#229 | Sara Wickham: The Risk of the Risk-Based Approach

Sara Wickham
Often the difference in risk is about the same as the difference in, you know, whether you decide to drive to your local shops or shopping mall over there, you have shopping malls, whether you decide to decide to the shopping mall on a sunny day, or if it's just raining a little bit, I'm not talking about a thunderstorm, I'm talking about a little bit of rain. So we know that statistically, you're a bit more likely to have a car accident if it's raining than if it's sunny. But it doesn't stop people going to the shopping mall. And I know that that might seem like a trite example compared to you know, we're talking about babies. But actually, the reality is that it's because it is so emotionally charged. That that it's so easy to persuade women and families to say yes to these interventions. We're actually the absolute risk is low.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Sara Wickham
My name is Sarah Wickham. I've been a midwife here in the UK for about 30 years now. I'm actually now a retired midwife in terms of hands on practice, which is to be honest, more about the fact that I can't practice in the UK in a way that I feel is safest and best not because I don't want to. But I've also in that time, been an educator, speaker, researcher and author and in the last few years, that's what I focused on the most and, and right now I'm pretty much a full time author. So people may or may not know me from some of my books, I think the most well known is in your own time, how Western medicine controls the start of labor and why it needs to stop. I think that's the subtitle. But I also have written anti D explained an anti D is Rodan you call that rogram in the US, group B strep explained vitamin K in the newborn, and what's right for me, which is about making decisions. So I I basically these days, I write books, which combine the two sides of me and there is there is the side of me that has been a home birth midwife. And I have you know, a home birth midwives heart and, and that's been my practice background. But I also have a background in maths and science and statistics. And, and I love maths and statistics and evidence, I have a PhD in evidence based practice. And I actually love explaining maths assisted statistics, you think I can say it by now to people who don't like maths and statistics. Because what actually these days in the culture that we live and work in and birthing, what we really need is for women and families to be able to understand the evidence in different areas, so that they can make the decisions that are right for them. And so these days, that's really what I do, I write books that help explain the evidence so that people can make the decisions that are right for them.

Trisha Ludwig
Well, we are both quite familiar with your work. And we really value everything that you have to say and we reference your work a lot. And we know our community also values very much what you have to say. So it is an honor for us to have you here today. And we are very much looking forward to talking about a topic that not very many people really talk about or understand but it is extremely important. And that is the you're going to better explain it than me. But I'm going to call it the risk of risk and the risk of focusing on prophylaxis and prevention in maternity care, which is basically how it's done in clinical practice and where everybody always talks about how important it is to follow evidence based medicine. But there is there is another piece to this. And that is learning to make your own decision and not getting completely caught up in looking at risk analysis. So can you explain it better?

Sara Wickham
Absolutely. And, and what I would say just to pick up on what you said about evidence, Trisha is that evidence based medicine is not always what is being practiced in maternity systems around the world in the US, the UK and many other countries. spend. And when people read my book, sometimes they say, Wow, so the evidence says this, and why are we doing this? And I mean, that's that's not what we're going to talk about today. That's another podcast. But I think that's a really important point to make is that actually, we are not necessarily the maternity care that is on offer in the systems of care today is not necessarily evidence based. It's also not always very kind. It's not trauma informed. It's, you know, it's not based on on what women and families want. So, but we know, we're going to talk about risk. And there has been, I mean, in our culture, there has been this growing emphasis on risk on health and safety. I mean, Cynthia, I know you've, you've taught childbirth education for a long time. And, and I don't know if your experiences like mine, but you talk to parents and, and talk about what what they do what you know, the areas they work in. And, and if I asked groups, how has the emphasis on risk and health and safety changed in your work over the last two decades, almost everybody I talked to no matter what their professional occupation, will say, will grow and say, Yes, we now have more rules, there is a growing emphasis on risk.

Cynthia Overgard
There's no doubt about that. The one thing that I had that I am very grateful for is that I'm in a position to observe trends, the risks just keep expanding. And the traditional midwives keep getting more medicalized. And the rhetoric keeps growing.

Sara Wickham
And we just this cultural focus on risk, we just, we just can't seem to get away from it and, and that pervades maternity care, just just like every other area of life. And so some of the work I've done throughout my books and work is to say to people, well, let's unpack the notion of risk. And let's look at what it's actually about. Now, mathematically, risk is simply a word that we use to describe the chance of something going in a direction that we don't want it to, you know, if something unexpected or untoward happening, and I don't know about you, but to me, it seems like that's also the kind of the definition of life, it's, it's really hard to, like live a life where everything goes, you know, as you as you want it to and, and risk is very linked with the notion of uncertainty. And we can, we can come back to this if you like, but I think that one of the reasons that risk is seen as something that really needs to be managed in some settings, and by some professionals and providers, and others, where others are calmer about it is actually to some degree, related to how much people feel the need to try and control what's going on around them. So but but risk in itself is risky. And we have this emphasis on risk. And in maternity care. There is and I'm sure you see this too, there's this constant constant emphasis on assessing for risk or saying, Well, you have this characteristic. So you are, you're over 40, you have a higher BMI, we, you know, we perceive your baby is too small or too big. And, and, you know, to bring that in for a moment that that which you talked about, Cynthia, we then have to ask, well, how are we measuring and how accurate and again, that's another kind of old tangent, I won't go down. But we have all of these risk factors that we pick up and then want to jump in and act on and right,

Trisha Ludwig
Clinicians love to check the boxes of risk factor and then put you in a certain category you are not safe for home birth, you need to go to Metro maternal fetal medicine, you out you risk out of the birth center, all of these things, just based on a list of of items or criteria that you know, somebody meets age is a perfect example. I mean, you could be the far healthier at 42 years old than some people at 30 years old.

Sara Wickham
And and they are these are crude factors. They you know, as you say they are they are kind of really simple, crude factors. Risk factors are used as a proxy for health. But they're not they don't reflect health. I mean, I've most recently, I mean, my next book, which is coming out this month, is is called plus sized pregnancy, and what the evidence really says about higher BMI and birth and that's a really good example where BMI is used. As a you know, body mass index is used as a really crude measurement to say, well, you need to go down This path and you need to go down this path simply as a result of the number. And it's not evidence based, it's deeply problematic. It doesn't reflect health. And so my, you know, kind of the topic that we were, we were, you know, we're going to talk about is the risks of risk itself, this whole idea about using risk to categorize to put women into risk categories, and then to offer prophylactic interventions tests to restrict their options to say, actually, you can't you can't use this midwifery practice, you can't use water because you're too big. You, you may not go to the birth center, you can't have a midwife because your baby's breech, you know, but using risk, this whole notion of risk itself is risky. There are a number of kinds of ways in which using risk is risky.

Cynthia Overgard
Coming from a background in finance, because I'm a former finance professor, and that my first introduction to risk was all statistics. And I've always thought about risk, because in the field of finance, the layperson says, with respect to the stock market, the greater the risk, the greater the return, which isn't true, in my opinion, it's like the greater the risk, the greater the potential return, but the greater the risk, the greater the potential loss. So you can convince any, any new investor, well, if you don't take risk, you're not going to make the big money. That's not at all how it works. It's about it's about potential variability in outcomes. And it's interesting, because as you're talking about this, I'm just thinking about risk, right, because there's the rhetoric around the risk of home birthing. And when I was thinking about that, the potential reward of home birthing is through the roof. When you do get the desired outcome. It is an impossibly satisfying, life altering event. But there are risks in the hospital. And there is variability in the hospital. And I feel like the greatest extreme of the variability is a traumatic birth. And of course, you can have the most satisfying birth in the hospital and the most traumatic at home. But I do think it's interesting how we throw around this word risk, and how we assume it implies safety, like the antithesis of risk. But really, it's linked to that possible variability in outcomes. What's the range of outcomes you can have if this is the risk you're taking on?

Sara Wickham
And mathematically, the word the word risk simply means chance. I actually say to people, we should use the word chance rather than risk because it takes all that kind of heat out of the word and the scariness. But it just means the chance of something happening.

Cynthia Overgard
Right? Right. possible outcomes? Well, let's hear your list. So we know you've given this a lot of thought. And it's really exciting because I don't think we've talked about anything like this before. What have you come up with as far as this approach toward risk and what risk really means or like what happens when we pursue birth through this framework of controlling? Suppose it risks?

Sara Wickham
Well, so obstetric research is really very narrow. And it focuses when it when we do research things. And actually, a lot of the things that we do, we don't actually have good evidence by even by obstetric standards, we don't have good evidence, a lot of things, as I said, at the beginning of the podcast, a lot of things that are happening on evidence base, and in fact, they're just based on tradition.

Trisha Ludwig
And sometimes the conclusion of the evidence is, does not align with the actual data in the study. And that's very clearly evidenced by the arrive trial. So not only do we not have the evidence, but we can't even trust at all.

Sara Wickham
And one of the things that I do a lot of you probably know, in my books, and when I'm teaching is to unpack that evidence, I'm never taking studies like the arrive trial at face value, what what I do in my work is to say, well, let's have a look at this. Because just because something has been published in a medical journal, doesn't mean it's actually good, doesn't mean it's any good. It might be very limited. I've written 1000s of words on questioning the road. So it's actually really hard to know where to start. But I mean, one of the problems is that some of the ways that we want to set up research trials, you know, randomized controlled trials are really set up to evaluate drugs. And when we're trying to evaluate interventions and practices, it is very difficult because if you are trying to evaluate, say, a drug that's designed to reduce somebody's blood pressure, you can make another drug that looks like it. So you've got a placebo and then neither the woman nor the care provider knows who's giving the drug and who's giving the placebo. But when it's an intervention, and or it's, you know, it's really hard. You can't double it. Ideally, you have a trial that is double blind, so neither the women nor the care provider knows which group she's in. But But in these sorts of trials, and unfortunately, it we just have to accept that that is how it is because it's, it's too hard. You know, if you're having a vaginal birth, or a cesarean section for your breech baby, it's really hard to blind for that. But should I move on? Should I move back to the Yes. So the the problems, you're asking for my my list of the risks of risk and risk, obstetric research just measures the short term outcomes. And as we've just said, it often does it in a partial, really problematic way that we could unpack all all afternoon. But whatever it's doing, it's genuinely measuring just the short term outcomes. So is there a live baby in the caught at the end of the shift? That is obstetrics measure of success. And so we medium and long term effects are very, very rarely measured in these studies. And one of the risks of, of using this risk focused approach is that actually the actual side effects of these interventions, so we're talking about things like giving antibiotics for Group B strep, and and we do that differently in the UK from you. So you offer antibiotics to any woman who is carrying Group B strep. And my understanding is that all women are offered a group B strep test in pregnancy, and I'm saying offered because that's what I think should happen. I acknowledge that's not what happens in reality. In the UK, we use risk based screening. So it depends on the risk factors in the woman's history as to whether or not she's offered antibiotics. But either way, an awful lot of women are having antibiotics, intravenous antibiotics in labor, in the hope of preventing Group B strep. And but we have the actual site, there are side effects to interventions and, you know, the the effects of side effects of Pitocin and prostaglandins and other drugs and mechanical interventions used in induction. So we have the side effects that occur at the time. And those are not always measured, are not measured well in obstetric research, even when they they exist in the short term, that they're not always being measured. But we also then, as I mentioned, we have the medium and long term effects, which are almost never measured, not in the sorts of research, the research studies that actually are used to change practice or to tell women Oh, well, you know, you are twice as likely to have this as that. They're not looking at the the medium and long term effects, and also the wider effects. So to go back to the example of antibiotics in Group B strep, B, for instance, antibiotic resistance, because we are giving around a third of labouring women antibiotics because of a tiny chance. I mean, in the UK, it's one in 17,000 Babies who who die from Group B strep disease, and and that's absolutely dreadful. I don't want to play that. Don't downplay that. I don't I don't want to gloss over the how how awful that is. But we also have to think about the wider picture. And the effects that the overuse of having antibiotics, we, you know, the other 16,999 Women and Babies who received antibiotics in labor, in order to save the one baby. And and and I, you know, it was a difficult decision to make, you know, I'm not saying these things are easy. But we also have to think about the effects that the overuse of antibiotics is having down the line, and how many babies are dying or will die in the future as the result of antibiotic resistance, or because one day antibiotics just will no longer work.

Cynthia Overgard
There, I can clarify what you just said that was so valuable. I want to make sure everyone understood. In the UK you have a risk based approach. So that's not to say that no women receive antibiotics. That means if they have a risk factor, such as

Sara Wickham
plenty of women receive antibiotics, it's just that the decisions as to who is offered antibiotics, Rite Aid on the basis of if you have a risk factor, rather than you are positive so some women are still screened culture based screening. Some women still have screening

Cynthia Overgard
and one in 17,000 is in that population you have in the UK whereas some receive it only based on risk and a majority don't receive the antibiotics in fact, are not even screened in pregnancy because they don't have risk factors. Is that where the one in 17,000 showed up? Oh,

Sara Wickham
It comes from a study that's 20 years old because we don't have because we're using old data, we know that we're actually predates it was in a time where fewer?

Cynthia Overgard
Do we know the data in the US were 17,000 women who were screened. And did they're not doing that work, are they? So that's kind of your point, you're saying? Is it really necessarily worth giving? blanketly giving 17,000 Women antibiotics because they tested positive at some point in pregnancy, usually, later in pregnancy? Is that really worth it? But right, but who's even to say, did it save that one child? Because it's not always effective getting the antibiotics? And then even if it did, you're saying, Who's to look at the lifelong effectiveness and how that showed up later for those 17,000 children who received antibiotics as their first intervention?

Trisha Ludwig
And just to add to that, it's also to say that the only risk that's being focused on is the risk is there is the risk of not getting the antibiotics. So this is not a true informed consent. We're focusing on one side of the risk. We're not nobody's nobody's mentioning all the other risk, as you just said, that comes with the potential of antibiotic resistance over time, or an allergic reaction, potentially, to

Sara Wickham
the baby's microbiome. Yes, you know, we, you know, we are depriving we are learning so much in recent years about the importance of the microbiome or the, the the healthy bacteria that live on and within our bodies. And we now know from studies how important that is for babies. And yet, by giving all of these women antibiotics in labor, they the antibiotics are not simply targeting group B strep, and that you know, that they there is an impact on the microbiome. And but this is not being considered we are, as you say, You You're absolutely right, we are focusing on the one thing, which is mortality. And, and I mean, to go back to answer your questions in here, I, I don't want to be I don't want to be in a position where I'm saying what should happen across the board? Because I have, I have a huge amount of sympathy for those who make these policy decisions. You're just saying

Cynthia Overgard
we haven't looked at the alternative. We haven't even studied the alternative is what you're saying.

Sara Wickham
What I'm also saying is that women and families need the information on all of these things. And they need to know where we do have evidence, and what the numbers are in the studies. And they need to know well, what are the problems with the studies? Was that a good study? What other questions they need to know these are the wider issues? These are the questions that haven't been looked at, because they are not considered to be a priority within obstetric research? Because the other thing is that I don't think there's a I don't think there's one answer for this, because everyone has to make the decision that is right for them within their own context. And we all have different values and different family situations and backgrounds and living situations. And, and my focus is all on saying, Look, this is the evidence, this is the information so that people can make the decision that's right for them. And then And then the last, I'm determined to get to the final release date. That's right, and then we can expand the last of the risks I want to throw in there is this is the one that people think about less often, because it's the impact, that this whole focus on risk has on women's confidence to be constantly told that you are at risk, you know, that your body's broken, it has the implication that your body's broken, it's not working well, you know, it's, it's, you know, we're not really sure you can do it by yourself, you need to come to the hospital, let this expert in a suit or a white coat, you know, come in and galloping on their white horse and save you and that's it's really harmful to women's confidence at the point where women are becoming parents or anybody is becoming parents, they need to be, you know, feeling super confident. And actually, what we're doing in the system, and with this whole emphasis on risk is we are undermining that. And it's, it's really disingenuous, because actually, we know from the evidence that most women would be really fine without all of this monitoring, intervention, you know, risk status, and actually, quite a lot would be better off because they would avoid all of the risks that I've just listed.

Trisha Ludwig
Just one other point when we were discussing stillbirth that we didn't talk about with risk is the difference between absolute risk and relative risk because it's so easy to convince somebody that something is very dangerous when you say that you have two or three times the risk. If you don't do this, or you you know, if you decline the induction, your baby has a two or three times risk of dying when you say that to a woman. You know, she's just going to accept the induction. Yeah, absolute risk. If you get down to the numbers and you look at apps solute risk, she may have a very different opinion.

Sara Wickham
Absolutely. And it's really scary, you know, to be told or your your baby is twice as likely to die four times as likely you know you, you have a higher BMI. So you are four times more likely to have this problem. And one of the things that I've done in the, in the new book, in fact, I've done in several books is to where I can get the data from the studies. And actually, it's really interesting because the researchers, they don't often make it easy for you to find out the absolute risk you I have to go in and do sums. And sometimes this is, this is where my math background comes in. Sometimes I can't do the sums because they don't give you the raw data. And sometimes I I feel like going back to what you were saying, Cynthia about, you know, whether there is bias in here, sometimes I wonder if they're not giving the raw data because they don't want people like me to come along and say, Well, let's look at the absolute risk here. But But yes, indeed, it's you know, we have a situation where the risk might be, you might be twice as likely. But if we're talking about the risk, the chance of something happening, shifting from one in a million to one in 500,000, do you know, it's actually you're still extraordinarily unlikely to have the problem, you are far more likely to be fine. But we don't present it that way. We don't say well, actually, there is a 99.96% chance that your baby is going to be alive and well. And in 20 years, you'll be moaning about the cost of university.

Trisha Ludwig
Imagine if that was the headline, you know, you're 43 weeks, and you still have a 99.9% chance that your baby is going to be absolutely fine versus the headline that says go past 42 weeks and your baby is twice as likely to die. That's how it's presented to people.

Sara Wickham
And one more example that I like to share which you're very welcome to to share if you're listening and you you teach childbirth education or anything like that, is that often the difference in risk is about the same as the difference in you know, whether you decide to drive to your local shops are shopping all over their you have shopping malls, whether you decide to decide to the shopping mall on a sunny day, or if it's just raining a little bit, I'm not talking about a thunderstorm, I'm talking about a little bit of rain. So we know that statistically, you're a bit more likely to have a car accident if it's raining than if it's sunny. But it doesn't stop people going to the shopping mall. And I know that that might seem like a trite example compared to you know, we're talking about babies. But actually, the reality is that it's because it is so emotionally charged. That that it's so easy to persuade women and families to say yes to these interventions. Were actually the absolute risk is low.

Cynthia Overgard
And here's the problem that I see. It was it's it's a little bit in line with what you're saying as your final point about how it affects women emotionally. But here's what happens in the thought process. Women along with their providers often conclude, you know what, let's just not take any chances. Let's just induce, yeah, let's just not take any chances. Let's just do a C-section. Now. Let's not take any chances, just do the GBS antibiotics, somehow we've been persuaded to believe that taking action is going to increase the likelihood of a safe outcome.

Sara Wickham
And psychologists have written about this. It's called Action Bias. And, and I've talked about this in one of my books, which is called What's Right For Me. And I mean here in in the UK, we play football, you call it soccer. And and we  know from studies that when goalkeepers are facing penalties, you know, they  can either stand still or they can dive to one side or the other. And Researchers looked at data to see well, what is the best thing to do? What is what should you do if you want to have the highest chance of saving a goal? And the answer is to stand still, if you analyze lots of penalties like hundreds and 1000s of penalties, goalkeepers are more likely to save the ball if they stand still, but you'll never see them standing still. And that's because of action bias because nobody wants to be the first to stand still. And, and this is a really important thing. And this happens in maternity care as well. People do not get kind of told off or mocked or ostracized or prosecuted for doing something they did; all those things happen where people don't do something. But if you take action, whatever it is, whether that's diving, save a penalty or doing some very and recommending induction, you can say well, I did everything I could. And we live in this culture where there is this massive focus on doing

Trisha Ludwig
in the US. Absolutely. surgeons are actually told and taught that they will never be sued for the Cesarean that they perform. Yeah, they will only be sued for the cesarean. They don't perform, that

Cynthia Overgard
They might be sued, they're more likely to have an adverse outcome, but they're not going to lose in court. Because their defense is, I had a concern, they can provide all the rhetoric leading up to their action. I had a concern, I didn't like what I saw. And that action bias is an interesting term. The same is true in the financial markets, you know, if you buy stocks or mutual funds and hold them for decades, invariably the index funds do better than the professionally managed funds where people are thinking and taking action, because they're being paid to take action, they start taking too many actions, and they're getting lower, lower returns than in in a stock market index fund. What about that impact? Emotionally, they'll because I'm so used to seeing that when women finish my class or any, I think any really great childbirth class experience, they're like, they're feeling so good. They're feeling so trusting, they're feeling so close to their partners, it's so connected to the baby, and so ready to give birth. And so often those women have called me two, three months later, as they're approaching their due dates. And they fear that they've somehow erased all the good work they did, because their providers are really messing with them psychologically, we never seem to take that into account. That's monumental. It and it affects the outcome of the birth, irrespective of the decisions whether she does induce even if she does, even if she declines induction, after the recommendation of her provider, that will keep her awake at night, wondering if she did it because of her ego, or because she's being reckless. And that's all. That's all it takes. So then she brings that into her birth, that appear that stress.

Sara Wickham
Absolutely. I mean, one of the the very first chapter I wrote when I when I wrote in your own time, which was actually the second book I wrote about induction, because I'd written about what happens, I'd written a book called inducing labor making informed decisions. And that was all about what is the process? What are the pros and cons for different indications and, and yet, I done all this work and saying, and I was like, We need a book that looks at the bigger picture. And the very first chapter I wrote in that book was called the advantages of spontaneous labor. Because we are always being told about the risks of waiting and the benefits of induction. But we're not hearing well, what are the advantages of spontaneous labor, there are enough that I filled a whole chapter on them. And, and I think that that emphasis is really important, as you say, because this is you, but you've given us a really good example of the emotional impact of risk on, you know, on on how people feel. And and of course, the irony is, the huge irony is that in late pregnancy, that worrying and anxiety kind of inhibits you from feeling relaxed, and letting all the hormones flow that are going to, you know, start labor.

Trisha Ludwig
And you're entering the process already in a fear based somewhat fear based mindset, because you just have now you just have this creeping doubt that you questioned the professional, you question that the person that you're supposed to trust? Yeah. But your intuition is speaking to you and telling you differently. And so now you're in this you know, split mindset, cognitive dissonance, and that's difficult.

Sara Wickham
Yeah. And that's, that's, again, that that is exactly the kind of the point I'm trying to make is that there, there is this huge emotional impact of the focus on risk, but it's not getting talked about enough.

Trisha Ludwig
So Sarah, we would love to have you answer a couple of questions that our community wrote in. And because induction is such a growing issue in the birth culture. I think the number one question that every woman really wants to know, is, what should she do? If she reaches 40 weeks, and she hasn't gone into labor? What What? What is the problem with going past 40 weeks in pregnancy, specifically, this woman was asking about a second pregnancy.

Sara Wickham
Okay, well, I mean, my my answer would be that that actually, many if not most women will go near or past 40 weeks, if we don't intervene. And just to remind everyone that that term is arranged, it's not we've become really focused as a culture on this due date. But actually, only 5% of women will go into labor on their due date. And so we've become over focused it's, it's a range and, and, yes, there is a slight increase in stillbirth rates at the end of the period that we caught him, but we've already addressed how you know the it's really important to look at the absolute data on that and not just go oh, you know, look at the relative risk, because the thing is, and this is there's, there's actually a load of information on this on my website, because I'm obviously gonna have to give you a short answer. I've got a whole information hub about induction. And can I shall I give the address of that? It's Yes, please, Sara wickham.com. And there's no h en Sara, Sara comm.com/induction. And I've got about 25 blog posts on there. And there's links to the books as well. But when it comes to it, actually, when it comes to induction for so called, post dates, or post term, the increase in stillbirth, it comes later than people think when you look at the data, the increase is lower than people think. There is still again, we covered this earlier, but I'm gonna say it again, because I think it's important, there is still a really, really, really, really high chance that your baby is going to be alive and well and happy, and there's going to be no problem at all. And also, what's also really important is that the evidence on whether or not induction actually makes a difference isn't clear cut for all the reasons that we've talked about in the podcast. So my answer is to what would I recommend? I would say, Go and have a look at the evidence Go in, go in, look at the evidence and and look at that within your context and how you feel you know, and take your own intuition how you feel about your pregnancy. Are you confident about your dates? Have your dates been changed to dates that you're not comfortable with? What happens in your family? You know, there's all sorts of things it's so important to become informed and look at the wider issues and then make the decision that's right for you.

Trisha Ludwig
One other question that we received, and we see through our community we see this happening so often is that women are being women are being encouraged to be induced because they're told that they have preeclampsia. And they may be told they have preeclampsia because they have an elevated high blood pressure. So this question says, What is your opinion on induction for suspected preeclampsia with no symptoms other than protein in the urine? Or maybe just an elevated high blood pressure?

Sara Wickham
Okay, well, I don't know what you do in the US. And I don't know what ACOG says. But what I can tell you is that in the UK, PCR, which is protein creatinine ratio, that is the diagnostic standard for preeclampsia. And what that measures is, is protein in the urine. So it's not just saying, we did a little dipstick test and you have protein in the urine. It's an it's an actual measurement that is used. And in our NICE guidelines, which are the national standard for health and social care in the UK. It says that the cutoff point that is generally used is 30. So over here in the UK, that would be the cutoff point. And I there's always a little bit of flexibility given the the individual picture and, and to be honest, that's something that you'd want to discuss with an obstetrician because, you know, that's their expertise. But generally, my understanding in the UK and I'm not currently hospital midwife is that if you have a PCR of over 30, you would usually be offered induction within the next 48 hours. But the nice guideline does say that if protein urea if protein in urine is the only symptom, then you know, further consideration discussion of the situation isn't unreasonable. And I mean, I think I don't want to be boring. But my answer in all of these situations is is to suggest that to women, ask your care provider questions about the evidence base for the recommendations and and see what they can come up with in terms of evidence. And then make sure that you've got adequate information about the pros and cons. But before you decide,

Trisha Ludwig
and to ask what the alternatives are, or to ask what happens if I do nothing? What if I just subsequently Yes, what happens? Yeah, yeah, that's the question we really want to know. Yeah.

Sara Wickham
And something that I also I also say to him in relation to induction generally is, if a care provider was desperately worried about your about you or your baby, they would not be recommending induction induction can sometimes take three days, I mean, perhaps less, so it's the second baby, but induction can often take a long time. And so if a care provider was deeply concerned about you or your baby, they would be offering an immediate cesarean section, not an induction so you know, I'm not downplaying preeclampsia either. But it's about getting gathering information.

Trisha Ludwig
That's a piece of advice we often give women is that you know, when you when there is an A really truly dangerous situation and pregnancy and especially in labor, will you know when that C section is being offered just sort of half heartedly Ah suggesting we should be thinking about the C section now, like, you have time, you don't have to accept that you will absolutely know with certainty when it is really problematic.

Cynthia Overgard
Yeah, well think of all the times that women are told on a Thursday, you know, you we've got to induce you has Tuesday because my calendar is booked between now and then. And the woman's like, I'm sorry, I beg your pardon, I thought you were just telling me how much danger my baby is facing. And then it's all about fitting it into their calendar. And that happens a lot. We hear a lot about that. So that's when their gut instinct tells them maybe something isn't really urgent right now.

Trisha Ludwig
And when your provider knows it, is they will make sure you know, they'll get

Cynthia Overgard
your attention. Yes, exactly.

Trisha Ludwig
So one final question from our community. Do you have any tips or suggestions on how to write a complaint to a hospital about a bad birth experience?

Sara Wickham
Okay, I think that, that I'm sure there are lots of tips out there. And I'm just going to cover one area, which is the area that I'm kind of focused on, which is about understanding the culture of birth, some of you some of my books are rooted in the idea that we, we if we can just understand better about what's going on and why things happen as they do in the hospital and the system and in the minds of obstetric li focused practitioners, we can that I think it truly helps us to understand that. So I think that if you are wanting to write a complaint, one of the first things to consider and this might this might not be what you want to hear is, bear in mind what the hospital considers the standard of care to be, we kind of touched on this actually before. Because if you are saying, you know, the I was I was told I need this this area, and I don't think I need this zerion Actually the hospital is, is may well think that you did and it might be quite hard to persuade them of that. And I think it's really key to understand a bit about where the hospital is coming from. And I'm not saying that we should not write complaints or defend it, but you can then word your complaint geared to the audience's that you are complaining to, and understanding where they come from, I think can help to focus in on that complaint. And also, I often say to women go in knowing what you want to achieve. Often, you know, women and families who want to complain, feel very emotional, and and I absolutely, you know, absolutely understand that we all do. It can sometimes be helpful to remember that the people who are going to read your letter probably didn't get their jobs by being very focused on people's feelings. That's not how you get high level jobs is not here. I don't know whether it is there, but I, I suspect it's not. And so I think it's probably important to think about that, think about who is going to get that letter, you know, focus on the facts and think about what it is that you want to achieve.

Cynthia Overgard
We are so close to women, and we do birth story processing sessions with women and maybe 10% of the time, the conversation does evolve into like, you know, this, this notion. And usually when women write a draft and share it with us, you have to imagine it landing on the least sensitive ears, from the providers perspective, where they're just going to be like, Oh, please, here's just an emotional woman complaining that this was a lot for her to handle. And really, they know, especially here in the US, they know they have the legal obligation to provide informed consent. So she doesn't need to focus on you know, nevermind, the first do no harm. They're all supposed to be following but was informed consent really not provided because it is their legal obligation to provide that and I think that's where they have to go. They have to talk where the you know, those those the legal team and the administrators are going to talk. I once contacted the president of a hospital locally because the mother refused an IV. And the doctor said that she was eight centimeters and doing beautifully when she arrived calm, beautiful, and the provider brutally pressured her into not an IV a headlock. And the woman said no in her gentle way, rather than saying I do not consent. And the doctor said, Listen, I'm telling you, if you don't put this in you right now you're gonna have to leave and give birth somewhere else. So she acquiesced, understandably, under all that pressure and she had her baby shortly after, and she called and she and her husband told me what happened. And I she said she would write a letter to the hospital at some point, but I asked her permission to call the hospital anyway, and, and lead on that I knew exactly what happened. And I knew what doctor did this. And they said, Yes. I called the hospital president and left a message of course on his assistants voicemail because that was the closest I could get to him. It's very, very well known hospital and I said, Oh, hi, this, this is who I am. And this is my job. And we have a mutual client who just gave birth there. And this is what happened. You and I both know that's unlawful. So I would just like to know if you support and condone what the doctor said, because this is very useful information for me to know about your facility, or if you don't support that, and I left a message along those lines the next day, this is a true story. It's not going to sound true, but it is a true story. The next day, one day later, the woman and her husband and baby were alone in their hospital room, that same doctor arrived in elegant clothing. She wasn't working, she was in high heels and elegant clothing and brought an elegantly dressed teenage daughter into the room with her. And the doctor went over to the woman and went down on her knees, took the woman's hands and said, I am so sorry for what I said to you yesterday about that headlock, I was totally out of line. I just hope you'll forgive me, I never should have said that to you, we never would have really kicked you out. And she literally begged her forgiveness, presumably because that President called her and said you get yourself in there right now. And fix this because a third party knows about it. And you presented a legal liability to us. So she was begging forgiveness, not because she felt she emotionally wounded and stressed that mom, because she presented a legal liability, and someone outside of that relationship knew about it already. Yeah.

Sara Wickham
I mean, it's dreadful, because what I want to say is what I actually want to do is gather up the women who have these problems and put them in a group and sit and knit and hugging and actually address what the very real aspect of their experience, which is, you know, almost totally emotional and social and all this stuff that we talked about. But, you know, the reality is that we are dealing with systems of care, which are based on entirely different principles. And, you know, and so my answer to that is, if you want to write an effective letter that may do something to change things, we need to be writing it in ways that might actually get heard and addressed on that level. I wish I could give a different answer to that.

Cynthia Overgard
Yeah, we need to speak their language, which is liability. Sarah, what's your what's your advice? I mean, all we never have quite the research we want. It's complicated. Research in itself is so complicated, because it's often they're hiding data, as you pointed out, they're manipulating conclusions. They're converting the conclusions into rhetoric, and they're running with it. They're there, their numbers are too low. They're not randomized. They're not double blind. And yet, it's all we've got. And everything is complicated. And most women aren't able or willing to do the research to the extent that you're doing it. What, what's your advice overall, in this complex system that we're all in?

Sara Wickham
I'm sort of hoping that the work that I'm doing in, in writing books creating information is, is is bridging that, you know, as you say, when there's too much research for everybody to go and do that the whole time. I mean, I, I realized a few years ago, that my midwifery colleagues, you know that they don't have the time it is very complex, looking at looking at the evidence, and because it's often the case that you need to see what the evidence says, and then explain the 25 problems with the study that you need to take into account. So my advice is to find sources of information, I would like to think that my website and books are one of them, find sources of information where you can find trusted people who have the same ideology as you and also the ability to understand the evidence, whether you know, whether, whether that is books, websites, birth educators, midwives, you know, beat people who understand and can help you to find ways to get informed. I mean, the reality these days is that we don't have enough time with care providers to actually find out everything we need to know. And I think that all women and families need to go further afield for information. I wish it wasn't the case. But it is. And part of the reason is, is because of this focus on risk and the fact that you are in contrast to how things were 20 or 30 years ago, you're going to be offered a different intervention or restriction or test at almost every term. So my advice is to do what you can to get informed surround yourself with good information and good people who are going to support you support your agency and and support you in you know, making the decisions that are right for you and your family.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.