Monday, 29 December 2014

7 Reasons Why Giving Birth In A Stable Definitely ISN'T Better Than A Hospital

How did Mary and Joseph know that baby Jesus was 7lb 6oz?
They had a weigh in a manger.

Boom-tish (and thanks to the NHS Epsom and St Helier twitter feed for that cracker standard joke)

I saw a link yesterday to THIS Article by homebirth advocate Milli Hill which claims that Mary was probably better off giving birth in a stable 2000 years ago than she would be in a modern obstetric unit.

I was er, a little surprised, and assumed it was a joke.

It wasn't a joke.

I could now do a big ol' post about the likely levels of maternal and infant mortality 2000 years ago, the high risk of obstetric fistula that would have been faced by a very young woman giving birth for the first time etc. etc. But Hill seems to have skimmed over that part, after all the most important thing when talking about birth is to say nothing that is in any way worrying to the poor little ladies. lest we cause The Fear. (It's perfectly ok to make hospitals sound utterly terrifying though BTW). So lets not worry about little things like death and permanent injury. Here are my other seven reasons why giving birth in a stable would have been sh*t.

1 The Sh*t Hygiene
Hill contends that hygiene is one reason why giving birth in a stable is better than being in a hospital (honestly, I'm not making this up). Because er, kids who have pets may be healthier and kids born vaginally at home might have different microbiomes (friendly gut bacteria) to those born in hospital. I've blogged about microbiomes before, it's a very interesting field but poor Mary is closer to securing a room at the Bethlehem Hilton Spa hotel than we are to understanding enough about the microbiome to base important decisions on it. Besides, even if there were proven microbial benefits to a vaginal home birth in a 21st century semi-detached, I'm not really sure how that equates to it being a good idea for a vulnerable newborn to enter the world surrounded by dung?

2-Birth Attendants.
There were no midwives in the school nativity play. Hill therefore assumes that Mary was attended by a skilled and caring local woman plus her team of Doulas. All of whom would remain awake, sober and competent for however long it took for the wee son of God to make his entrance (thus avoiding the horror of, gasp, a shift change). Maybe, I hope so for Mary's sake as the other explanation is that there were no skilled attendants, just livestock and Joseph. So basically poor Mary had to accept that the first time her intended future life partner would get a look at her virgin lady-bits, they would be pushing out the head of another man's child.

3-No Bed
We know that Jesus was laid in a manger in swaddling clothes, thus contravening any number of modern health and safety recommendations. But at least he got somewhere to sleep. Hill sees the lack of a bed for Mary as a good thing, encouraging (well basically forcing) her to keep moving in labour. Ok, movement in labour helps a lot of women but what about afterwards? After a straight forward hospital birth many women are now home within hours but Mary was in that cow shed for days. Labour is tiring, so it breastfeeding a newborn. Surely the poor woman deserved more than a hay bale smelling of goats? On which subject...

4-Clearing up the mess
Birth is a messy process, there will be blood and most likely poo and vomit too. At least in a hospital birthing room the bodily products are likely to only be from the mother, or a member of the same species at any rate. They also tend to get cleared away pretty sharpish by the staff. There are no staff in the stable. I can't imagine that the nausea many women experience in labour would be eased by watching a goat chow down on your freshly produced afterbirth.

5-Visiting hours
Postnatal ward visiting hours can be very problematic, especially if partners are kicked out but the stable sounds like a total free for all! First there was the huge gang of blokes in dresses, singing and blaring trumpets right over where poor Mary was trying to get some kip on the aforementioned goat stinky hay bale. Then some random local agricultural workers arrived for a good stare. Oh but at least they brought a lamb, because obviously if you are in a cattle shed the thing you most need is more bloody livestock. Finally, just when things seemed to be calming down a bit, three dodgy looking old men turned up, and banged on about how very wise they are before giving the baby some funeral incense. Hardly a relaxing environment to bond with one's new born deity. When I had my babies my family brought me Brie sandwiches and tons of fudge. Those are wise gifts, Myrrh? Not so much.

6- No Modern Medicine
For Hill this is another good thing about the stable, there is no modern medicine, no machines, no pain relief, and nothing to speed up a long labour. All of which works wonderfully for a lot of women who choose that route but Mary had no choice. Some mothers want pain relief, some feel more relaxed knowing medical backup is close at hand and some decide they want it all over and done with as quickly as possible. There is nothing wrong with any of that.

Yes, this post is intended to be a bit tongue in cheek, but to be serious for a moment Hill's article annoyed me. I support home birth. I absolutely support the move away from the doctor knows best, lie on your back and do as you're told, childbirth of the past. But that doesn't make it OK to spread fear about hospital birth unless you have rock solid evidence and Hill doesn't. There are many problems with hospital birth, but to suggest that you would be better off 2000 years ago in a shed full of livestock than in a modern western hospital is plain inaccurate and and does a huge disservice to the many women who want or need to give birth in a hospital. Their fears are every bit as real and their choices every bit as valid as those for whom home birth is the best option. To propagate excessive fear of hospital birth does absolutely  nothing to further the goal of genuine informed choice for everyone. At the risk of sounding like a broken record, there is no one right way to give birth.

7- The Smell
Sure hospitals can have a certain whiff about them that isn't all that nice, but personally, I'd prefer that to the stable which most likely reeks of Bull Sh*t.


Wednesday, 10 December 2014

Breastfeeding: Not Glorious, Not Grotesque, Just Ordinary

So, inevitably, as soon as the media have finished telling us all how to give birth it's time to start instructing us on how to feed those born as they should be babies.

There were two main stories in the news this week about breastfeeding and a third which touched on it so, as this is my blog, I'll be starting with the sciency one:

On first look it's tempting to assign this to the yet more breast is best propaganda pile, but the study is actually quite interesting. One thing the headlines don't make clear is that the study doesn't call for more women to breastfeed, but for more support to help those who want to to do it for longer. And while the cost savings headlined are just estimates, what's interesting to me is that they are based on all the factors proven to be effected by breastfeeding in the UK. These are - certain infections in young babies, breast cancer risk for mothers and  - and that's it.

Contrary to all manner of claims, there is no good evidence that breastfeeding increases IQ, reduces obesity or improves social skills*. True, there have been individual studies which suggested all these things and got many column inches in response but they all suffered from one major flaw: Overwhelmingly in the UK women who breastfeed are well educated and well off (hence the recent dubious voucher scheme) so these studies aren't just comparing breast v formula fed babies, they are comparing rich v poor. Was it the breastfeeding that made the difference? It's possible, but it could also be the better diet, reduced smoking, better housing, less stress, etc. etc. etc. Basically, if you are born relatively privileged in this country then you will most likely do better than your poorer peers, however you are fed as an infant.

Before I go on I want to be quite clear - I'm not anti breastfeeding, far from it. I near as damn it exclusively breast fed both my girls for at least 14 months each. At times it was exhausting and excruciating but ultimately I'm very glad I did it. Even if all the health benefits were removed it is still cheaper than formula, less faff than sterilising bottles and you can't forget to take a boob with you when you go out for the day. I absolutely agree that there should be more, better and more consistent support for mothers who want to breastfeed. But I also think that support needs a reality check sometimes. If trying to breastfeed is placing a huge strain on a mothers physical or mental health then there are times when it is better for everyone, especially the baby, to say that bottle would be best.

This last point came to mind last week with the tragic story of a Mother in Bristol who walked out of hospital one night with her newborn baby, both were found dead the following day. The press suggested that she had stopped taking medication for mental health conditions so that she could breastfeed. I have no idea if that is true, whatever happened it's a heartbreaking story and the causes were no doubt complex, I really don't want to speculate further than that. But as the news came out that day a number of people on twitter began to relate their own experiences of being advised or coerced into stopping important medication so they could breastfeed. Sometimes with terrible long lasting effects for their whole families. The self-abnegating mother, sacrificing her own health for that of her child is a nice romantic story, but in reality the health of the mother is utterly interwoven with that of the child and when all we're talking about is the potential for a few less infections for a few months, in a country where we have access to antibiotics and top quality medical care, sometimes, breastfeeding just isn't worth it.

So we have a tricky balance to make. How do we encourage those who want to breastfeed without stigmatising those who don't or can't? Well perhaps we could start by normalising breastfeeding, by just making it completely and utterly ordinary.

And that brings us nicely to the whole  Claridges-Napkin-Farage-#Ostentatiousbreastfeeding media opinion-fest.

For the benefit of my non-UK readers, Claridges is a very swanky hotel. Recently a woman breastfeeding her small baby in the restaurant was told to cover up with a large napkin. She posted photos on twitter, people got cross. Then the ever hideous politician Nigel Farrage, weighed in to criticise "ostentatious breastfeeding" and suggest feeding mothers should sit in the corner because some older people found the sight of them uncomfortable. And lo was born a very amusing #hashtag.

Frankly, in my little corner of South London, you are more likely to get a dirty look if you are caught bottle feeding a baby, and at least one local friend was praised by an elderly woman for public breastfeeding, something the woman wished she could have done when a young mother herself. But I appreciate that the sight of a breastfeeding mum is a bit uncomfortable for some people. But why? 

This uneasiness isn't the result of some natural aversion to an unsanitary act. In an stroke of stunning hypocrisy the Sun newspaper actually likened public breastfeeding to urination on it's front page (UK readers will be well aware of what is on page three**). But the only reason we feel unnerved by breastfeeding is because it's not a common sight. In our culture, breasts are purely sexual objects, and as such decent people shouldn't get involved with them, at least not in public. But this is our own invention. The day after MissE was born I shuffled along to the obligatory breastfeeding workshop, taught by a wonderfully frank, loud and hilarious African midwife who told us all:

 "You women here are all afraid to get your breasts out because you think it's all sexy! But you all walk around in your short short skirts with your asses hanging out! Your breasts are for your babies, not for the men! Put your asses away and get your breasts out!". 

Seriously, she was the only good thing about that hospital stay.

She was also completely right (well maybe not about the skirts). If some people feel uncomfortable at the sight of a woman breastfeeding then I am sorry for that, but the best way to cure that sexy-lady-things-feeding-baby-AHHH cognitive dissonance isn't to hide breastfeeding, it's to normalise it, to make it ordinary. People used to freak out at the sight of woman in trousers or a tiny flash of ankle, even UKIP are probably ok with that now, because we see it every single day, it's not special and it's not shocking.

The bottom line (covered by a nice long skirt for the benefit of that midwife) is that there are benefits to breastfeeding, but in the context of a developed nation they aren't huge. If women want to breastfeed then it's worth the NHS investing in helping them but it's also important that women know it's not that big a deal. It's lovely for the individual mum and baby, for the rest of society - meh. The problem is it will always be a big deal when any hint of a breast being used for something non-sexual is splashed across the press and open season for idiot commentators (I'm aware I'm perhaps putting myself in that category right now). It will also continue to be a big deal if we go on haranguing mothers with piles of unproven claims about the wonders of breastmilk and holding it up as some magical, perfect act of motherhood. If only women could breastfeed in public without comment, and do the same with bottles, if only it was just as ordinary as changing a nappy or giving your toddler a hug when they fall over, then perhaps we could stop damning women whatever they do. Breastfeeding is neither glorious nor grotesque, it's an ordinary everyday thing, or at least it should be.


*The other often quoted benefit of breastfeeding is that it aids bonding of mother and baby. I've not included this as I've never seen any research either way on it. If anyone has some please let me know. Personally I'm doubtful that the mother-baby relationship really suffers because of bottles. I also have to admit, when breastfeeding I rarely spent all those hours staring in dewy eyed adoration at my babies. With a good arrangement of cushions or a sling, breastfeeding is almost hands free, so I was generally on twitter/facebook and/or watching boxsets of Downton Abbey. Not terribly bondy but it got me through the utter tedium of it all. It was the times I used a bottle that I actually concentrated, that seems to require about 3 hands!

** For the benefit of non-UK readers the Sun is a national newspaper which has a daily, topless," page three girl".

Wednesday, 3 December 2014

Home Birth, Hospital Birth and Not So NICE Advice

I've written previously here and here about the draft guidance from NICE on where women should give birth, but (as you'll have noticed if you were anywhere near UK media this morning) the final version is now out. The headlines mostly read something like this (From the Mirror):

Mums-To-Be Warned "Have Your Baby At Home, It's Safer" By Health Chiefs

An awful lot has been written on this subject today but, having looked at much of it and at what the new guidelines actually say I think there is a fair bit of confusion and a lot that annoys me too. What follow is long, be warned, but I hope it will clarify things for people or at least vent my frustrations. (Also fyi, it's not as well checked over as normal because I also have a sad, snotty two year old on my arm).

The Confusing Stuff

It's not all Mums
Firstly, this advice doesn't apply to all Mums-to-be. It is solely for low risk mothers who have already had at least one baby. The guidance also covers low risk first time mums but it does not say that home birth is safer than hospital for this group as there is a slight increase in risk to the baby with home birth. I'll be coming back to this.

The Meaning of "Safer"
What do you think of when you hear that word related to child birth? Is a safer birth one where mother and baby are less likely to die or suffer lasting harm? Well yes but these reports also consider a birth safer if there are no interventions such as emergency caesareans, forceps deliveries (so far so sensible) and epidural pain relief. I'll be coming back to this too.

There is no, single "right" place to give birth
Crucially, the NICE guidance itself doesn't actually say that there is a single best option for where women should give birth. Here's what it actually says midwives and doctors should do:

  • Explain to both multiparous and first-time mothers that they may choose any birth setting (home, FMU, AMU or hospital obstetric unit), and support them in their choice of setting wherever they choose to give birth.

This is the first point in the "Key Priorities" section of the document, and it doesn't say "tell all women to have home births" it says, tell those who are low risk that they have choices, then respect those choices.

Here's my fantasy headline:

NHS Told "Women are Intelligent Individuals, Facilitate Their Informed Decision" By Health Chiefs

Well, I can dream.

The stuff I'm coming back to

To be clear, I am not against home birth. I am certainly not against birth in a midwife led unit - it's what I chose myself first time around. The thing that is bugging me is the headlines which suggest there is one, best, safest, correct way to give birth. I just don't believe that. No two women are the same, our, bodies, minds, life experiences and social situations make each and every birth utterly unique. 

What about the "other" women?
The fact that this guidance doesn't apply to all mums anyway is very important and it's something the media has pretty much overlooked. What about all those women who aren't low risk? Who are told that for them, the best/safest/correct way to give birth isn't an option, they have to be in the dangerous hospital with it's terrifying interventions. Firstly, these stories only add to the fear and stress of those whose situations are the most difficult to start with. Then, after the birth there is the lingering guilt that many feel for having failed to give birth properly. For more on this see this post over at Headspace Perspective

My safe or your safe?
The recommendations published today are based mostly on the Birth Place Study, which I covered in  (much) more detail here. It looks at how likely it is a baby will suffer one of a list of adverse outcomes and how often women have a range of interventions but (as I say in the post) how you interpret that risk is a very personal matter. What is more worrying a very small chance of something dreadful happening to the baby at home or a greater chance of having to endure interventions in hospital? There is no right or wrong answer to that. It's a personal, individual choice.

One thing that really bugs me is the inclusion of epidurals in the intervention list. While I doubt that anyone would want a forceps delivery or an episiotomy, there are perfectly good, intelligent, valid, reasons for choosing an epidural, - it's the best way to make the very hurty thing stop hurting being the main one and the risks are very low. So I don't think having one should be a measure of a bad or unsafe birth. 

The Stuff That Just Makes Me Cross

In a home birth no one can hear you scream give you an epidural
This is a real biggy for me and I say this as someone who didn't want an epidural and, were I magically a low risk pregnant mum again, still wouldn't want one: 

There is nothing wrong with wanting pain relief in labour.

You can't have an epidural at home or in a midwife led unit. If you plan to have one in advance then your only choice on place of birth is an obstetric unit. Women need to be made aware of this.

Transfer Rates
Something else that very few of the media reports mention is the transfer rates. The Birth Place study grouped women according to where they planned to give birth, not where the birth actually happened in the end. For first time Mums, a whopping 45% of those who planned a home birth ended up in hospital (It's only 12% for those who've done it all before). Again, it is vital that Mums have this information and are realistic about the possibility of a transfer. How would that feel? - Is it worse to be surrounded by the trappings of medical birth all along or to be bundled into an ambulance in the full throws of labour? No right answer, personal choice.

Why Are there more interventions in hospital anyway?
There is no clear answer to this, it's generally supposed that women are more relaxed at home or in a midwife only unit and that this helps labour progress better, though the evidence for that is sketchy. and of course some women find it reassuring to have modern medicine on hand. Another possibility is that doctors are overly keen on interventions, they see the rare cases that go bad and so over medicalise everyone to avoid them (and the ensuing law suits). I suspect it's also likely that most women having home births (only 2% of UK births) are very committed to it. So they are less likely to agree to eg. a drip to speed up labour if it comes with an unplanned ride to the hospital and the abandonment of all their carefully worked out plans. If many more low risk mums started out at home, would it always be the same story?

It's probably a combinatinon of many reasons, but whatever it is we should be finding out and doing something about it. Simply telling women to give up and go home is fine for some but it does nothing to improve care for the many women who want or need to be in an obstetric unit.

The Care Factor
Where I live there is already a two tier system for midwife care. If you are lucky enough to be in a certain area, be low risk, planning a home birth and well enough informed to contact them early, then you can have a caseload midwife. She will look after you throughout pregnancy birth and the postnatal period. She'll come to your home for some of your appointments and take time to get to know you. She'll also ensure that you have chance to meet the other members of her small team in case they are on call when you go into labour. If you aren't so lucky you may see a different person every time for rushed appointments and give birth with complete strangers then be looked after by whoever turns up, if they turn up. Why shouldn't women going to hospital have this standard of care too? It's probably one of the reasons why there are fewer interventions at home - women are supported. You shouldn't have to choose between an epidural or good care.

Midwife Units
The media and admittedly me too, keep talking about this as home v hospital, but what the NICE press release actually says is that Midwife led units are safest for straightforward births. They offer both the low risk to the baby that comes with hospital birth and the reduced intervention rate of home birth, so why aren't we cheering these on more?

Well for one thing,  not everyone has access to one and when there is so little money about do NICE really think NHS trusts will put in the massive capital outlay to build them? 

 Women's bodies

But what's the other reason why the media aren't talking about midwife units? It's because no one is all that passionate about them. Women choosing them aren't  ****ing hippies risking their babies for bragging rights about their orgasmic home births. They aren't cold, too posh to push bitches, so removed from what is right and natural for a mother that they have their poor babies surgically removed at a convenient time. They aren't even the terrified masses, strapped to a bed by an unfeeling doctor because they watched Eastenders too many times and were afraid to be anywhere other than hospital. In short (which will be a first for this post) they are women making reasonable, informed decisions about their own bodies* not caricatures to be judged and vilified, and for some reason, that is something our society and the media that reflects and feeds it, still struggles with. 

I'm going to shut up soon, I promise.
What the NICE guidelines actually say is that low risk women should have a choice of home, hospital or midwife unit. They should be informed of the pros and cons of each choice and they should be supported, whatever their decision. Well done NICE, now can the rest of the country catch up please?


*as indeed are the vast majority of women who choose, home, hospital or even C sections!

Thursday, 20 November 2014

Paying Women To Breast Feed - Update And Early Results

I wrote last year about a new study that aimed to see if mothers in deprived areas could be encouraged to breastfeed by giving them shopping vouchers if they did. I promised to report back when the results emerged and a few are to be presented soon at a scientific meeting organised by the medical journal The Lancet. So here we go...

It's worth saying that presenting something at a meeting isn't the same as publishing it in a scientific journal. So none of this has yet gone through the process of peer review where other scientists in the field look at the work and check it's been done well.

Plus, I'm not that impressed.

Of the 108 women eligible to join the program 58 signed up and at the third check point, when their babies were 6-8 weeks old, 37 were still breastfeeding. This works out to 34% of those eligible, which is better than the 21-29% which is normal for area the women live in.

But - oh, there are a whole lot of buts in this story:

Firstly, women were considered to be breastfeeding if they and a medical professional signed a form to say they were. Presumably said professional didn't trail these women 24/7 so they can't be sure how much the baby is actually breastfed - exclusively? half the time? only when a health professional is in front of them with a form? How is the result actually defined? The Mum is of course incentivised to say she is breastfeeding and not only to get the voucher. She may not want to admit to having "failed" at breastfeeding or may even be concerned about letting the researchers down. Similarly, health professionals may be inclined to give a woman the benefit of the doubt so she doesn't miss out on the vouchers.

But the big question in my mind is - if breast feeding has increased - how do we know it's the vouchers that did it? One of the participants is quoted by the BBC news as saying she gained a lot of confidence and made friends by being part of the program. In the video interview in the piece the same participant talks about how encouraging it was to receive a letter, praising her for continuing to breastfeed. It seems reasonable to assume that the women in the study were getting time with health care professionals to talk about breast feeding and get help (as those professionals had to sign the forms for the vouchers). So in addition to some gift vouchers, the women were gaining encouragement, praise, friends, a support network and professional advice. I know how hard it can be to breastfeed and how damn near impossible it can be to get consistent professional help if there are problems. I also know the huge value of having friends with babies the same age and the peer pressure to continue breastfeeding that that can also bring. There doesn't appear to have been any kind of control to rule out these other factors in this study and to me it seems screamingly obvious that they would have an effect.

Perhaps the vouchers serve the purpose of drawing women into the scheme and the help and support it offers? But we can't tell that from the data in the published abstract as it could be that all the participants intended to breast feed anyway (the one interviewed by the BBC says she did). The standard feeding rate at 6-8 weeks in the area only tells us how many women managed it for that long, not how many wanted to but gave up through lack of support.

I have Two final issues with this, firstly what effect will this have on those mothers who want to breastfeed and don't manage it? It's something often associated with a lot of guilt and can worsen post natal depression, but it's utterly unnecessary for women to be made to feel that bad about it. The benefits of breastfeeding, if you have ready access to formula, clean water and a steriliser, aren't that big. Looking at the whole population could the added burden of guilt on those failing to get the vouchers do more harm than good? (I say this as someone who exclusively breastfed both kids for over a year btw, I have nothing against breastfeeding!).

 But finally,  assuming that there are some benefits to breast feeding and that most mothers are told about these ad nauseum during pregnancy, are we really suggesting that mums in deprived areas can only be convinced to do something that will benefit their baby if they are bribed into it? You don't have to be a middle class mum with an NCT group and an expensive pram* to want the best for your child surely?

No doubt I will be returning to this at some point, it's very early data and it will be much more informative to see what is happening at the 3 and 6 month time points. Presumably there will eventually be a proper paper which may answer some of my concerns over the methods. The aim now is to do a much larger study. Hopefully this one will have a few controls - the obvious one being a group of women who get every benefit of the scheme except for the vouchers.  In the mean time I remain unconvinced.


*I say this as a middle class mum with an NCT group and an expensive pram btw, I have nothing against us either!

Monday, 17 November 2014

Good News From Grim Headlines

Today is world prematurity day and several news outlets have been covering a recent global study published in the Lancet which reveals that problems related to pre term birth are now the single biggest cause of death in the under 5's. I can imagine nothing more tragic in this world than the death of a child and prematurity is an issue that has effected several people dear to me but, believe it or not, there is actually some good news behind these grim headlines. The main news outlets have touched on this but I think it's at least worth a few paragraphs on my little blog.

Clearly there is a great need for more understanding of pre-term birth, more research is needed into why it happens, how to prevent it and how best to care for these tiniest of babies. But it's not really prematurity that I'm going to talk about, others can do that much better than me*.

If you were to read only the headlines (as many people do) you could well think that more and more babies were being born dangerously early, driven by some new and worrying factor in modern life. The media coverage even offers up suggestions for what those causes may be (more on that later). But, if you read the actual paper it seems that deaths related to pre-term birth have actually reduced over the period of the study (2000-2013) by 20-30%  The reason they are now the leading concern in infant survival is because so many other causes of death have decreased even more and this is where we can find the good news story.

In the year 2000, for every 1000 babies born alive around the world, 76 wouldn't make it to their 5th birthday, by 2013 that number was 46. It's a remarkable change in just 13 years. The biggest difference has been made by reducing cases of pneumonia, diarrhea and measles. These haven't been big killers of children in developed nations for decades, but in other parts of the world they carried on needlessly taking young lives. But humans can be be amazing sometimes and through hard work, research and frankly a fair bit of cash, we have saved literally millions of young lives. All just by making sure that more children have access to vaccination, sanitation and basic medical care. In a world where the news is so often dominated by war and brutal terrorism, here is an example of people working together, across the barriers of nationality, culture and religion to protect the most vulnerable amoungst us. Personally I think we should be bloody proud of that.

That said, we could still do more, despite these improvements the world will fail to meet the millennium development goal that aimed to reduce infant mortality, but the fact that we have come so far shows that we can have an impact, now we just need to work even harder in those areas where infectious disease is still a big killer and on the harder to tackle problems such as prematurity.

I find it very frustrating that the media often focus souly on the negatives in stories about health research. I'm going off topic for a moment here (forgive me) but Cancer is a prime example of this. More people get Cancer now than have ever done before, and as a result of this some people (understandably) think that there must be something in the modern world causing the disease. Looking at it that way, decades of research costing millions upon millions of pounds seems to have been utterly pointless. Really what is the point of it all if we can do nothing?

 Except we've done a hell of a lot.  Of course smoking and obesity etc. can cause cancer but overwhelmingly the reason more people have the condition now is because they haven't died of something else first. Dying of an infection in your 20's is a sure fire way to ensure you don't get cancer when you're 75. But (at least in developed countries) we have largely conquered the diseases that made life short and brutal for our ancestors. Clean water banished many of them and vaccination headed off others. Readily available antibiotics have turned potential killers into something just a bit annoying. This is a remarkable achievement and one our species should be proud off and draw hope from. When a polio epidemic was killing children around the world in the last century, it seemed unstoppable, but a few clever humans developed vaccines and now the disease has been wiped out in all but a handful of countries. It wasn't easy, but we did it and to my mind that gives us hope that one day we will be able to say the same about these old killers in every part of the world and about premature birth, cancer and all the other other new big killers. Perhaps I'm a bit of a hopeless romantic when it comes to the achievements of science or overly optimistic about the motivations and abilities of my species. If so, I hope I get to stay that way. Surely we can both highlight the importance of what still needs to be done and celebrate what we've achieved so far?


more on that later....

I mentioned above that some of the media coverage of this research was speculating about the reasons for an increase in pre-term birth. The UK press is concerned that we seem to fare quite badly and suggests various things that may contribute to that including the increase in average maternal age, obesity and fertility treatments that can lead to more twin and triplet pregnancies. That all seems pretty reasonable although from my reading of the stats, buried deep in the enormous appendix to this study, I'm not convinced that there actually is an increase in pre-term birth here (anyone reading this who can clarify that please comment and I'll amend the post, this isn't my field!). 

However, one suggestion on the BBC news article, which was also brought up by one of the study's authors on today's Woman's Hour, was that the rise in the number of caesareans is a factor. I'm honestly a bit perplexed by this. I really don't believe that there are lots of women in the UK demanding to have their babies delivered surgically and premature without a very good reason. I certainly can't see their NHS doctors agreeing to it! When I had an elective c section the doctors were quite strict about it not being even a day before 39 weeks (37 weeks is considered full term). Perhaps the problem is that a caesarean increases the risk of preterm labour in future pregnancies? But I don't recall being warned of this and it's not one of the risks listed on the NHS website. I'm inclined to think the link between c-sections and prematurity is utter nonsense, in which case it's really inappropriate and potentially harmful to suggest it. But then I am perhaps biased and as soon as the author used the phrase "too posh to push" on Woman's Hour, my hackles were admittedly raised. Anyway I sent a tweet to the author asking for clarification and references, if she gets back to me I'll update the blog and if anyone else can offer an insight please comment below, I'm willing to grudgingly change my mind if presented with decent evidence, that's science folks.


* For a far more personal blog about pre term birth here is Headspace Perspective written by Leigh Kendall who sadly never got to take home her beautiful boy Hugo, but who is working to improve things for other parents of premature babies.

Monday, 10 November 2014

When Is The Best Time To Have An Epidural?

Ok I'll do it for you - Shortly after conception and for the next 18 years Boom-tish

I wrote recently about a new study which disproved the idea that inducing labour increases the liklihood of a women ending up with a Caesarean section. Hot on it's heels came another publication which called into question more of the perceived wisdom about childbirth. Namely the idea that it's best to wait until labour is well advanced before having an epidural.

The Science bit:

Like the previous study this was a large systematic review looking at lots of previous work so it's pretty reliable and avoids or at least accounts for the many issues that can plague individual studies. It included 15,752 first time mums and compared those who had an epidural "early" in labour, which was defined as less than 4-5cm dilated (the exact cut off varied a little between studies), and those who had epidruals "late" (ie. they were more than 4-5cm dilated).

The Results:

The conclusions of the study are pretty clear. Having the epidural early or late in labour made no difference to the babies' Apgar scores or to the likelihood that a woman would go on to have a c-section or an instrumental delivery. It also had no effect on the length of the second (pushing) stage of labour. One area where the individual studies did vary a lot was on the overall length of labour, so the review wasn't able to make any firm conclusion about the effect of an early epidural on this. Interestingly though it seems it's not just unclear if an early epidural increases labour time, it's not impossible that it has the opposite effect. Lead researcher Dr Ban Leong Sng said:  

"We can't rule out the possibility that starting epidural pain relief earlier may lead to shorter labour, ...This is because there was a lot of variation in the results of the studies we looked at in terms of the length of the first stage of labour."

Asking around there seems to be a great deal of variability in when a woman is "allowed" an epidural. Personally, my midwife agreed as soon as I asked for one, but I had already been in labour for 24 hours at this point and, frankly, I think she needed a rest too. However, other women are told they must wait until their labour is more progressed. For some this doesn't only mean that they are left in pain for longer than they want (which is bad enough when it's so avoidable). Some end up not getting the epidural at all. I had a long wait for one as all the anesthetists were busy, but I wasn't too concerned as I still had a long way to go and starting the gas and air took the edge of. But others have told me that, having been refused an epidural, their labours then progressed rapidly and and it became impossible to find an anesthetist, and get the epidural in and working before the baby arrived. For women who had decided they wanted pain relief this can be very traumatic.

There are of course plenty of pros and cons to having an epidural at all and this study makes no comment on that. In reality most women find childbirth to be extremely painful and many will want to take that pain away. An epidural is probably the most effective way to do this. In my opinion it is neither stupid to want to experience the pain of birth nor weak to want that pain removed. It is a personal choice for each woman and one that can't be finalised in advance. What this review tells us is that, if a women has decided she definitely wants an epidural, she shouldn't feel she needs to hold out for as long as possible and she certainly shouldn't be forced or coerced into waiting because of some idea that it will be better for the baby or the birth process.

So when is the best time for a woman in labour to have an epidural? - 
Whenever she decides she wants one.

PS. Here is a link to the full Cochrane review in case anyone needs to wave it in someone else's face!

Wednesday, 1 October 2014

In Which SouthwarkBelle Says Something Nice About The NCT

The following statement may come as something of a surprise to regular readers of this blog.

Well done the NCT!

No seriously.

Last month I wrote about a new piece of research showing that inducing labour wasn't as problematic as is often made out. I included a quote from the NCT website:

Induction of labour may set off a ‘cascade of intervention’, and before you know it you may be drawn into having drips, electronic monitoring, epidurals and all the trappings of a medically complicated, high-tech birth

The website went to to suggest a variety of dubious, unproven and expensive "alternative medicine" ways to start labour.

I thought I would send the NCT a link to my post and suggest that they update their website. I've been quite critical of them but it seemed only fair to be open about that and give them the opportunity to respond. They did reply, but to be honest I wasn't holding my breath.

Now I'm not claiming any credit for what happened next, the page was very clearly out of date so the NCT  may well have been working on it anyway. Also Pseudoscience debunker in chief Ben Goldacre is speaking at the NCT conference this weekend which may have been a nudge. I tweeted him a link to my post today and got this, very encouraging response:

(although I would add that the page was current when I wrote my post so I'm at most 3 weeks out of date!)

Sure enough if you go to the NCT page now (here) the scare story buzz words are gone, no more "cascade of intervention" and no more unproven, expensive alternative remedies either.

So, genuinely, well done NCT for responding to evidence and for removing misleading information that could have been very worrying to overdue pregnant women.

There are plenty of other things I could pick fault with on the website still, but it's a good start, I'm keeping everything crossed for more of the same.

I'll even say it again,  well done NCT.


Thursday, 25 September 2014

Boob Hacking and Baby Wearing Warriors

I've got a(nother) stinking cold. On the plus side this means I can make use of the greatest of the working Mum benefits - I've called in sick and am home alone with a Lemsip! Yay! (sort of yay). I would go back to bed at this point but there are several tons of machinery and a dozen shouty builders resurfacing the road outside so instead I'm going to share two of the more curious things I've found on the internet while poorly sick.

The - Make The Breast Pump Not Suck- Hackathon:

Breast pumps suck, and not just literally. Once my babies were born I often felt that my sole purpose on Earth was to lactate. Regularly plugging myself into an uncomfortable, fiddly device that made loud Mooo Mooo noises really did nothing to stop me feeling like little more than a one woman dairy herd.

But maybe there is hope. Last weekend MIT media lab held a hackathon. Hackathons are usually intense sessions where software engineers and programmers get together to create something new or solve problems. This event took that idea and applied it to breast pumps, it also brought in designers and, most importantly, the Mums who have to use these things. They then spent 2 days working in small teams to re-invent the dreaded breast pump.

I'm guessing this is the first hackathon with a sewing machine, though perhaps not the first with fake boobs
Photo Credit - Che-Wei Wang

The winning team came up with a tool belt system that allowed for discreet hands free pumping - (apparently you could pump on your commute, can't imagine trying that on the 9.01 with my massive mooing device). It also records data about your milk which you can then track on a smart phone app. I'm not sure how much that last bit appeals to me but it could provide reassurance for women worried about milk supply or quality.

The runners up focused on imitating manual expression by building a bra containing chambers filled with warmable beads that can be gentle inflated. This also sounds like it would be a great help for Mums with mastitis and certainly better than my attempts to juggle boob, hot water bottle and pump while hideously feverish!

Never to young to start hacking (or napping)
Photo Credit - Che-Wei Wang
More info about the Hackathon and the ideas it produced can be found here. Let's hope this is the start of lots more innovation to make Mums lives easier (and less bovine).

Baby Wearing Warriors:

Baby wearing, carrying babies and young children in a sling rather than in a buggy, is increasingly popular. Devotees claim that it promotes attachment (not just physically!) and bonding between parent and child and is more natural as it's what our ancestors did and what many mothers in non-western societies still do. But what if historic baby wearing wasn't about nurturing the child at all or even just a matter of convenience? What if strapping a screaming child to your back was actually a serious military strategy?

In case you're wondering, no, this isn't serious but it did win an award at last years BAHfest - that's the Bad Ad Hoc Hypothesis festival by the way, and it made me giggle:

Right I'm off to make another Lemsip and probably a large mug of tomato soup.


Tuesday, 23 September 2014


I seem to be having some gremlins with this blog at the moment and my banner and links keep vanishing. I'm working on fixing this but in the meantime, should you need them, my contact details can be found here:

Monday, 8 September 2014

Induction - Cascade - Caesarean Section

It's well known fact of modern childbirth: Inducing labour sets off a cascade of other interventions which often lead, with grim inevitability, to an emergency C section.

But is this actually true?

update, 1/10/14 - Since writing this post the NCT have updated their information on inductions and removed the section quoted below. More on this here.

 - Firstly, hat tip here to This Blog - I'm writing my own aimed at people who probably aren't regular readers of Scientific American (confession, I'm not either) and because I have one or two opinions ...

When I went overdue with MissE I dreaded being induced. I'd heard nothing but horror stories and  according to my NCT teacher it was basically entirely awful and unnecessary. It would also completely scupper my plans for a natural birth in a midwife led unit. But at the same time I was BLOODY MASSIVE. It was August, and hot, I was desperate to meet my baby and had had quite enough of being pregnant. So I agreed to booking an induction and did everything I could think of to make that booking unnecessary*. In the event I got my wish (although I still ended up going through much of the induction procedure after 24 pointless hours of contractions... but anyway)

41 weeks. Bloody Massive

So was I right to fear the induction? It seems the answer to that is no.

A recent study has shown that being induced doesn't increase the likelihood of having a caesarean. In fact women having a single baby, who are induced at term or when overdue are slightly LESS likely to have a C section than those who hang on for nature to do her thing. They are also (again, slightly) less likely to have a baby who dies or who needs to be admitted to intensive care.

This goes against so much other information - Can we really trust this new study?

We often see piles of scientific studies that contradict each other, one minute coffee causes cancer the next it cures it etc. etc. so how reliable is this one, given that it goes so strongly against the generally accepted view?

In this case the authors of the paper didn't set up their own experiment or trial. Instead they did what is known as a meta analysis. This is important because a meta analysis is far more reliable than most of the scientific studies that make it into the media. The authors took the data from 157 different trials and did some serious number crunching. Looking not just at the results of those trials but at their weaknesses too. For example, many of the individual trials were pretty small, meaning their results are less reliable than bigger studies. By putting all this information together they are able to overcome most of the errors and biases that inevitably influence the results of individual studies. We rarely find perfect answers in anything associated with biology, but a meta analysis is about as good as it gets.

So now what?

The differences seen are fairly small, they certainly don't warrant more or earlier inductions but they do call into question the generally accepted view of induction.

Here is what the NCT, the UKs largest parenting charity says about induction on it's website:

Induction of labour may set off a ‘cascade of intervention’, and before you know it you may be drawn into having drips, electronic monitoring, epidurals and all the trappings of a medically complicated, high-tech birth. If you go two weeks past your dates, you can ask to have regular checks on the baby rather than have your labour induced.  ...

 Other methods you may want to consider are acupuncture, hypnotherapy, reflexology and shiatsu. There is no clear evidence that these methods work, but they may be worth a try.

This was written before the recent study was published, but it is a good example of the prevailing view of induction. That it is something to be avoided, even when doctors recommend it and that it's better to go with completely unproven* (actually disproven may be better) and generally quite expensive alternative remedies, rather than risk the dreaded descent into a "high-tech" birth. 

Its strong stuff and something I absolutely went along with when I was pregnant. After all, the NCT are the foremost childbirth charity in the UK. We paid a LOT of money to attend a course given by one of their most senior teachers, who told us that everything she said was evidence based. It turns out that that evidence never existed. 

I sincerely hope that the NCT will now update it's website and ensure that it's instructors are giving accurate, evidence based information to expectant parents. Of course there are plenty of people who've had a bad experience of induction and many who ended up with a C-section but the same is true of others who held out for a natural birth and plenty who went into labour at about the right time anyway. Childbirth is unpredictable with or without a medical kickstart.

Looking pretty rough after 34 hours of labour and an emergency C section - but hey at least I wasn't induced!

This is a good news story 

The result of all this is that women are now better able to make an informed decision, and I for one am all for that.  Of course there are still plenty of other reasons why an individual may or may not want to be induced (having been through much of the procedure I entirely sympathise with both sides). Ultimately it will always be a complex and individual decision and the last say must go to the mother. Always. But we can now remove from the decision the fear of that dreaded cascade into the operating theatre. It's simply a bunch of unpleasant anecdotes.

 This study also has implications for the recent advice that all low risk mums should be advised to give birth at home or in a midwife only unit. In these settings induction is unlikely to be available and this may actually increase the number of caesareans. As I've written before we need to ensure that all birth places provide a good level of care. Women shouldn't be scared to have an induction because it means they'll loose the better standard of care often available in midwife units or at home births.

The NCT and others in a similar position of authority now need to get this message out there. Much is made about the problems of fear in childbirth and here is one less thing to be afraid of so let's shout that from the hills. Or at least on the NCT website!

* For what it's worth I was so very desperate to get MissE out that I wasted a not inconsiderable sum on an acupuncture session in the hope of starting labour. I knew, really, that it wouldn't work but I wanted to do something, anything to avoid that induction. Oh and no, it didn't work and yes I am embarrassed I even tried.

Thursday, 17 July 2014

Pureed Evidence - Is Baby Led Weaning Scientifically Better Than Spoon Feeding?

It was puree all the way when I weaned MissE. I'd heard of Baby Led Weaning (BLW) , where babies are given whole foods and feed themselves, but I was terrified of her choking. To be honest, she was my first baby and I was terrifying of pretty much everything. By the time her sister came along, the twin gifts of experience and absolutely no time to over think, meant that I was somewhat more chilled out. I also had no idea how I would manage the infinite chore of peeling, steaming and blending with a marauding three year old in addition to the baby. So I decided to give BLW a go. MissM shared in whatever the rest of us were eating, it saved me a lot of time and worked well. Yes a lot of stuff ended up on the floor, but a fair bit made it into the baby too.

It is unclear if she was enjoying the broccoli, but she was clearly getting nutrition somewhere

Being me, I then decided to do a bit of research. I'd heard plenty of people claiming that BLW was just hippy dippy nonsense but many others were total devotees so I got hold of a copy of the most popular BLW book to find out more.

I was disappointed to find that, rather than offering practical tips for following BLW, much of the book was devoted to criticising puree feeding, and the criticism was pretty harsh. Get through all of it and spoon feeding could seem barely a step away from force feeding. Shovelling gunk into a poor, subjugated baby and setting them up for a lifetime of eating issues. The book is also very clear that there is no scientific evidence to support spoon feeding. That's probably a fair point, until BLW came along I doubt it occurred to anyone to prove that spoon feeding was the way to go - there was no alternative. But if the book can ridicule puree for a lack of evidence, there must be some pretty hefty science behind BLW? Right?

I turned to the reference section of the book to check it out, I'll be honest I was already feeling a little doubtful but I expected to find a few scientific papers, hopefully even a review that analysed a whole group of studies. I  really hadn't expected how many references there would be.


They are:

2 Dictionary's
4 Websites
1 Other book by the same author
1 Unpublished MSc thesis, by the same author
1 Scientific paper from 1928

For the whole 256 page book, which scorns spoon feeding for it's lack of evidence and suggests that mothers using the traditional technique could be harming their babies, there is only one proper, peer reviewed paper and in scientific terms it is ancient history. It may still have some valid information, but the way we eat now, the variety of food available and the ways we cook and store it, are all vastly different to what they were 86 years ago.

Spoon feeding; disappointingly not mess free

Now, before too many people start to get all defensive, I'm not saying there is anything wrong with BLW. I did it with my second child and would happily recommend it to friends who wanted to try. I just wish that the book had focused on the positives; How nice it is to eat with your baby and have both your hands for your own food, how much easier it is to only have one meal to prepare for the whole family and how much fun babies can have playing with new foods and lobbing them around the room. It could have given recipes and meal plans to help sleep deprived, befuddled parents. Instead it made a big deal about the lack of science behind the alternative and if you're going to do that,  you should have pretty damn good science for your own claims.

Dictionaries are not scientific evidence. Websites may be very informative or they may be complete nonsense. I could write here that:

I am a hummus expert - It has been scientifically proven that hummus is toxic and produced as part of a plot by our alien overlords to destroy the educated middle classes, so as to make it less likely that the clandestine alien takeover of the government will make it into a Guardian article.

Anyone else is now free to reference this blog as indisputable proof of the evils of chickpea based dips.

Referencing your own book and MSc isn't exactly convincing, I've not read them but I'm guessing the author is quite likely to agree with the author? I also have to wonder - if the MSc provides strong evidence that BLW is superior to puree, especially if it shows that puree is detrimental to health and development, then that is big news. So why wasn't it published? I've seen some pretty dreary, unimportant papers come out of MSc projects, this would certainly be worthy of a few pages in a major peer reviewed journal.

So where does this leave us? Is science behind baby led weaning or spoon feeding? Well, as far as I can tell, neither. There have now been a few studies comparing the two, and suggesting benefits for BLW but in every case it's quite possible that these benefits are down to other factors. BLW babies are, on average, far more likely to be exclusively breast fed for at least six months, to eat their meals with the rest of their family and to have parents who are well educated and fairly wealthy. All these things are likely to influence a child's subsequent diet and health. Most of the studies also rely on the parents opinion about their child's health and behaviour. So it's possible that the BLW devotees are expecting great benefits for their child so give more glowing responses than those spoon feeding parents who are less emotionally invested in their choice (for more detail on this see here).

So again, where does this leave us? It leaves us with two, perfectly valid, safe ways to wean our babies. Parents should be supported to do whatever works for them. In practise most people are probably doing a combination of the two anyway. But why must we have books that advocate one method by trashing the other? Mums can be pretty quick to judge each other, but we are lightning fast at feeling judged ourselves. Such a pile of negativity only feeds this. Surely what we really need is clear, non-judgemental advice about the best nutrition for our little ones? Not propaganda for the drawing of battle lines?


Thursday, 10 July 2014

London With A Four Year Old: The Natural History Museum And Beyond

For those who like them, sorry for the lack of science rants recently, if you're going to blog about people getting complicated stuff wrong you have to put in a lot of time making sure you aren't also talking out of your  own *ahem* and time has been in short supply of late.

Today's strike didn't really help with that, but rather than moaning about it I decided to make the best of my far too short notice surprise day of annual leave. Miss M was in nursery so I had a rare opportunity for a day out in our home city, with just my big girl and no school holiday crowds. 

For those with only tiny children - it is so liberating to have a day out with no buggy, changing bag or fixed meal and nap times. We headed off with just rain coats and an Oyster card (and Ana of course) and had a great day - here it is in photos.

Waiting for the train

Pulling faces in the train window

The Natural History Museum - amazing before you even get through the door.

Bring on the Dinos

Anamatronic T-Rex, I'll be honest, it was a little scary

Contemplating a blue whale tail

Lunch time treat in the museum restaurant

Watching the Guards at Buckingham Palace

After a long hunt we finally found one of the Pelicans in St James's Park

Then her buddies turned up too

Hourseguards Parade

Bloomin tourists

Finally worn out we "drive" the number 12 bus past Parliment, Big Ben and the London eye, all the way home.

Miss E was fast asleep by the time we past our old home