Sophie says “Pull yourself together, woman, its only a baby!”

Speaking as something of a science geek, one of the more pleasing developments in the ongoing Leveson Inquiry into the culture, practice and ethics of the press occured on the very first day of proceeding when, in setting out the parameters of the inquiry, Robert Jay QC announced that, amongst other things, he wished to look at newspapers that abuse scientific data to write tendentious stories.

A review of this issue is, to say the least, long overdue and will, no doubt, lead to some extremely interesting evidence sessions; particularly if, as I hope/expect, Brian Deer is called to give evidence on the role of the press in promoting Andrew Wakefield’s now discredited ‘research’ into a wholly fabricated link between autism and the MMR vaccine.

In light of Jay’s announcement, on 14 November, you might well think that the press would take the hint and exercise a little more care and attention when reporting scientific issues, but no, the culture of bullshitting for profit is so deeply ingrained in the tabloid and, particularly, mid-market national press that it would that they just can’t help themselves, hence the misleading and rather tendentious headline that the Daily Mail has deployed to lead off its coverage of NICE’s revised clinical guidelines for caesarian sections:

Caesareans will be offered to women in fear of labour amid concerns some are so afraid they seek abortion

– New guidelines say women with fear or anxiety will be eligible for a Caesarean

– Fear of childbirth affects one in ten mother

– 24% of women give birth by Caeserean – up from 12% in 1990

All this is given in bold text and above the byline – Sophie Borland – who’s main qualification as a ‘health journalist’ appears to be nothing more than a willingness to conform rigidly to the Daily Mail’s ‘house style’ of ‘Bullshit first – Caveat later‘, which is hardly surprising as it appears that Sophie has long been willing to do whatever it takes to get on in her chosen career:

The Mail on Sunday has been accused of “fanning the flames of Islamaphobia” after allegations it offered students £100 to infiltrate Muslim student societies in an attempt to uncover evidence of “extremism” at universities.

Mail on Sunday casual reporter Sophie Borland contacted Pi, the student magazine at her old college, University College London, offering student reporters £100 to attend muslim society meetings and report back on what was discussed.

Guardian Media – 10 March 2006

Moving on to the meat of the article, the very first thing that the Mail does is repeat its claim that there are ‘concerns’ that some pregnant women might opt for an abortion due to their fear of childbirth.

Maternity wards are relaxing the rules on caesarean births amid concerns that some expectant mothers are so afraid of childbirth they seek abortion.

Out here in the real world, what’s actually happened is that NICE have asked RCOG and the Royal College of Midwives to revise the previous guidelines on C-sections, which were published in 2004, taking into account new clinical evidence published since the last review, some of which relates specifically to the psychiatric impact of pregnancy and childbirth. In other words, this is nothing more than an exercise in good practice in evidence-based medicine – every once in while, you review your existing guidance and update it in line with the best available evidence, taking into account new evidence published since the review.

Under new NHS guidelines, pregnant women who are very anxious about labour will be able to have the operation even if there is no medical justification

For starters, define the term ‘medical justification’.

What the Daily Mail mean by ‘medical justification’ is a physical reason, e.g. the foetus being in the breach position or the woman having previously undergone a C-section due their being unable to deliver naturally. But good clinical practice is about more than just the physical/biological aspects of medicine  – a good clinician should also be concerned with the psychological well-being of the patients who in their case and its precisely this that has prompted NICE to make the following, new, recommendations.

Maternal request for CS

34. When a woman requests a CS explore, discuss and record the specific reasons for the request. [new 2011]

35 If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth (see tables 4.5 and 4.6) and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife and anaesthetist) if necessary to explore the reasons for the request, and to ensure the woman has accurate information. [new 2011]

36 When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner. [new 2011]

37 Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care. [new 2011]

38 For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. [new 2011]

39 An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS. [new 2011]

So, its not just a case of women saying ‘I feel a bit anxious about this, so I’d like a C-section’ and the doctor saying ‘Fair enough, I’ll book you in’. If women do ask for a C-section because they are fearful of the experience of childbirth, for whatever reason, then, in future, this should trigger, at the very least, the offer of a referral for further mental health support and only if that fails to allay the woman’s concerns and support them to overcome their fears, will a planned C-section be offered.

Now, even without reviewing the evidence behind this new guidance, that looks to me like nothing more than an exercise in good clinical practice, but there’s more to this than just a desire to maintain to good ‘bedside manner’:

Currently they are only offered a planned caesarean in certain circumstances, such as if they are expecting twins or triplets, they have high blood pressure or diabetes, or the foetus is in the wrong position. But under the guidelines from the National Institute of Health and Clinical Excellence, women with ‘mental health issues’ including fear or anxiety will also be eligible.

Oh dear, its the dreaded scare quotes around the words ‘mental health issues’ while, in tabloid-speak, means that these ‘mental health issues’ aren’t proper mental health issues at all and this is all just a matter of NICE pandering to silly women who really should just pull themselves together and stop making a fuss because childbirth is the most natural thing in the world, etc.

The correct clincial term for this is, of course, congential testicular verbosity or, colloquially, talking a complete load of bollocks.

These recommendations have not just been pulled out of a midwife’s arse, they’re based on research evidence, for example:

Alipour et al (2011) found, in a small study of 160 women, that:

“… the presence of antenatal state and trait anxiety at 28 and 38 weeks of gestation significantly increased the risk of postpartum depression during the first three months after childbirth.”

Nilson et al (2011) reports, from a longitudinal population-based study conducted at three Swedish hospitals, that:

“FOC (fear of childbirth] during pregnancy in multiparous women was associated with a previous negative birth experience (RR 5.1, CI 2.5-10.4) and a previous emergency caesarean section (RR 2.5, CI 1.2-5.4). Associated factors for FOC one year after childbirth were: a negative birth experience (RR 10.3, CI 5.1-20.7), fear of childbirth during pregnancy (RR 7.1, CI 4.4-11.7), emergency caesarean section (RR 2.4, CI 1.2-4.5) and primiparity (RR 1.9, CI 1.2-3.1)”

For those not versed in medical teminology, multiparous refers to women who have given birth on two or more occasions, while primparous refers to women who have given birth only once, and what this study shows is that for some women, fear of childbirth is rooted firmly in prior negative experiences

Elsewhere – Norway, in fact – Storkson et al (2011) report these findings from a study of the possible association between fear of childbirth and anxiety/depression:

“Eight percent (137/1 642) of the women had fear of childbirth W-DEQ > 85), 8.8% (145/1 642) had anxiety (SCL-anxiety ≥18) and 8.9% (146/1642) had depression (EPDS ≥ 12). More than half (56.2%) of the women with fear of childbirth did not have anxiety or depression. However, presence of anxiety or depression increased the prevalence of fear of childbirth (odds ratio 2.4 95% CI: 1.1-5.2 and odds ratio 8.4 95% CI: 4.8-14.7, respectively). Women with both anxiety and depression had the highest prevalence of fear of childbirth (odds ratio 11.0 95% CI: 6.6-18.3).”

So, of the women who did exhibit a marked fear of childbirth, more than 40% exhibited clear symptoms of depression and/or anxiety in pregnancy and this, as Heron et al (2003) noted, ‘increases the likelihood of postnatal depression.’

Some of the evidence is rather mixed – studies conducted in Scandinavia have found an association between fear of childbirth and a subsequent elevated risk of emergency C-section, but these results were not confirmed by a UK-based study which suggested that this may be a matter of cross cultural differences and a quick run through some of the reseach at PubMed did turn up a delightfully overblown foray into post-modernism based on a ‘Foucauldian discourse analysis’ which led the authors, one of whom sports the gloriously gynaecological surname ‘Douché’ (no, I am not making this up) to contend that:

“the discourses of autonomy, desire and risk unite with broader societal discourses to expose a pathologising paradox in which normal bodily performance emerges as abnormal and the abnormal as normal. The trend has implications for both future healthy populations and the equitable distribution of maternity resources.”

Frankly, Po-mo’s can contend all they like, I’m more interested in the actual evidence which does show that fear of childbirth is anything but a trivial issue and one that fully deserves to be taken seriously by clincians.

Getting back to the Daily Mail, the abortion claim resurfaces yet again:

Senior doctors and charities say that some women are so afraid of giving birth naturally they are having their pregnancies terminated.

So that’s three times and – so far – no supporting evidence, but before we finally get around to the source of this particular claim, the Mail find the time for another minor digression:

This fear of childbirth is known as tokophobia and it is estimated to affect one in ten expectant mothers.

No, the fear of childbirth is known as ‘the fear of childbirth’. Tokophobia is a phobia of childbirth and, in strict clinical terms, a very different thing from just a fear of childbirth.

This is an important point – it is perfectly normal for pregnant women to feel a bit anxious and even fearful about the prospect of giving birth. Giving birth, especially for the first time, can be extremely painful and stressful and its also a stage in pregnancy where there is a risk that thing can go very wrong. So, some degree of anxiety is perfectly normal. What elevates this to a phobia is when that anxiety becomes so difficult to control that it begins to have a marked, adverse, impact on what should be everyday activities, generating symptoms that can include nightmares, sleep disturbance and insomnia, problems with concentrating on work or on family activities, panic attacks and even the development of psychosomatic complaints.

That said, many of the women who do exhibit a fear of childbith sufficient to prompt them to request a C-Section even though their other symptoms fall short of those necessary to justify their condition being classified as full blown phobia.

As regards the claim that tokophobia affects 1 in 10 expectant mothers, this is both misleading in terms of conflating fear of pregnancy with tokophobia and questionable in terms of the reliability of current estimates.

There do not appear to be any UK-based prevalence studies, so most of the date we do have comes from Scandinavia and may be prone to confounding from cross cultural factors. Nevertheless, I’ve picked out three studies which neatly illustrate the difficulties that we have with current estimates.

Kjærgaard et al (2008) suggest that the ‘prevalence of troublesome fear of childbirth (FOC) in Western countries is about 20%, of which approximately 6-10% suffer from severe FOC that impacts daily life’ in a study which found severe FOC in 10% of its participants. This is, however, based on sample of only 165 women (55 Swedes, 110 Danes) putting it at the low end of the scale for reliability.

Waldenström et al (2006) is rather better in terms of group size (n=2662) and reports that:

“97 women (3.6%) had very negative feelings and about half of them subsequently underwent counselling. In addition, 193 women (7.2%) who initially had more positive feelings underwent counselling later in pregnancy.”

Before going on to conclude that ‘At least 10% of pregnant women in Sweden suffer from fear of childbirth’. That said, only 3.6% reportedly had ‘very negative feelings’ which may be consistant with actual tokophobia and the abstract does not indicate whether the women included in the study had previously given birth, or not.

Finally, Laursen et al (2008) offers what looks to be quite a reliable estimate of prevalence, based on data from the Danish National Birth Cohort (n=30480), giving the following results:

The odds ratio for fear of childbirth among women with anxiety symptoms was 4.8 (4.1-5.7) after adjustment for socio-demographic, lifestyle, fertility and depression variables. During the study period, the prevalence of fear of childbirth was stable. Fear of childbirth was reported by 7.6% in early pregnancy and 7.4% in late pregnancy. Only 3.2% of the women expressed fear of childbirth in both interviews.

The main drawback with this study is that it look only at nulliparous women with singleton pregnancy, i.e. one foetus, never given birth, and therefore tells us nothing at all about the prevalence of fear of childbirth and/or tokophobia in women who have previous given birth, even though we known that prior negative birth experience are a significant risk factor.

So, it actually very difficult to give any kind of reliable estimates for the prevalence of fear of childbirth, let alone for tokophobia, at the moment as the evidence is still rather limited in both scope and reliabilty.

Now, at long last, we get to the evidence that supports the Mail’s claim that there are ‘concerns’ that fear of childbirth prompts some women to seek abortion, and I should say, before we start, that I’ve already done a literature search and found precisely nothing.

Malcolm Griffiths, consultant obstetrician and gynaecologist at Luton and Dunstable Hospital, said he did not think it was ‘uncommon’ for women to ask for terminations following previous bad experiences giving birth.

He said he had recently seen one woman who had undergone two very traumatic labours and had asked to be referred for an abortion because she could not bear the thought of going through it all again.

Yes – if you guessed that this was all heading for a prime example of ‘proof by anecdote’ give yourself a pat on the back. The evidence for the Daily Mail’s headline claim is a single anecdote from an Ob/Gyn consultant although, to give Mr Griffith’s his due, he also chaired the panel responsible for drawing up these guidelines.

In fact you’ll also find Mr Griffith offering his opinions on the new guidelines in articles at the BBC, Sky News, The Guardian and in NICE’s own press release.  In fact, according to Google’s news search, Mr Griffith’s name turns up in a total of 271 news reports an an article about these new guideline…

… only one of which mentions the word ‘abortion”.

To be honest, we can skip the rest of the Mail’s article as it consists only of random quotes from NICE press release and figures for the rise in the C-sections since 1990 and the relative cost to the NHS of C-sections vs natural births as it’s is all just a bit aof  lazily put together column filler, because…

…out of 271 articles covering the release of the new guidelines, only this particular article, and this particular newspaper, has attempted to shoehorn a reference to abortion into a story that has absolutely fuck all to do with abortion other than the fact that both abortions and C-sections are gynaecological procedures, while at the same time taking the opportunity to sneer at the very idea that doctors, and midwives, should take the genuine fears and anxieties of pregnant woman at all seriously.