andrewducker | Interesting Links for 25-11-2011

Crossposts: http://andrewducker.livejournal.com/2587201.html

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Interesting Links for 25-11-2011

IPv6 for consumers on DSL at last
(tags: ipv6 adsl isp uk internet broadband )
Apple is the UK's second most popular shopping site (after Amazon)
(tags: apple shopping uk )
Google and Samsung confirm Galaxy Nexus volume bugs - glad I'm not upgrading until January!
(tags: google samsung android )
Badoo - the billion pound social network you've never heard of (massive in Brazil, Spain, France...)
(tags: business socialnetworking sex culture badoo )
Genetic Study Confirms: First Dogs Came from East Asia
(tags: dogs asia genetics )
Britain has had a record-breaking freakishly warm autumn
(tags: autumn weather uk )
Courts cannot force ISPs into broad filtering and monitoring for copyright-infringing traffic, ECJ rules
(tags: law privacy internet copyright EpicWin )
Offshore unit launched to tackle international tax avoidance
(tags: tax uk )
UK switching cervical cancer vaccine to one which also protects against genital warts
(tags: uk nhs vaccine women )
Seeing nude people tunes up the brain
(tags: nudity brain psychology )
Some very interesting stats on home births, midwives, etc.
(tags: birth children healthcare )
Ethical bank Triodos opens its first UK branch (in Edinburgh)
(tags: uk scotland edinburgh bank ethics )
Organising movie posters by different tropes they use. Strangely hypnotic.
(tags: posters design cinema movies art poster )
It's nice to know that there's at least one class out there getting decent sex education
(tags: sex education sexuality society )
Willpower Is more than a metaphor: Self-control relies on glucose as a limited energy source.
(tags: glucose sugar willpower self-control )
Journalists tried to reach JK Rowling through her five-year-old daughter. Can we shoot them now?
(tags: journalism uk media jkrowling )
50p tax rate not actually causing a massive problem.
(tags: tax uk )

Home birth 'carries higher risk' for first-time mothers

I always thought it was elementary or high school biology that the human female body put up with more potential dangers during pregnancy and childbirth than most mammals, but apparently the message is being lost due to romanticism about nature these days. I won't deny there are a lot of assholes and clueless doctors out there, indeed I think it's harmful to the cause of the anti-quackery crusade, but medical advances and technology for pregnant women aren't an evil conspiracy against women, its saved so many mothers and babies.

The rest of the article, too much pro-homebirth propaganda, just because there are lower rates of cesareans doesn't mean it's a better outcome for the woman and child. The Skeptical OB makes a pretty good analysis of... nearly anything really-

http://skepticalob.blogspot.com/2011/11/its-official-homebirth-increases-risk.html

The emergency Caesarean rate for the low-risk women...

Low risk can become high risk very quickly, they're estimations, not psychic inquiry in to the future.

The BBC article on increased risks in home births is news?

Anyone who, through a process of informed choice, chooses to put themselves far away from hospital is electing (but not guaranteeing) themselves and their unborn child for a Darwin Award.

Anyone who has convinced themselves that birth is some kind of magical, low risk activity because it is 'natural' is deluded. It is painful, frightening, bloody and fraught with risk. Afterwards, it is magical.

No amount of home comfort will make up for a child, carried for nine months, that dies through any number of sudden complications that might otherwise have been saved if the appropriate teams and equipment had been on hand.

Of course, a hospital birth is by no means a guarantee. But I would say that it's the equivalent of adding an extra couple of D20's to a Saving Throw and I, for one, would rather have those the increased odds of survivability.

This is true for a first child (doubling of risk from 0.45% to 0.93%, but not even slightly true for further children, where the article states "For a second birth there was no difference in the risk to babies between home, a midwife-led unit or a doctor-led hospital unit."

According to this single study.

From a personal point of view, I would ask myself: does waiting for an ambulance to arrive and then get to hospital increase risk to mother or child when a sudden complication arises? Bearing in mind that if the midwife could cope with the complication, the ambulance would probably not have been called.

I would choose to already be in the place where the specialist teams and equipment are.

This single study being the largest one carried out in the UK, covering tens of thousands of births. If you want to dispute its findings then feel free to point to opposing data.

Looking at the data for second children:
For multiparous women, there were no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units.

For multiparous women, birth in a non-obstetric unit setting significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy.

So your outcomes are as good at home, and the odds of you not being sliced open are better.

https://www.npeu.ox.ac.uk/birthplace/results

We're still talking about general odds here. None of which are satisfactorily granular for me.

There were complications when dalglia was born. Suddenly. He could have died or been permanently mentally disabled. Fortunately, we were already in the NRIE and within seconds a medical team was in the room. They acted like poetry in motion, like they were telepathically linked. Stuff happened. And dalglia was delivered safely.

Would I want to have waited for an ambulance? No. dalglia could have died. Would I want to have waited for the ambulance to reach the NRIE from the wrong side of the city? No. dalglia could have died.

I realise this experience may skew my opinion but: fuck that study.

Forget the statistics for a moment: can adding 30 minutes of delay to treatment of an ongoing life threatening situation increase the risk of death? Let's say... ::shakes magic 8-ball of deadly childbirth complications::...massive bleed out from mother after birth due to tearing.

If we're going anecdotal, my son nearly died due to complications caused and worsened by hospital procedures and conditions. For one thing, the hospital had no air conditioning or hot water - I'm not kidding! I had both at home.

Then they saved him, then he had an 8 minute seizure. He's only marginally impaired.

I was very tempted to have my second baby at home, but lived more than an hour from hospital so decided it wasn't prudent. He was born with no doctor in the room because I had him so fast they didn't have time to get there from down the hall.

In light of my experience, I absolutely believe that, in the case of a healthy woman who has been screened for complications and attended by a midwife, home within reasonable range of a hospital is just as safe as hospital.

Apparently there's a saying going around Microsoft now; bowdlerized, it's, "the average person has one breast and one testicle." It's a caution against relying on statistical models without examining the context.

I strongly suspect that the reason second-child home-births have the same complication rate as hospital births is that those who were most prone to complications (as demonstrated the first time) went to the hospital. This skews the result heavily... indeed, I'm surprised that home-birth for second children doesn't show a greater safety rate because of that bias.

Of course I haven't seen the study design or how they controlled for this so perhaps I'm being unfair.

-- Steve's not a stats genius in any case.

Yup, that's what I'd expect.

Which means that the sensible thing to do is to have your first child in a hospital, and then make a decision about the second child based on the results of that experiment.

Because complications are rare, pulling complications out of the home birth pool is like pulling tokens out of a bag with a lot of tokens. So removing the mothers who had complications the first time shouldn't affect the home birth statistics positively enough to detect. Which is just what we observe: home births rise to the safety level of hospital births on and after second birth, but do not exceed it, despite the theoretical skew from first-birth complications electing hospital the second time around.

Edit: the study is talking about comparable risk of complications occuring between different birth settings for the second birth but doesn't cover what happened when there were complications.

So, the risk of complication is roughly equal between birth settings for the second birth, but: where there were complications, was there an increased risk to the health/well being of mother and child being away from hospital?

As the quote I left just above makes clear, there were no significant different in outcomes.

At the risk of sounding flippant: a statistically insignificant outcome can feel pretty damn scary and significant when your result is one of the outlying exceptions to the rule.

Dalglivk did an obs and gynae attachment at St Johns and saw the fallout of enough outcomes, that would have been statistically insignificant for this study, to convince her that hospital was best for her births.

I'm with danieldwilliam: I'd want to be where all the surgeons hang out.

Of course a statistically insignificant outcome feels more important when you're in the middle of it.

This is why anecdotes make for awful recommendations, and the people who are mostly exposed to the things that go wrong have a more negative view on things.

(See, also, doctors who deal with people who have massive alcoholism problems, and thus want to ban everyone from drinking. If you only get involved once people have problems, of course that makes a bigger effect on you.)

Actually, I thought the GMC had given guidance that everyone can drink as long as they do it in moderation. Sadly, the general drinking populace are generally incapable of understanding 'in moderation' and come up with things like 'alcopops don't count' etc. So it's easier for government to say 'don't drink at all'. Of course, government also has an agenda to reduce NHS costs which are hammered by heavy drinking related illness and injury every Friday and Saturday night...

Sadly, the general drinking populace are generally incapable of understanding 'in moderation' and come up with things like 'alcopops don't count'

I'm not convinced that a majority of people are like that. Certainly there's a loud cohort who make people's lives a misery on a Saturday night, but I don't think that's that many people out of the whole population.

The GMC aren't bad - but you end up with some doctors advocating tougher and tougher measures on alcohol pricing, because of the alcoholics they see, without seeming to realise that this is have a large affect on ordinary people, without making much of a difference to the actual alcoholics.

(Don't get me started on the "You shouldn't be allowed to smoke in your car..." stuff that came out a couple of weeks ago.)

I correct 'general drinking populace' to 'loud cohort who make people's lives a misery on a Saturday night'.

And agreed re GMC. The problem here is that some members have a political and ambition agenda that they can only further by spouting heavy handed garbage.

This is true. I do think that doctors get a negative view of people, because they only see the ones that have fucked up in some way (or are unlucky). I know a few GPs who have ended up thinking largely of the general population as incompetent idiots who can't be trusted to look after themselves.

And I think that _sometimes_ they have a point, but I'd rather that most people got to make their choices than we restrict everyone because of a few people.

The anecdote is to illustrate that even with statistics on your side, shit still happens.

In that scenario, where would you rather your wife and child be?

If you step outside of your door you could be instantly shot and killed by a rogue police marksman.

In that scenario, would you go outside?

(Less flippantly, Julie gets to make the call, and I'm sure she'll do oodles of research before deciding anything. First child will almost certainly be born in a hospital, and choices about further ones will depend on what happens then...)

Edited 2011-11-25 13:45 (UTC)

I not sure that question is a fair comparison. They do not carry like for like possibilities of 'complications'.

Now: if i lived in a 200 window building and I knew that a rogue police marksman was aiming at a random window and was going to shoot whoever opened it, would I open my window? Probably not. I'd find a less risky way of getting fresh air.

.

Aaah, so it comes down to probabilities.

In which case, what _are_ the odds of a situation occurring which gives different outcomes depending on whether you're at home or in the hospital?

Because I read a study earlier today that said the differences were statistically insignificant (for second child and onwards).

Let's see how far we can take this analogy :)

Let's say risk of 'complication' from rogue police sniper is 1% in an apartment block 45 minutes from the hospital and a hospital block being terrorised by another rogue police sniper.

What the statistics of the study say is that, for people who have already been shot by a rogue police sniper once before ~45% of the unlucky 1% who get shot back at the apartment block end up have to go to hospital anyway (albeit mostly for flesh wounds). Critically, the statistics say that the risk of dying from being shot by a rogue police sniper the second time around is the same whether your at the apartment block (a 45 minute ambulance journey from the hospital) or at the hospital block (where all the surgeons are).

You know what? I'd still rather be shot by a rogue police sniper at the hospital block.

And I am absolutely fine with you making decisions that aren't backed up by data. Tis your right!

Reading more on this. It's quite fascinating seeing the different studies from different groups with different agendas.

Oooh, more data please!

Of course a statistically insignificant outcome feels more important when you're in the middle of it.

This is why anecdotes make for awful recommendations

LIKE THIS COMMENT

Thank you

I broadly agree with your sentiment.

I remember discussing this forcefully with My Lovely Wife in advance of the birth of our first son. I also remember my mum (a doctor) threatening to bully MLW into going to the hospital. After a 36 labour resulted in an unplanned C-section all of us were glad we’d been in hospital. Saying that being able to nip off to my own spare bed for a kip would have helped me function a lot better.

However, doesn’t the research indicate that home births are just as safe as hospital births for second births with parent-child combinations that are low risk?

As above: risk of complication was found to be equal between birth settings for second child by the study does not appear to cover the risk of how complications are dealt with in those birth settings, if they occur.

I would still choose to be already in the place where the specialist teams and equipment are, rather than be hanging about for an ambulance with wife in agony/baby dying.

Ah - I see.

I guess you pays your money and you takes your choice on whether the additional risk of the ambulance ride and consequently anxiety if thing go wrong are worth being at home at all that loveliness are worth it to you.

Personally, I'm with you on. Take me to the place where the surgeons hang out.

Next time tho' I'm taking my own blow up bed and blanket.

I'm with you there. No beds for spouses in our local hospital. blanket is a good idea :)

Also chocolate. I never under estimate the moral boosting power of chocolate.

Frustratingly I noticed the "guest bedrooms" near the wards in our maternity hospital on the way out with my four day old son.

I definately felt that having a few hours sleep was really beneficial during the birth process. MLW was very tired, (close to exhausted) and full of a cocktail of several pain killers and other chemicals and my ability to translate what the doctor was saying in English into stoned, tired, anxious, pained MLW-ees was useful. I think had I had four hours proper sleep lying down with a blanket I'd have been able to do a better job.

There's a strong chance you would have to hang about by a hospital bed with wife in agony/baby dying - waiting for the right doctor to be found, the OR to be prepared, the team to scrub up, etc etc. There is a usually a delay between requesting even the most emergency of emergency procedures (especially ones involving complicated kit/specific people; which is what we are talking about because midwives have the easy kit with them and lots of training) and actually receiving the procedure.

How that delay compares to the time spent waiting for / in an ambulance depends of course on where exactly you live.

The safest option is, of course, to either not get pregnant in the first place, or to have the thing aborted as soon as you notice. This is infinitely safer than carrying a foetus through to term. The difference in risk between a home birth and a hospital one is minuscule in comparison.

Any woman who, through a process of informed choice, chooses to become pregnant and continue with that pregnancy, usw...

Well, quite. :)

And then squirrels would rule the earth as humanity died out !

:-) now that has been MY choice. I have no desire for children, and never have - BUT I think that even *if* I did, the risks of death, injury and long standing and profoundly unpleasant health problems for myself (diabetes, lost teeth, single or double incontinence, fistula(e), prolapse...etc. etc..) would STILL probably convince me otherwise.

My choice too. Despite my Home Ec teacher at high school who once thought it was appropriate to tell me I was silly for not wanting children and that getting pregnant was the only way I was ever going to have decent sized breasts...

Ah, but you forget the other side of the coin - for a birth that has no complications and proceeds in the normal and expected manner to produce a healthy child and healthy mother a hospital setting carries additional risks (generally speaking simply being in a hospital carries risks such as increased exposure to MRSA; specifically speaking many women experience hospital births as involving more stress, and more unnecessary/unwanted medical intervention during their birth).

There are many women and babies whose health post partum are vastly improved by not being in a hospital setting, and simplifying that to "home comfort" is unfair; it is desperately unpleasant to think about but, yes, I would venture to suggest that for most people there is a number of people in perfect rather than slightly-dodgy health that "makes up for" a single death collaterally caused. What you feel that number is, and how it fits into the evidence presented here, are things that I obviously do not know.

The risk equation also requires further information which is non-obvious (although presumably covered in this report) - exactly what procedures are there which you are very likely to be able to access in hospital but not at home? Home births supervised by NHS midwives are not the same thing as a birth free of medical intervention or assistance; not all hospitals are able to guarantee to offer all types of intervention that are theoretically available (that is, that exist, are approved etc); what is the likelihood of experiencing unexpected complications? Further - how far is your home from the hospital, how long will it take you to get there in an emergency situation, which you should compare with how long you would have to wait in the hospital for the appropriate teams and equipment to be available to you when you are considering what risk you are actually running by having a home birth.

So; yes. It's news. Just because the answer turns out to agree with your gut-feeling about the risks doesn't mean that you were correct to trust your gut-feeling rather than go out (well, send someone out) and collect evidence about the question.

Yes this. By their nature these things miss out the personal experience bit. I know two women who opted to give birth at home for their first child. Neither of them are stupid, they both did their research and decided the added comfort and reduced medicalisation outweighed the extra risk. They were both lucky enough to have no complications and found birth a more positive experience than several other women I know, who had a horrible time in hospital. Including one who still had to wait for an ambulance and be transferred because the hospital she was in couldn't perform the necessary intervention.

By which I mean that if we rely on people's gut feelings and personal experience, we get a story based entirely on who is in our sample.

It turns out that I am an opinionated old fart, lucky enough to have friends like Andy who are patient enough to keep arguing their corner. The result was that I went away, read some more around the topic and am now more sympathetic to other point of view.

Hurray!

I can entirely sympathise with your position given your experience, it's very hard to be objective about medical statistics when it's you or your family whose lives are saved (I made a similar point here about mammograms).

I should point out that I think your approach is absolutely defensible, that 0.5/100 is perfectly common enough to be worried about, and that I'm sure there are cases where being right next to a bunch of doctors has saved people's lives.

Which leads me to think that either there _is_ something wrong in the statistics or there must be cases where being in a hospital is actively bad for your health (like increased chance of catching something nasty, or passing doctor's deciding to run experiments on you).

As well as the chances of catching MRSA etc, hospital births tend to be 60 % longer, which can increase the chances of complications. In a hospital, a woman is more likely to give birth on her back (not helped by a lot of medical professionals who think you need to be lying down if you have monitors attached to you) which is apparently much worse than squatting.

(This info is via the Boy who is training to be a nurse; I'd look up some articles to reference but a) I should be working or turning the laptop off and b) no-one without a journal subscription is likely to be able to read them)

I'm unclear whether the data on the length of hospital births is comparing like-for-like births, or whether it is affected by higher risk births being almost entirely hospital based, unfortunately.

I'm not advocating shooting journalists or bankers but I am surprised that neither group has seen members become the victims of vigilanties or terrorists.

Could you put a note in the link title when it's a PDF?
(Or recommend a Firefox plugin that can open them rather than download :)

I didn't realise Adobe Reader didn't work on a Mac!

Try this? http://www.schubert-it.com/pluginpdf/

Eh?

I was confused to. There are numerous mentions of Adobe Reader not working as a plugin for Firefox Mac, but some of the pages seem to be out of date. I'm confused, frankly.

Not too sure myself. I have Adobe Reader installed, because it came with my Adobe CS4 Design package thingy, but I don't actually use it. PDF support is built-in to the OS, and you have to actively tell Safari (not my main browser) to save a PDF rather than just open it. In Firefox, I just set it to automatically open them in Preview.

> PDF support is built-in to the OS,

Yup.

> In Firefox, I just set it to automatically open them in Preview.

Yeah, but I'd rather be warned upfront that I'm going to have a bouncy dock icon and then a download window open and then another application opening and then a file to trash from my downloads folder...

Chrome on the other hand opens them in a browser tab. I'm sure FF used to do that too -- I possibly removed the Adobe PDF browser plugin because it was crappy and crashed.

If you're interested in reading more about the glucose/motivation stuff, Roy Baumeister keeps a lovely page where you can get pdfs of his papers emailed to you. He's also looked at sex drive.

Gardasil has been in use here for a few years, though it's only been approved for use in women up to age 26, if I recall correctly. Sucks to be older than that -- you can't get it on request, It Hasn't Been Approved.

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Interesting Links for 25-11-2011

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