Otherwise engaged

Dr Aust has not been blogging much lately.

Well, actually Dr Aust never blogs all that much, being much better at ranting off-the-cuff in the comments threads of other peoples’ blogs (thanks again, Holfordwatch, Orac, Dr Crippen at NHS Blog Doctor, Ben Goldacre and David Colquhoun) than at penning considered well-researched essays (too much like work). Another problem is that, like many ageing academics, Dr Aust likes to take his time writing things. And to make sure that what is in them is (mostly) accurate. Sadly, this takes time, which is rather at loggerheads with topicality. Blogosphere stories go round the world like waves, and are often seven day wonders. So by the time Dr Aust has got round to laboriously concocting a comment, the Bad Science Blogoverse has usually moved on. And typically several other people have already covered whatever-it-was far better than I would have done.

As a result, quite a few Dr Aust posts that are lengthily gestated never actually reach the point of delivery.

Which brings me, in a desperately tortured link, to the more specific reason why I haven’t finished anything for the blog recently.

It’s a boy

Yes, Dr Aust and Mrs Dr Aust have recently taken delivery of our second child, henceforth “Baby Aust”. Baby Aust (who is a he) arrived just over a week ago, after a rather short time in hospital (just under two hours “door to floor”), but following the usual nine months, plus a few days past due, of angst-y anticipation – and also following about eighteen hours of uterine contractions, though according to Mrs Dr Aust it was only the last four or five hours that really hurt.

The contractions started, as they frequently do, at around 2 am, though Mrs Dr Aust – who is a stoic sort – soldiered on through most of the next day pretty much as normal. We made it to hospital in the early evening, having cooked an early dinner and then deposited a mildly protesting Junior Aust with relatives. Mrs Dr Aust was finding it rather difficult to eat between the by-then distinctly painful spasms, but after last time we know the food at the local hospital only too well, so we figured it was eat now or not at all.

Dr Aust’s main (only?) contribution was to drive to the hospital without crashing the car, while Mrs Dr A sat in the passenger seat making strange noises and sinking her nails into the dashboard trim. Thankfully the Aust-mobile is over ten years old, and was a cheap-as-you-can-get box on wheels to start with (who says scientists don’t make the big money?) so the damage will not have decreased its current market value of zero pounds.

Hard labour

The birth itself was a contrast to our previous time a few years back. Junior Aust’s arrival was very high-tech, a past due induction of labour, with painful labour for nearly a dozen hours, epidural anaesthesia, full-bore Syntocinon (synthetic oxytocin) drip, and continuous electronic monitoring of uterine contractions and foetal heart rate.

This time was quite different, as we were shown into the “active birthing suite” – a bit like a hotel room, complete with sofa, en-suite kitchenette, CD player and whale music CD, large padded floor mat and a kind of giant inflatable exercise ball. Although we passed on the whale music, all went smoothly, and something less than 90 minutes later, there was Baby Aust, looking somewhat jaundiced (literally and figuratively), but otherwise fine and with all his bits in the right places.

Birth – all very political

Now, apart from ending up with a caesarian section, or an instrumental delivery (which we probably avoided first time around by about twenty minutes), one could not really have had a more “medicalised” techno-birth than our first time. And apart from a water birth in a darkened room, or a home birth, one could not have had a much more “minimal intervention” delivery than our second one.

I have to say, though, that I honestly couldn’t tell you which one was “better”. Well, of course, I’m only a bloke, so what would I know.

So – I asked Mrs Dr Aust which one was better. And she, too, says she has no opinion one way or the other. All she said was “Well, I was pleased it was quicker this time”.

Thinking about it, we are of the joint opinion that the only thing we cared about was having a healthy baby – which we have, thankfully. All the other stuff that is nowadays ringed around the experience of childbirth just seems like… baggage. So to us, the two very different experiences were equal in terms of THE THING THAT ACTUALLY MATTERS.

Which makes me wonder why modern childbirth is an issue that provokes such tremendously heated arguments. Examples are home birth versus birth in hospital, pain relief or not or what, midwives versus doctors (for the record, we had both Junior Aust and Baby Aust in a midwife-led delivery unit with one-to-one midwife care and on-site consultant-level medical cover, though we never saw a doctor during either delivery) and even independent midwives versus NHS ones.

The things that seem to prod people away from hospital births (a line that some advocates pursue with missionary zeal), are bad experiences of hospital care, fear of “medicalised” birth, and sometimes an ideological drive to “de-doctor” the process.

Now it is hardly news that NHS maternity care is not 100% marvellous in every respect. While our experience of the local delivery suite and its staff has been brilliant, I have to say that the pre-natal and post-natal wards left something to be desired. The food is bad. The wards are inevitably noisy and make sleep difficult to impossible. You have to wait ages for things to get done. But… how big a problem is being stuck hanging around for a few hours waiting for the paediatrician to show and do the routine next-day check on the baby?

Irritating, certainly. Stressful, perhaps.

Life or death – hardly.

In the end, the only thing we cared about both times was ending up with a healthy baby. And the most logical place to choose for that seemed to be a hospital delivery suite, with access to the full panoply of medical back-up just in case the sh*t were to hit the fan.

Of course, I know people who have taken other views, including among the neighbours in our nice middle-class enclave, and among friends of friends. I have known a couple of people who fought to get homebirths when the doctors and midwives advised against it. These pregnancies ended happily, with healthy babies and happy parents.

But does that prove that home birth is as safe as the advocates tell you?

I have also known people who had complex pregnancies and births, up to and including serious trouble that was life-threatening to mother and baby. If some of these folk had not made it promptly to well-equipped hospitals with specialist maternity care, Special Care Baby Units and Adult Intensive Care, the outcome would likely have been dire. And I used the word “dire” there euphemistically – you can say “dead” if you prefer.

So does that show that you would be mad to give birth at home?

It’s the statistics… again

As so often in modern healthcare, the devil is in the detail. The medics will tell you that homebirth statistics loudly quoted by homebirth advocates to show that homebirth is safe are misleading, because the people having homebirths are mostly a carefully-selected population of low-risk mothers; youngish, in excellent health, and often having second or third children after having had a normal delivery with a first baby. (The point, of course, being that this is predictive of a low likelihood of complications). In addition, pregnancies slated for homebirth, but where indications of “non-uncomplicated-ness” appear at any point, will often be “re-routed” to be hospital births for safety’s sake. The result, say the doctors, is that the “birth at home is safe” statistics you get quoted are not representative of a general population of the women giving birth in the UK. The homebirth advocates, unsurprisingly, dispute this analysis.

One interesting (though anecdotal) thing – Mrs Dr Aust and I know an awful lot of female doctors with children, and we only know one who opted for a home birth. Are all the others brainwashed? Or just careful?

So you could say that, at bottom, it is a matter of statistics. And, once you have the statistics, of your personal beliefs about, and attitude to, risk. And, critically, your view of the relative importance of the things you are risking, or weighing up.

Unless, of course, you pick the ideological view first – perhaps, the kind of “birth experience” you want -and then select the statistics that match the ideology. In which case, you are not REALLY making your decision looking primarily at the risk at all.

Now, I would say I am relatively ideology-deaf, but I am pretty risk-averse. And Mrs Dr Aust, being a doctor, is extra super-duper risk-averse. When it came right down to it, “Why take the chance?” is very much the way we looked at it. So hospital birth for us, thank you very much. And we are very happy with how it turned out, both times.

Because, when all is said and done, it is ending up with a healthy kid that matters. Not whether there was a CD player and candles.

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20 Responses to “Otherwise engaged”

  1. Dr* T Says:

    Congratulations to the three of you.

    Your blog post is positive, valuable and helpful – Mrs Dr*T and I (although not quite at this stage) have had this discussion and came to a similar conclusion as yourselves. We have just had a run of 5 births from close friends, some homies some not, but thankfully all OK.

    You’ll find you’ve probably got loads of time to blog now, what with two kids and no sleep?

    T

  2. dvnutrix Says:

    Many congratulations to the Family Aust and felicitations on a straightforward birth.

    Is Ben Goldacre going to ask your baby to pose in an “MMR is safe – tell your friends” bib?

  3. draust Says:

    Thanks guys

    Dr* T, you’d be amazed how you get used to functioning on little sleep – although Mrs Dr Aust, who is doing the feeding work, sleeps less than me. I excuse this by pointing out that she worked as a doctor doing on-call for more than a decade, and is thus trained not to need to sleep.

    If you want to have children, best not to leave it far past the mid-30s, if you ask me. One’s early 30s seem to me to offer the right combination of having some experience and perspective but not being so old as to be completely bloody knackered (like me). I was, sadly, prevented from taking my own sage advice by a lack of a suitable co-volunteer.

    dvn, would be happy to photograph the young lad in a Bad Science bib – provided we can score a free one, money being a bit tight at the moment – but it’ll be a while yet. Weaning probably at 6-12 months chez Aust.

  4. Liz Ditz Says:

    Dear Family Aust,

    Very great felicitations from California!

    Mrs Dr Aust and I know an awful lot of female doctors with children, and we only know one who opted for a home birth. Are all the others brainwashed? Or just careful? — I would suspect that maternal age is a confounding factor, and I’m assuming that the moms m.d. might be older than the average.

  5. Madsadgirl Says:

    Congratulations on the safe arrival of the new family member.

  6. Claire Says:

    Congratulations to Mrs Dr Aust and yourself on the safe arrival. I hope any sleep deprivation schedule Aust Jnr 2 might be devising isn’t too ferocious!

    Difficult, ‘medicalised’ first birth followed by relatively straightforward second delivery sounds familiar to me. One of my abiding memories of the first time was the morning after, when myself and the woman in the next bed (both of us after long labours, induction, forceps – ouch) were approached by a very nice, well spoken lady to talk to us about birth control. At that particular point, being rather sore and tired, Indira Ganhdi-type solutions were probably more what we had in mind – we were jolly well not doing that again! – but we did listen. Until she produced the femidom. I believe women in developing countries find the femidom most useful but I’m afraid it’s appearance of having been dreamed up by an engineer playing with a polythene bag and a couple of plastic reinforcing rings (and being tired and perhaps overwrought) sent us into such an uncontrollable fit of giggles that the contraception pep talk had to be abandoned. She did leave us some free samples, though.

    I’m totally in agreement with your views on birthing and concluded some time ago that the ‘baggage’ around birthing is generated by a probably small group of true believers, who gain the attention of the media and relentlessly promote their cause. But to be fair, perhaps the fact that hospitals now appear to make great efforts to provide sympathetic surroundings for giving birth has something to do with the campaigning efforts of the ‘birth experience’ lobby.

  7. manigen Says:

    Congratulations!

    It seems like quite a lot of this debate is framed in terms of the old “natural must be good” argument. I wouldn’t begrudge anyone the right to choose where they gave birth, unless there was some indication that the birth was going to be a difficult one, but it seems foolish to dissmiss hospital births out of hand.

  8. elaine Says:

    Congratulations on the safe arrival of your son.

    This is an excellent and unbiased view of the home birth / hospital birth debate (never mind whether you then go on to more extreme views either way, from water births, eating of the placenta (yuck, and cooked I hope) and no analgesia to the analgesia from the first contraction (I think I would vote for that!) to being ‘too posh to push’)

  9. DMcILROY Says:

    Congratulations to yourself and the affectionately named Mrs Dr Aust.

    You’re right about the age thing. What seemed like a doddle first time round has been far too much effort for our most recent (and last).

  10. jdc325 Says:

    Wahey! Congratulations to both Dr Austs.

  11. leet01 Says:

    Congratulations to you all

  12. draust Says:

    Thanks to all for the good wishes. Much appreciated.

    Liz D – age is certainly a potential confounding factor, though possibly not in this specific context, see below.

    Medical school here in the UK is a 5-yr undergraduate degree, so with entry at 18-19 most people graduate aged 23-24. Most of the female doctors we know have “podded” some time in their early to mid 30s, but in the UK I think this is also now typical for other middle-class professional types.

    Obviously the “global” population average for age at first motherhood in the UK is lower than this, though probably not by all that much now – the last figure I saw for the UK was 29 in 2000, so it will almost certainly be over 30 by now. However, there is a big social class divide at work here. In the UK women in “unskilled manual occupations” still have their kids young, while for anyone doing clerical work and upwards the age trend is to have children progressively later and later. Among my University-educated peer group I cannot think of a single woman who had kids before age 29. So if the average UK age at first time motherhood is now 31 (say), then the average for middle class professional types will almost certainly be nearer the mid-30s. Basically the middle classes hardly have kids under 30 in the UK any more.

    Mrs Dr A and I do joke about being twice the age of some of the other customers down at Obstetrics. Our local hospital serves a “mixed” population, socio-economically speaking. You tend to see all the teenage mothers when you arrive, as they are usually sat outside the Maternity Department entrance in their dressing gowns having a smoke.

    Increasing age at first pregnancy would be a “contra-indication” for home birth. However, I would suspect a large fraction of the people wanting first-baby homebirths in the UK will be middle-class and well-educated (though not necessarily well-informed), so that segment are probably pretty well matched age-wise to the “MD mums”.

    Sorry, that has got terribly long-winded. What I probably should have said was

    “maternal age will certainly alter the risk, and thus perhaps the choices – but the people in the UK wanting homebirths are largely well-educated middle-class types, so probably the same age as the “MD mothers”

    .

    Claire – agree completely. I think the “de-medicalise birth” lobby have definitely had some positive influence in the ways you describe, paralleling attempts to roll back what one might call “old-style paternalism” in other branches of medicine.

    Regarding “how to run maternity”, it seem obvious to me that continuous one-to-one care is the most reassuring for mothers, and equally obvious that there would be no way that could happen if the people caring for the labouring women were doctors – impossible on cost grounds, there aren’t enough doctors for this and that’s simply not how their jobs work, at least in the NHS. So one-to-one care in hospital from midwives for most births, full on-call medical back-up if you need it, and the obstetricians to manage the really iffy deliveries, seems to me to be an eminently sensible and practical solution. Again, quite why people get so hot under the collar about it beats me.

    Re the birthing baggage true believers, it is shocking how one-sided some of the media coverage is. A fairly typical example from the Guardian is here. I would call this “ill-informed advocacy masquerading as journalism”

    Elaine – I knew one neighbour of a friend who took the placenta home and buried it under a shrub in the front garden. Never yet met someone who ate one, though. Yeech. And isn’t it cannibalism? Or at least autophagy.

    I have some local scientific collaborators who work on human placenta, funnily enough. But no-one wanted Mrs Dr Aust’s one. At the hospital we went to they are only collecting study samples of placentas from the teenage mothers.

    Manigen – yes, I think a lot of it starts with the “natural must be good” argument. Mrs Dr Aust, who used to do anaesthesia for Obstetrics a few years back and has seen some pretty hairy births, gets particularly exasperated when she hears this one:

    “Natural?! That’s why so many women used to DIE in childbirth, then, is it? Splendidly bl*!dy natural. Idiots.”

    - is a paraphrase, though I’ve left out some of the swearing.

    I think the real danger of the “extreme homebirth” lobby is that some of them promulgate this line of:

    (i) hospital birth is nasty and impersonal
    (ii) you can always have a homebirth;
    (iii) it will be wonderful;
    (iv) there is no added risk; and
    (v) if the doctors or hospital midwives try to tell you it is riskier, they are just saying this to frighten you.

    Err… no, they’re saying it because it is carries some risk, and it is their professional business to know exactly how much. An idiotic term that the dafter end of the homebirth / independent midwifery lobby use, and which drives Dr Crippen into paroxysms of rage, is “shroud-waving”.

    As you say, if people know and understand what the risks are, and make the choice, they have the right. But the choice often seems to be terribly misinformed, and largely based on ideology.

    D McIlroy – I know, I know, I should have given ‘er indoors a better pseudonym than Mrs Dr Aust, but I was worried I would come over all Rumpole and start calling her “She who must be Obeyed”. Or possibly just “The Boss”.

  13. coracle Says:

    A belated congratulations from me too. Hope everything goes well for the latest addition to family Aust.

    On the subject of medical births, I remember a Guardian article on female obs specialists choices. An interesting read those with a stake in the issue.

    ‘We know the reality of childbirth’

  14. draust Says:

    Yes, I remember the article, Coracle. I think it actually misstates it in the other direction, if you see what I mean. Again, from our personal anecdotal sample of medical acquaintances, most have favoured normal delivery unless there is a genuine medical reason for elective section. The commonest reason is a breech presentation baby that does not turn.

    Of course, one can see why prospective mothers are so confused when you compare this article with the almost diametrically opposite one I cited earlier – both, note, in the same newspaper, and probably in the same section of the paper. The joys of choice, eh?

    BTW, according to medical gossip the people who are REALLY into elective C-sections are all those female celebs who feature in Hello! or similar in heavily airbrushed photo-spreads headlined “How I shed my baby fat in 4 weeks”. The oft-repeated medical black joke is that these folk all opt for delivery by elective C-section at 36 weeks, thereby saving themselves the final 4 weeks worth of weight gain and stretching. It is, of course, easier to shift the weight by not gaining it in the first place. Perhaps Mrs Dr Aust and I should write a book called:

    “Heath facts: what your celebrities won’t tell you”

  15. Sceric Says:

    Congrats from Germany to a) your new family member and b) to good posts!
    Just as a one piece case study: Our son is now 7 months old and we had the “mechanised” birth version in a hospital (including me holding a hand while watching something out of a splatter movie). And that was good, as with a natural birth at home, this would have resulted in a least one of my now two vavourite persons people beeing dead. The cord beeing around his neck and not long enough for him to put pressure on his escape route (and not it was almost impossible to see that in the scan, even with the use of the Doppler effect), he wouldn’t have come out of there without the fast and qualified help of a midwife, the doctors and a sharp knife.

    Then I wish the four of you a lot of fun and hey, perhaps you’re lucky as we are, as our source of joy and diapers ususally sleeps from 2000 to 0800.

    best regards
    Sceptic Eric

  16. draust Says:

    Vielen Dank Eric

    Entschuldigung, dass ich nicht früher respondiert habe

    - hadn’t been back to this post for a while. Our newer source of joy is quite a well-behaved little chap (not so little now – 5.3 kg and growing), though he doesn’t sleep for ten hrs at a time – that sounds like the baby sleep-deprived parents dream of! Our biggest task is actually getting Junior Aust (aged 4) not to be jealous of Baby Aust… a few “adjustment issues”, but will doubtless all settle down in time.

    And agree completely about first births. The whole idea of not being in hospital for a first birth with a 30-something mother… not for us. Reiner Unsinn, hatten wir gedacht.

  17. Rob A Says:

    Hey don’t shoot me, but I just want to say that we have had three sons, the first was born in hospital, and the others at home, and the home births were superb. My wife describes the third, which was in a pool in our dining room, as ideal.

    Perhaps we were foolish to take the risk, but we did not do it against medical advice, the pregnancies were unproblematic and we did at least have two midwives present.

    NB we had no candles, chanting or whalesong, and placenta pâté was not on the menu.

  18. Dr Aust Says:

    No worries, Rob, the Kalash stays in the cupboard.

    Actually, after our latest uncomplicated delivery, followed by an irksome full 24 hrs’ wait to be allowed to go home, Mrs Dr Aust was heard to mutter something like “effing bleep, I could have had him at home and saved myself all this arse-ing around”… though I would have hated to be the person who had to wash the towels.

    I don’t think homebirth is “always” contra-indicated – though as I am not a doctor, I recognise that mine is not a learned opinion on the matter – and nor, it seems, do the Royal College of Obs & Gyne, though some of the medical commentators (like Dr Crippen) clearly do – at least, unless you have an “Obstetric Flying Squad” on permanent standby in case of sh*t-hitting-fan eventualities.

    If a woman is having a second or third child after a normal vaginal first delivery, and there are absolutely no indications for hospital birth, home birth is clearly an option, as any increased risk (and some people dispute there is one) is statistically very small. I would imagine that was the advice you were given.

    What I was really looking at was the modern message that comes from some of the nuttier independent midwives and certainly from the homebirth advocates – see the response to Maningen in the response back up the thread here for a version of how I understand their credo. The thing is that the circs where I would be lairy about homebirth (as the doctors are) is with a first-time mother in her mid-30s or up – but this is precisely where the big demand for “the right to homebirth” seems to come from.

    As for the people who want homebirths second time through after having scary problems first time around and flatly against the medical advice – I can perhaps see where they are coming from psychologically, having talked to one or two, but I really can’t see that the risk is worthwhile.

  19. Mothers, HIV tests, consent and choices « Dr Aust’s Spleen Says:

    [...] second reason is that back in July Mrs Dr Aust and I became the parents of Baby Aust, our second child. Mrs Dr Aust opted for the routine HIV test (again). Baby Aust did not, as it [...]

  20. Tweets that mention Otherwise engaged « Dr Aust’s Spleen -- Topsy.com Says:

    [...] This post was mentioned on Twitter by Dr Aust, Dr Aust. Dr Aust said: Birth thoroughly "politicised", sadly. Mrs Dr A & my take on childbirth is in post on arrival of Baby Aust 2 yrs back http://bit.ly/h9Sp0K [...]

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