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Whose Risk?

A very interesting article by British midwife Virginia Howes, questioning the disparate ways we gauge “risks” in our minds and in our research. (2009)


We are just about there in the UK with regards to the safety of homebirth. Studies which demonstrate homebirth as a safe option for most women have just about been accepted by our medical colleagues [1, 2 - refs below]. Except for the most obstinate practitioners who refuse to keep updated despite the evidence having been around for a decade or more, most obstetricians will support a homebirth as long as a woman does not have any risk factors.


Yet all women, even the ones considered low-risk, have risk factors - a low-risk woman has a 2.7% chance of an unexpected complication occurring in labour [3] A complication that may need urgent assistance and delay could result in the problem becoming compounded. That is considered a low risk.


The number of babies that die unexpectedly following a prolonged pregnancy further than 42 weeks is approximately 2:1000 or 0.2% [4.] but that is considered so high a risk that 20% of UK women have labour induced [5], and that number of women are included in the 1:4 or 25% of women that make up the caesarean section rate in the UK. 


When she has a section, the woman faces up to 16 times times the risk of death, and 10 times the risk of emergency hysterectomy, than a woman giving birth vaginally [6]. Yet a woman who plans a homebirth roughly halves her risk of ending up with a caesarean and all the risks it involves, compared to someone of the same risk level planning a hospital birth [2] She also roughly halves her risk of her baby being born in poor condition [2] - so why are some risks considered more acceptable to take than others?


Once the woman has had the caesarean section she is told she now has a 1:200 or 0.5% risk of a scar dehiscence which is considered high-risk and the medical profesion would be highly unlikely to support a decision for a home birth. However that number includes induced and augmented labour and benign dehiscence that is seen at elective caesarean section - most studies find a greatly reduced risk of rupture in spontaneous-onset labours which are not augmented with oxytocin. Maybe if figures were quoted for both actively-managed VBAC labours and for spontaneous, unaugmented VBAC labours, the risk perception would change and the place of birth and labour management would be more open to discussion 


The most bizarre I think in the calculation of risk is the 1:10,000 or 0.01% of vitamin K deficiency bleeding. It is recommended that mothers agree to injecting a substance into all newborns because they are, apparently, fundamentally flawed and do not have normal levels of vitamin K at birth. Who says what is abnormal and what is that abnormality measured against? Sara Wickham considers that statistics for Vitamin K are the same risk as wearing a hard hat every time you walk outside your front door in case a roof slate falls off and hits you on the head. [ 7.] There has never been a follow-up study on children whose parents refused vit K. 




REFERENCES[1] British Medical Journal No 7068 Vol 313, 23 November 1996[2] Home Births - The report of the 1994 Confidential Enquiry by the National Birthday Trust Fundpub. The Parthenon Publishing Group, 1997. [3] Effective Care in Pregnancy and Childbirth, eds. Enkin, Keirse,Renfrew & Neilsen, 3rd Edition (published 2000, OUP), p360[1a] Chapter 38, section 6. "The probability of requiring an emergency CS for other acute conditions (fetal distress, cord prolapse or antepartum haemorrhage) in any woman giving birth is approximately 2.7%"]. [4] Menticoglou SM and Hall PF. Routine induction of labour at 41 weeks gestation: nonsensus consensus. BJOG 2002;109:485-91 [5] NICE Guidelines on Induction of Labour, July 2008, S1. : "In 2004–05, 19.8% of all deliveries in the UK were induced." [6] BMJ. 1998 Aug 15;317(7156):463-5. Should doctors perform an elective caesarean section on request? Maternal choice alone should not determine method of delivery. Amu O, Rajendran S, Bolaji II. [7] Wickham, S, Vitamin K - A flaw in the blueprint?, Midwifery Today, 2000; 56: 39-41. [8] Social Benefits versus Social Risks by Chauncey Starr, Science ,1969 .

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