medicine, and those who use the
public system, around 98% of the former have caesareans. Midwives barely
exist in Vitoria; almost all births are attended by obstetricians, and
similarly, of the female obstetricians I have interviewed, the great
majority would choose caesarean. It is likely that some of their motives
are the same as for the British obstetricians, but I wonder whether some
similar cultural attitudes are being adopted in Britain.
As private medicine takes over the "cream" of the population, ie.
those in better social conditions and better reproductive health, the
poorer women are left with what is perceived to be an inferior service.
If caesarean rates increase in private medicine it will be considered to
be a symbol of social status, as it is here in Brazil. Doctors will
eventually lose practical skills in vaginal delivery and the whole thing
snowballs. The problem is that whilst the women with financial means
return to a comfortable home with the luxury of being able to afford the
necessary antibiotics and painkillers, the poor woman has to cope with her
new baby without these aids, and caesarean may come to be viewed as an
unneccessary aggression after all.
The debate amongst medical professionals is often devoid of social
content and it would be good to see a little input from social scientists
on this point. I am going to risk my neck in suggesting this in a letter
to the BMJ, but we are not just dealing with a financial and physiological
cost-benefit analysis, but with whether bio-medicine should be allowed to
totally dominate what was originally a completely normal, natural, family-
centered event. When most women are now having only one or two children
there is very little risk of damage to the pelvic floor and perineum,
especially if she has been well prepared during pregnancy, and is allowed
to give birth in a vertical position (see Gardosi et al. 1989; Liddell
& Fisher, 1985; Stewart et al. 1983; Van Lier 1985).
Gardosi, Jason, Noreen Hutson and Chris B. Lynch, "Randomised,
Controlled Trial of Squatting in the Second Stage of Labour", Lancet, July
8, 1989, 74-77.
Liddell, H.S. and P.R. Fisher, "The Birthing Chair in the Second
Stage of Labour", Australia-New Zealand Journal of Obstetrics and
Gynaecology, 25, 1985, 65-68.
Stewart et al. "Randomised Trial to Evaluate the Use of a Birth Chair
for Delivery", Lancet 1, 1983, 1296-1298.
van Lier, D.J., "The Effect of Maternal Position on the Second Stage
of Labour", PhD diss. 1985 University of Illinois at the Medical Center
Graduate College.
Competing interests: No competing interests
Editor
The communication from Dickson and Willett regarding the prefernces
of midwives for a vaginal birth was interesting reading (1) and provided a
marked contrast to the preferences of female obstetricians. However, in
the eight years that I was a trainee anaesthetist I often had to visit
post natal women to ensure the quality of any anaesthetic intervention in
their labour had been of appropriate standard. Midwives who had indeed had
vaginal deliveries always commented that they had never realised how
painful it could be. Midwives who had undergone caesarians also stated
that the pain was much worse than they had anticipated and they were
horrified in some cases about how little pain relief they had provided
post caesarian mothers with in the past.All had said that they had not
realised how difficult breast feeding would be.
Perhaps a more useful survey would be a pre and post natal
questionnaire comparing midwife and female obstetrician ante natal
expectations, and post natal experiences, and discovering if they would
opt for the same mode of delivery for their second pregnancy.
1. Dickson M.J. Willett M. Midwives would prefer a vaginal delivery
British medical Journal 1999 319. 1008
Competing interests: No competing interests
"Not wrung from speculations and subtleties, but from common sense, and observation.."
"Not wrung from speculations and subtleties, but from common sense,
and observation.."
T. Browne, 1663-1704
EDITOR-
At last the deafening silence from midwives regarding their personal
preferences and choice of delivery has been broken 1. However, Dickson and
Willetts' research methodology and degree of speculation need to be
addressed.
Al-Mufti's paper 2, examined a group of London based obstetricians, which
the authors admitted as potentially having a selection bias. However, Al-
Mufti had sufficient foresight to use an anonymous questionnaire-based
study. Instead, Dickson and Willett, two male obstetric registrars,
"directly approached and asked" practising midwives their personal
opinions.
The reader is not told where the midwives worked, or whether they
gave the reasons for their preferences in this study, yet, the authors
speculate that 96% of midwives prefer a vaginal birth because of their
work experience.
We have completed two confidential questionnaire-based studies examining
this area for both obstetricians and midwives. Initially, we tested the
validity of Al- Mufti's results on a national scale by surveying the
personal preferences of all practising obstetricians in the Republic of
Ireland, using a similar questionnaire to Al- Mufti's 2. Our response rate
was similar to the London based study, (71%, 165 responses from 234
questionnaires posted), however, only 7.3% Irish obstetricians (compared
to 17% London based) would choose elective caesarean section as their
preferred mode of delivery in an uncomplicated singleton, cephalic
pregnancy at term. Even allowing for the potential confounding factor of
gender due to the increased number of female obstetricians in the London
based study, the Mantel-Haenszel p value was still significant (p= 0.037).
As in Al-Mufti's study, female obstetricians were significantly more
likely to prefer an operative delivery compared to male obstetricians, (15
compared to 4%, p= 0.03) 3.
We have also obtained data on midwives' opinions, using the same anonymous
questionnaire given to obstetricians. This was distributed by midwives
working in the three Dublin maternity hospitals to their colleagues
working in the labour wards of the same hospitals over the course of a
week. Whilst an admittedly select group were surveyed, confidentiality was
assured. The response rate was 89% (80 replies), with 7.5% of the midwives
expressing a preference for an elective section in the absence of any
clinical indication, a figure strikingly similar to the national figures
obtained from obstetricians.
Although, we accept the limitations in comparing these studies (we are
presently conducting an anonymous questionnaire-based study for UK
midwives). We feel that the diversity of these results needs to be
highlighted, and hope that the findings of the ongoing national study (Dr.
M. Maresh, personal communication 4) will provide more light than heat to
this area.
References:
1. Dickson MJ, Willett M. Midwives would prefer a vaginal delivery- BMJ
1999; 319: 9th October.
2. Al- Mufti R, Mc Carthy A, Fisk NM. Survey of obstetricians' personal
preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol
1997; 73: 1-4.
3. Mc Gurgan P. Active management of labour revisited. B J of Obstet
Gynaecol 1999; 106 (9): 1002.
4. Maresh M. Joint Royal Colleges National Survey (Obstetricians and
Gynaecologists, Midwives and Anaesthetists), personal communication.
Authors:
Dr. Paul Mc Gurgan,
Specialist and Research Registrar,
Obstetrics and
Gynaecology, Bradford Royal Infirmary, BD 9 6RJ.
Catherine Littler,
Staff Midwife,
Bradford Royal Infirmary, BD 9 6RJ.
Mr. Peter O' Donovan,
Consultant Obstetrician and Gynaecologist,
Bradford Royal Infirmary, BD 9 6RJ.
Competing interests: No competing interests