Anxiety about labour; a self-fulfilling prophecy?
Those of our readers who have practised Obstetrics for more than two decades may recall the enthusiasm for the active management of labour that swept through the UK in the 1970s until the 1990s. This was chiefly inspired by the low caesarean section rates that were reported by the National Maternity Hospital in Dublin who used and enthusiastically disseminated the Active Management regimen at a time when caesarean section rates were rising steadily throughout the UK. The tenets of active management of labour included strict criteria for the diagnosis of labour, the use of the partogram, routine amniotomy, early use of oxytocin and a commitment to never leave a woman unattended in labour and to limit the maximum duration of labour. Some individual components of this protocol were subject to randomised study during the years of enthusiasm for this management, such as early amniotomy and use of oxytocin, and in most the studies there appeared to be little effect in reducing the caesarean section rate. It was not until the mid-1990s that an adequately controlled randomised study was reported for the Active Mangement of Labour package taken as a whole (Frigoletto et al. N Engl J Med 1995;333:745–50). This study did not show a reduced caesarean section rate, although labour was shorter and maternal fever was less common. Subsequent studies have largely confirmed these findings.
One component of the situation at the National Maternity Hospital in the 1960s and 1970s, that in retrospect does seem very important, is the use of one-to-one care in labour. The compelling evidence for the effectiveness of Doulas (a nonmedical person who assists a woman before, during, or after childbirth) in reducing the caesarean section rate (Hodnett et al. Cochrane Database Syst Rev 2007:11 Feb 16;(2):CD003766) and the suggested benefits of case-load midwifery care, where a small team of midwives cares for pregnant women, supports the idea that reducing anxiety in labour will improve progress in labour and reduce complications. There is also a long trail of evidence that women with greater anxiety before labour are more likely to experience labour complications. Studies dating back to the 1960s using standardised assessment of anxiety such as the Manifest Anxiety Scale, the State-Trait Anxiety Scale, and more recently the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), have shown either longer or more complicated births in women with increased anxiety, or no effect. Studies conducted on women in the 1920s, with very questionable ethics, demonstrated that parenteral adrenalin will halt labour, as well as lead to fetal death (Bourne A J Obstet Gynaecol Br Emp 1927;34:249–72).
On page 1238, Adams et al. report the results of their study on the effects of fear of childbirth on duration of labour in 2206 pregnant women with a singleton pregnancy. Fear of childbirth (W-DEQ sum score ≥85) was present in 7.5% of women and, in these women labour was 47 minutes longer than in women without fear of labour (after adjustment for factors that could affect length of labour). The rates of instrumental delivery and caesarean section were higher in women with fear of labour (17.0% versus 10.6% and 10.9% versus 6.8%, respectively) although these differences did not reach statistical significance. The analysis adjusted for parity, counselling for pregnancy concern, labour induction, labour augmentation, emergency caesarean section, instrumental vaginal delivery, offspring birthweight and maternal age at delivery. There was no adjustment in this study for the nature of the support for the labouring women or at the time of birth. The ‘Doula effect’ suggests that the nature and behaviour of the people present during labour may have an important impact on birth outcome, and this may either increase or reduce the prelabour effects of fear of childbirth.
To be mischievous for a moment, the rise in caesarean section rate in the UK not only coincided with a great increase in hospital births, but also an increase in the insistence that partners should be present at the birth of their children. Not all partners are able to provide the support that they wish they could, and I am not alone in thinking that some partners may effectively be ‘anti-doulas’ (Michael Odent, personal communication, 2007). I confess that, despite my best intentions, I think I fell into that category during my wife’s first labour.
Alcohol in pregnancy. To err is human; to forgive, divine
The controversy about the effects of alcohol consumption on the offspring of women who drink in pregnancy has continued for decades. This debate is reflected by the differences in advice that different national bodies across the world give about drinking in pregnancy. The National Institute for Health and Clinical Excellence (NICE) in the UK advises ‘avoiding drinking alcohol in the first 3 months of pregnancy if possible’ because of a possible increased risk of miscarriage, and that ‘if women choose to drink alcohol during pregnancy they should be advised to drink no more than one to two UK units once or twice a week’ as ‘at this low level there is no evidence of harm to the unborn baby’ and that ‘getting drunk or binge drinking during pregnancy (defined as more than five standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby’. In contrast, the current advice from the Surgeon General in the USA is that ‘alcohol consumed during pregnancy increases the risk of alcohol-related birth defects, including growth deficiencies, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development’ and that ‘No amount of alcohol consumption can be considered safe during pregnancy. Alcohol can damage a fetus at any stage of pregnancy’ and further, ‘The cognitive deficits and behavioral problems resulting from prenatal alcohol exposure are lifelong’. The National Health and Medical Research Council of Australia in 2009 stated that ‘a “no-effect” level has not been established, and limitations in the available evidence make it impossible to set a “safe” or “no-risk” drinking level for women to avoid harm to their unborn children, although the risks to the fetus from low-level drinking (such as one or two drinks per week) during pregnancy are likely to be low’ and concluded ‘for women who are pregnant or planning a pregnancy, not drinking is the safest option’, but that ‘the risk of harm to the fetus is likely to be low if a woman has consumed only small amounts of alcohol before she knew she was pregnant or during pregnancy’. The World Health Organization (WHO) Framework for Alcohol Consumption in the WHO European Region (2006) states that ‘Alcohol … can cause problems during pregnancy and can also harm the fetus. It is not known whether or not there is any safe level of alcohol consumption during pregnancy. Nor is it certain if any particular stage of pregnancy is the most vulnerable to the effects of drinking. In the absence of demonstrated safe limits, abstinence from alcohol during pregnancy is recommended and should be encouraged.’ An extensive WHO guideline on substance abuse in pregnancy is scheduled for completion in early 2014.
This edition of the journal contains five articles (page 1180–1231) from the same study about the effects of drinking alcohol in pregnancy on intelligence, attention and executive function in the offspring at 5 years using data from the Danish National Birth Cohort. We have also commissioned a commentary from Sulik et al. on page 1159, which briefly comments on these studies and considers the neurobiological effects of alcohol. The reader may feel that five studies on one subject from one group in one edition is a bit much, but this arrangement resulted from extensive debate within the editorial team which lasted several months. At the outset seven papers were submitted and five editors dealt with these papers. It was decided to send each paper to different pairs of referees so each could be judged on its own merits. Following their overwhelmingly positive opinions, an amalgamation of papers was recommended at an Editors’ face-to-face meeting and agreed by the authors. All of this was accompanied by extensive statistical refereeing. We think that the upshot of our deliberations are five interesting papers, each of which adds useful data to specific aspects of the debate about alcohol use in pregnancy.
What about the papers themselves? The data are from a follow-up study of 1628 women and their children sampled from the Danish National Birth Cohort. Maternal alcohol consumption was assessed in detail by telephone interview during which women were asked about the average number of beers, glasses of wine and glasses of spirits they currently consumed during a week, and the number of weekly drinks was calculated, one standard drink being equal to 12 g pure alcohol. Information on binge drinking (defined as intake of five or more drinks on a single occasion) during pregnancy included data on the number of binge episodes and the gestational week of each episode. Low drinking was defined as one to four drinks per week and moderate drinking was defined as five to eight drinks per week. For the early pregnancy interview the median week of gestation of the interview was 17 weeks (range 7–39 weeks).
The offspring were assessed at 5 years using standardised well-validated tests performed by ten trained psychologists blinded to child exposure status. Intelligence was assessed using six subtests from the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), attention was tested using the Everyday Attention for Children at Five (TEACh-5), and executive function by the Behavior Rating Inventory of Executive Functions (BRIEF). The BRIEF is a questionnaire for parents and preschool/school teachers assessing behaviours indicative of executive function in the home and day-care environment. All results were adjusted for core confounders, which included parental education, maternal IQ, prenatal maternal smoking, the child’s age and sex, and the tester.
What were the effects of binge drinking? There were no systematic or significant differences in general intelligence between children of mothers reporting binge drinking and children of mothers with no binge episodes, except that binge drinking in gestational weeks 1–2 significantly reduced the risk of low, full-scale IQ (OR = 0.54; 95% CI 0.31–0.96) when adjusted for core confounders. Binge drinking at 9 weeks of gestation or later was significantly associated with elevated scores in two components of the BRIEF questionnaire, the Behavioral Regulation Index parent scores (2.04, 95% CI 0.33–3.76) and the Metacognitive teacher index (OR 2.06, 95% CI 1.01–4.23), but as these were only two components of the BRIEF questionnaire the authors concluded that ‘only weak and no consistent associations between maternal binge drinking and executive functions were observed’.
What was the effect of low to moderate drinking in early pregnancy on behaviour or intelligence at 5 years? No statistically significant differences were found in BRIEF test or WPPSI-R scores comparing abstainers and low to moderate drinkers. For women reporting nine or more drinks/week (20 women only) no differences were observed for mean IQ score differences. However two of three of the components of the IQ test were lower in the offspring of these heavier drinkers, the Full Scale IQ (OR 4.6; 95% CI 1.2–18.2) and the Verbal IQ (OR 5.9; 95% CI 1.4–24.9) tests.
A final global analysis of all the data (page 1180) used a multivariate analysis of all neurodevelopmental outcomes; intelligence, attention and executive function. Understandably this final set of data had a number of missing values in each outcome variable, ranging from 0.5% for FSIQ to 15.3% for TEACh-5. This global analysis showed no statistically significant effects on any neurodevelopmental measure of average weekly alcohol consumption or any binge drinking, individually or in combination, essentially replicating the findings from the separate analyses.
Will this study lead to changes in the current advice concerning alcohol use in pregnancy? As no safe level of drinking during pregnancy has been established, the conservative advice for women not to drink alcohol during pregnancy is likely to remain in place. However, the data presented extensively in this issue suggest that small amounts of alcohol consumed occasionally may not present serious concern. To err is human; to forgive, divine.