Aoife Molloy: Where your baby is born—informing mothers about the choices they face

Aoife MolloyThis is not a birth story blog, hear ye! However, as a doctor and a mum who’s gone through the whole process of childbirth twice in the last two years, coupled with the scores of birth stories I’ve exchanged in playgrounds and toddler clubs, and the timely release of updated guidance from the National Institute for Health and Care Excellence on care of healthy women and their babies during childbirth, I think it is a good time to consider the babies of Christmas past, present, and future and the choices their mums make.

The media and social network dialogue surrounding the release of the new guideline hailed it as a return to natural order. NICE has “finally caught up with the evidence” (mumsnet), “call the midwife-no surprises here” (Guardian), and “home births are ‘best for many mothers’” (BBC). Reading the small print though takes us to the real issue here: it is “important to offer women the options.”

As Professor Mark Baker, NICE’s clinical practice director, says, “There is no reason why women at low risk of complications during labour should not have their baby in an environment in which they feel most comfortable.” It is all about informed choice. But what does that mean? How do healthcare workers inform women? And what choices do they face?

Looking into childbirth with my first baby, I tried to decide where was best to give birth. To inform my decision, I toured the labour ward and birth centre . . . and I was sold. Definitely the birth centre. I wasn’t given any statistics, but the birth centre was like some sort of cosy gym: nice colours, bean bags, big bouncing balls, and paddling pools.

The labour ward was clinical and lonely, the most obvious equipment a cold metal resuscitaire—a place for the baby, under a bright light and on top of pale blue tissue paper—as if a sad premonition of the silent baby it might hold in Christmas future. “I hear they don’t let you drink water during labour in hospital in case you need a section,” whispered one mother on the tour. I thought I could choose to have a normal birth, so I chose the birth centre. I thought a birth plan was about the labour soundtrack and the colour of my toenail varnish.

Becoming a mum is a time in your life when you make lots of decisions about who you are going to be as a parent. Let’s be clear, for most mums there is no limit to what they will do to produce a safe, healthy child. Breast is best, limit mercury intake by not consuming tuna more than once a week, spend some time in the downward dog pose to help baby turn: you have an illusion of choice and control. Which buggy transport system is safest and the right colour for baby? Coffee cup holder or no? Is this really the lens through which we want to make a decision about where babies are born?

The choices I made on where to have baby number one were different to the choices I made on how to have baby number two. After having an emergency caesarean section for baby number one, I had a discussion with a consultant obstetrician about vaginal birth after caesarean section (VBAC) versus caesarean section. I felt empowered, informed, and respected. The choice was up to me and I understood the risks associated with each option. I was given time to think about my options. How can a specialty that kept me so well informed me on the choices I faced with my second child, previously have offered me so little clarity on the choice of where to have baby number one.

It is wonderful and lovely and great and fluffy if you are lucky enough to be risk free, and for you and your baby to survive, to suckle, and for you to slurp tea and munch toast on your couch while your midwife cleans up your water bath. But since when is good health and surviving a major health event a personal achievement and a lifestyle choice? Only in the area of pregnancy and childbirth would such an approach be conceived, not to mind propagated. Imagine if we approached breast or prostate cancer in this way. Oh, you choose advanced cancer? A complicated hospital stay? You didn’t try to push it out after curry, sex, and raspberry leaf tea? Were you nervous? Had you not practised your breathing? You decided to choose the clinical route? The sterile wards of a tertiary referral centre to sit in over Christmas while your neighbour sips brandy at home?

Having a baby is a time of great vulnerability and coincides with a strong desire to fit in—to your new playgroup community, NCT group, yoga mum group. Everybody has an opinion on what choices you should make.

It is about choice. However it’s also about the health of mother and baby, and with that (less frequently) comes ill health, complications, interventions, bad outcomes, and disappointment. It is about choice, but let’s be clear on what the choice is. It’s about informed choice, and it’s about doctors coming together and communicating what they are doing to help patients. It’s about raising the awareness of the pairs of lives saved every day across the UK by dedicated and trained obstetricians.

Each birth story is unique.

My first childbirth experience: a crash section, a blue baby, and the cry she gave as the paediatric crash team burst in the door—the most beautiful sound I have ever heard in my whole life and I can still hear it ringing in my ears. While my second baby was lying sideways, and though she somersaulted for weeks, she never really decided to engage in my pelvis, she preferred floating free. I was admitted to hospital for elective caesarean section. The transverse lie of the baby put her at risk of cord prolapse if I went into labour, and it wasn’t possible to turn her owing to my previous caesarean section.

Despite these facts, I was counselled many times by midwives during my hospital stay on not being afraid of having a vaginal delivery: “we can still help you have a normal birth,” “we’ll get baby to engage.” It would have been nice, I tried, but I “chose” to go down the clinical route. A hospital birth is still a beautiful thing.

It’s about choice.
It’s about information.
It’s about personalisation of care.
It’s about accepting complications.
It’s about respecting women and the choices they make for their babies.
It’s about doctors speaking out and coming together to promise to always fully inform patients about the options available to them.
It’s about moving care to the community, but fully acknowledging that a hospital is a key part of a community.

It’s not black and white or red and green.

It’s about understanding that there are things we don’t have a choice in. Au natural is all great until someone gets sick. Perhaps we could look at the figures and see this: that women who had complications in hospital births could be glad that they were in hospital to have them treated; that complications weren’t caused by being in hospital; and that these women had chosen to have their babies in hospital for reasons that weren’t quantified, but that meant they were in the right place for them.

For the babes of Christmas past, present, and future, let’s accept that there is enough pressure on mothers to get it right. We are not free to choose an uncomplicated birth. However, we can choose how well to inform mothers about the choices they face.

Aoife Molloy is a specialty trainee in acute medicine and infectious diseases. She is currently a national medical director’s clinical fellow at the National Institute for Health and Care Excellence (NICE).

Competing interests: Nothing declared.