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Jim’s tweet

April 11, 2015

Home birth after three Caesareans

A few days ago I tweeted:

Hvba3c

The link (click here) was to a mother’s post about her successful home vaginal birth after three Caesareans (HVBA3C). The recipients were James Titcombe whose son Joshua died in Morecambe Bay NHS Trust, led the campaign for a public enquiry, and was vindicated by the Kirkup Report (click here). Amy Tuteur is a retired US obstetrician and blogger who campaigns against, as she sees it, anti-science attitudes in pregnancy and childcare. Her views on anti-vax parents are mainstream, but her rejection of the idea that natural childbirth is a good in itself, and specifically her uncompromising hostility to home birth, (click here for her blog) get some people’s backs up.

Sheena Byrom, a retired UK midwife, and author of many books about natural childbirth tweeted; “I am so shocked that you engage this way on Twitter Jim. Is it a game?”

HVBA3Cc

Byrom had crossed swords with Tuteur before – she regards her as an internet troll who enjoys picking fights with supporters of natural childbirth – and felt it inappropriate to copy a mother’s personal, albeit public, blog about her happy and successful birth to such a person. James Titcombe defended me, and soon found himself embroiled in the row. Others accused me of being unprofessional, and likened Titcombe, Tuteur and Thornton to Macbeth’s three witches.

Before long Tuteur had lived up to Byrom’s expectations by fanning the flames as hard as she could (click here and here). Tuteur has a pungent writing style – I’m sure neutrals find her a good read, and you wouldn’t have to look hard to find health professionals who agree with her – but she does go for the woman not the ball!

I’m afraid I kept my head down – accusations of unprofessionalism, especially when copied to the RCOG make me nervous; I’m still in clinical practice and have had run-ins with them before – and when something goes viral it is difficult to avoid digging a bigger hole. But the argument and retweeting have gone on and on. So here are my thoughts.

Background

My initial tweet was not out of the blue; I don’t search the internet for risky birth stories to show Amy Tuteur. It followed an invitation to comment on another mother’s blog (click here) describing her successful vaginal birth after two Caesareans (VBA2C).

VBA2Ca

Like the anonymous obstetrician criticised in that blog, I strongly discourage VBA2C, but the references cited, and RCOG guidance suggest I may be wrong, and I’ve also reluctantly looked after a couple of cases myself, which I admit turned out OK. So I said what I usually say, “discourage but support”.

Soon I was invited to comment on another post. The one whose link I later forwarded, namely the home vaginal birth after three Caesareans (HVBA3C).

VBA2Cb

Calling HVBA3C a “first world problem” was flippant, but I still think that home birth in that situation was foolhardy.  The risk of uterine rupture is at least 1 in 200, perhaps higher without continuous fetal heart rate monitoring, or if the woman is determined to push on in the presence of slow progress, and the baby will certainly die if rupture occurs at home. It’s not as dangerous as Russian roulette, but considerably more so than not buckling yourself or your baby into your car seats. So rightly or wrongly, I forwarded the link to Titcombe and Tuteur.

Why did it cause such trouble?

There is a battle here, and some truth on both sides.  Modern obstetrics, the stuff I do every day, is obsessed by reducing risk. Caesareans for breeches, antibiotics for positive group B strep swabs, and heparin for anyone with a risk factor for thromboembolism are all unnecessary most of the time, but heaven preserve the doctor who skips them if a bad outcome occurs. We drill our staff again and again about how to interpret fetal heart rate abnormalities, and even then we don’t trust them completely; every few hours we insist on a “fresh eyes” review.  We’re trying to squeeze the last drop of risk out of childbirth, and that’s not a bad thing.  Parents want a healthy baby. They don’t want to hear:

“We’re sorry things turned out bad, but your complication is rare. To prevent your baby’s death we’d have to monitor hundreds of babies, do hundreds of Caesareans, or give thousands of women antibiotics.”

They would rightly reply:

“Why not? I’d have a Caesarean for a 1 in 200 risk, or take penicillin for a 1 in 1000 one.”

But our obsession with safety has a cost. It causes anxiety. Fetal monitoring does lead to unnecessary Caesareans. People popping in and out of rooms to review progress, give antibiotics and check heart beats, stops women relaxing and may actually slow labour.

And supporters of natural childbirth are right. Hospitals are not perfect. Too many women still labour on their backs. Doctors make stupid decisions. And even if we were perfect, it might still sometimes be better to take a bit of risk to allow nature to take its course. Homebirth might be less risky than we believe.

The Birthplace Study (click here), undoubtedly the best quality research into the question, showed that for low risk multiparous women, looked after by properly trained midwives in the UK, home is as safe as hospital.  Even for first pregnancies the additional risk is quite small, such that some women might rationally decide to take it.  I’m not an opponent of home birth.

But, there surely is a line we should not support, and birth at home after Caesarean is on the wrong side of it. We can’t stop parents making bad decisions, but professional supporters of home birth unavoidably tread that line. Read the HVBA3C story again (click here).  Did the midwife who told the mother she could have “a natural birth no matter how many sections I’d had” cross it?

Last year, the Kirkup report on Morecambe Bay concluded:

“Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.”

When I read that at the time, my reaction was: Surely not. I’ve never met or, until Kirkup, even heard of a midwife acting like that. Lots of other things went wrong in Morecambe Bay, but this sounds like someone is dumping on the midwives.

And I’ve read Sheena Byrom’s writings, and I know people who know her well. She is not “pursuing natural childbirth at any cost”. At the risk of putting words in her mouth, she would say that once a woman has decided to have a home birth whatever the risk, typically after being told ad nauseam by people like me and Amy Tuteur that she is risking her own and her baby’s life, there is nothing to be gained and everything to be lost by banging on about the dangers again. We cannot arrest women. If they fall out with their home birth midwife, they don’t always return meekly to hospital. They sometime deliver at home with no assistance at all. That is much less likely to end well. I get all that.

So let me be plain. Amy Tuteur is wrong. Sheena Byrom and her colleagues are also trying to make birth safer. I am sorry my tweet led to their motives being impugned yet again.

But …

When one of the retweeters wrote about the HVBA3C blog “What an amazing story thanks for sharing let’s hope it empowers more women”, I did have sympathy with Amy Tuteur’s response:

“Let’s hope it doesn’t kill anyone”.

hvba3ce

Midwifery and obstetrics are tough jobs. We tread narrow lines.

Jim Thornton

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18 Comments leave one →
  1. April 11, 2015 11:46 am

    Hi Jim! Thanks for your very balanced and nuanced post on this issue. Interestingly (to me), this happens to be the subject that I decided to do my PhD on in the end.
    I am still in the mids of interviewing women, partners and caregivers (both midwives and OB’s) on their experienced, but so far my conclusion move along the same lines you put so succinctly in the post.

  2. Cecilia permalink
    April 11, 2015 2:17 pm

    as somebody that “tumbled” on this “twitter-spat”, I have some thoughts.

    + “…felt it inappropriate to copy a mother’s personal, albeit public, blog about her happy and successful birth to such a person. James Titcombe defended me, and soon found himself embroiled in the row. Others accused me of being unprofessional, and likened Titcombe, Tuteur and Thornton to Macbeth’s three witches.”
    first, that mother posted her story on the internet, that is NOT personal anymore. if you can link to something…..that ship has sailed
    second, I see nothing unprofessional about what you did: I have not found any safety well-made trials on this subject (vag birth after 3 c-sections!!), and therefore I can’t stand by it, no matter how many anecdotes I hear
    thrid ” Macbeth’s three witches”: really? why? the only troll from hat conversation was the people attacking you and Mr Titcombe, as far as saying “drop the victim card”, I would never say such a thing to a patient , and if I did, I am sure I would be disciplined. those comments were the most unprofessional thing I have read in long time, and they all came from the midwife or midwife advocates. I have not had many encounters with this profession, as in Spain midwives work in hospitals, and home births are not done. Spaniards are very pragmatical people, and birth is not an objective in itself, but a process that is meant for mother & baby to have the least morbidity/mortality possible. not very touchy feely over here….

    + “Like the anonymous obstetrician criticised in that blog, I strongly discourage VBA2C, but the references cited, and RCOG guidance suggest I may be wrong, and I’ve also reluctantly looked after a couple of cases myself, which I admit turned out OK. So I said what I usually say, “discourage but support”.
    I have not read the RCOG guidelines, but what are they based on? what kind of trials? are they well done? is the evidence strong?. also, remeber, anecdote (cases that went well) is NOT evidence…

    +”accusations of unprofessionalism, especially when copied to the RCOG make me nervous;”
    that was simply horrid. I don’t now who copied the ob society, but they should be ashamed of themselves

    +”Calling HVBA3C a “first world problem” was flippant, but I still think that home birth in that situation was foolhardy”
    of course it is foolhardy!!!!!!!! yesterday my blood bank was depleted from a uterine rupture, mother lived, baby died, this is NOT a thing you wnt to face at home, and as I said, I have not found any evidence on its safety. And HVBAC3C IS a first world problem. if you tals to anybody from the “developing world and ask: where would you like to have your baby? they would laugh you out of the room. I do not understand why would anybody want that risk. why?

    +”So rightly or wrongly, I forwarded the link to Titcombe and Tuteur.”:
    you can forward whatever you like, as long as it’s not illegal: the people berating you were on the wrong here. I imagine you have to work with them or people that know them, and brits do not like confrontation (;)))), but you made no gaffe. this was completely professional in every sense. what was not professional was the bullying you and Mr Titcombe received. ( I think Dr tuteur can handle it, and is farther away from it to harm her)))

    +”The Birthplace Study (click here), undoubtedly the best quality research into the question, showed that for low-risk multiparous women, looked after by properly trained midwives in the UK, home is as safe as hospital. Even for first pregnancies the additional risk is quite small, such that some women might rationally decide to take it. I’m not an opponent of home birth.
    But, there surely is a line we should not support, and birth at home after Caesarean is on the wrong side of it. ”

    that is 100% truth: low-risk pregnancies can be done at home, and not only by Uk midwifes…I recall a paper from Sweden or Denmark that reached the same conclusion..

    but VBAC, even after 1 c.section has not shown evidence of safety when done at home, has it?.
    and I speak as somebody whose OB recommended a vag birth after 17 months of having a c-section. it turned out I had placenta acreta, and I almost died….and after running many times with blood products to obstetrics complications, I fear them more than anything.

    “Did the midwife who told the mother she could have “a natural birth no matter how many sections I’d had” cross it?”
    if she said that, she super-super-uber-crossed the line. in fact, crossing the line is an understatement. I cannot understand how that person is not investigated and sanctioned. that is NOT good medicine
    of course you cannot arrest women, but I seriously think that any midwife that is OK with taking that patient on, and assist in a risky situation is not a colleague I would trust. you cannot arrest women, but you can say” sorry, I am not comfortable with assisting with what my professional judgement says is very risky” if every midwife turned that women down, then she could not do it.
    I would not assist a patient asking for their chemo to be done at home because it’s more “natural”

    “When one of the retweeters wrote about the HVBA3C blog “What an amazing story thanks for sharing let’s hope it empowers more women”
    are you kidding me? let’s empower women to have non proven and very risky procedures!!!!
    is there such a thing as evidence-based midwifery????.

    as I see it, you did nothing wrong, and what happened afterwards was like reaction that one would expect of a clique of teenagers.

    I’m sorry, but after what I saw, I do not consider Dr Tuteur a “troll” (although I think her ideas would be better served if she only went after the ideas, not the people), and I consider the people that went after you and Mr Titcombe as bullies.

    and the story of the HVBA3C makes me believe the conclusion of that report, they did come across as more interested on tthe process of “normal births” ( a thing that does not exist)than on safer births.
    if they are not, they are doing a poor job of showing it.

  3. Amy Tuteur, MD permalink
    April 11, 2015 4:38 pm

    Saddened by your predicament, Jim, but I certainly understand. Fortunately, I’m not constrained

  4. Amy Tuteur, MD permalink
    April 11, 2015 4:40 pm

    Saddened by your predicament, Jim, but I certainly understand. Fortunately, I’m not similarly constrained. I will continue to speak out for the babies and mothers whose deaths are ignored by this sisterhood of deadly enablers.

  5. fiftyfifty permalink
    April 11, 2015 5:22 pm

    “and felt it inappropriate to copy a mother’s personal, albeit public, blog”

    That was not the woman’s personal blog. It was the business webpage of her midwives. They were using her story as advertising.

    • April 12, 2015 9:57 am

      Fiftyfifty, you’re right. I’d not noticed that. However, don’t rush to condemn her. We only have the mother’s version. The duty of confidentiality prevents midwives giving their side of the story in a public forum.

      And don’t rush to condemn the OneToOne independent midwifery practice. They provide a rare genuine choice for UK women giving birth. In most of the country it’s the NHS or nothing. I’m a big fan of http://www.onetoonemidwives.org/.

      But it would be good if they added a cautionary note to that particular post. Perhaps they will.

  6. April 11, 2015 8:30 pm

    Thank you for writing this. I follow you and several of the others involved in this conversation and found the whole thing to be difficult reading. I can appreciate why you decided to lay low at the time but I don’t think you did anything wrong in forwarding a publicly shared story to someone else on twitter (however opinionated and abrasive that someone may be). I really hope that midwives, doctors and mothers will continue to work towards improving maternity services and that all opinions, even challenging ones, will at least be heard.

  7. Wombatish permalink
    April 11, 2015 10:13 pm

    Why can’t it be reasonable to say that if a midwife doesn’t tell the woman the true dangers, with appropriate statistics, she is failing her duty of informed consent? Let alone talk about failure to risk them out.

    A woman may not go back to the hospital if she has a falling out, but I’d say there’s a good chance she’d go if the midwife she trusts and has a good relationship with tells her outright: this is too dangerous for home. You can still try for natural/vaginal, but need to be in at least a hospital _attached_ birthing center.

    Also, we can’t and shouldn’t arrest moms. But we can arrest lay women with no credentials (admittedly more of a problem US side than UK) who attempt to practice medicine. We absolutely would do so in any other specialty.

  8. Mrs. Smith permalink
    April 11, 2015 11:09 pm

    How exactly is Sheena Byrom trying to make childbirth safer? From where I sit, she seems to be trying to silence critics of natural childbirth, without much regard to whether or not it is safer. I’m not sure why her “motives” matter, if the actual implications of her beliefs and actions are to make childbirth less safe. In the wake of Morcambe Bay and now Royal Oldham, subjective motives need to take a back seat to figuring out what is really going on to lead to such awful outcomes. If an ideological adherence to “normal birth” is playing a role, then it doesn’t matter whose feelings get hurt.

    • Amazed permalink
      April 18, 2015 3:26 pm

      Screw motives, face facts. Sheena Byrom treated a loss father with contempt, compared death from the bad care her colleagues provided to the risk of getting up in the morning, tried to silence critics of midwives with all she had – and all the author here has to say is that Amy Tuteur is wrong and poor Sheena does not pursue natural birth at any cost? Don’t make me laugh, dear author. I don’t take the third-hand “testimony” you have from your friends as God’s truth. And let’s be honest. You don’t really believe she can write “I support natural birth at any cost”, do you? Because actually writing it will expose the whole duplicity of midwifery position: they are presumably only there for low risk birth, they try to seize more than that but they can NEVER admit it in writing. Really, how would it make them sound?

      I suppose you know this but you won’t admit it in writing because it’ll give you additional trouble with their ilk and I’m sorry for the ones you’re already facing. But the part about Sheena Byrom’s pure motives was something the piece could really have gone without. Actions speak louder than words and ascribed motives and her actions show her as she truly is.

  9. April 12, 2015 2:41 pm

    I don’t quite understand tweeting that to a loss parent?

  10. April 12, 2015 2:56 pm

    Hi Jim
    At the risk of being pedantic you are not risking uterine future, which inevitably leads to fetal death, often maternal death and may involve bladder and ureteric injury but Caesarean scar rupture, often with minimal bleeding and a live baby. Having said that i find myself a little credulous that women in ‘high income countries’ want to to take ‘low income country’ risks. Working as I do as a fistula surgeon i find it difficult to understand why women would wish to put themselves at this needless risk for some intangible benefit. What I see from delayed caesarean section is fetal loss and loss of continence, which despite our best endeavours may be permanent, not a good outcome.

  11. mabel permalink
    April 14, 2015 3:24 pm

    I stumbled across your twitter spat, and I have nothing but sympathy for you personally, and a huge amount of anger for those ‘colleagues’ and their unprofessional bullying. Copying in RCOG is nothing more than bullying-it is at the level of ‘your’e mean and nasty and I’m going to tell on you’. What sort of behaviour is that from grown women? Do they have no confidence in themselves, their qualifications or experience to be able to address any disagreement calmly and sensibly like adults, or have we all gone back to middle school level? And as for some of the comments of Ms Byrom to Mr Titcombe, I would like to see her justification for telling a loss parent to ‘don’t let’s get on that roll again James’, or for telling him to stop playing the victim. And as for implying that he isn’t a fit person to be on the review body? How can someone who publicly makes this sort of comment to a parent who lost their baby in the worst of circumstances, and then bemoans the fact that she is feeling put upon be held up as any sort of role model?

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