Wednesday, 28 May 2014

Blog awards, The Pox and Camping Solo with a Four Year Old

To summarise,  last weekend basically went like this: bad thing, bad thing, Brilliant, lovely awesome thing.
Now in slightly more detail:

Blog Awards:
On Friday the finalists for the Brilliance in Blogging awards were announced and sadly I didn't make the cut. Even so I'd like to say a huge thank you again to everyone who took the time to vote for me. I often suspect that this blog doesn't fit well in the parent blogging world. Advocating proper scientific evidence over anecdotes, beliefs and what seems "natural" isn't generally all that popular and, compared to personal stories, it's hard to turn a bunch of dry statistics into a compelling read. So, although I'm calling Friday's announcement a bad thing,  I'm still utterly delighted and shocked just to have made it to the shortlist. Yay!

The Pox
MissE had chicken pox 10 days ago (non-UK readers, the vaccine isn't routinely given here), and so with grim inevitability MissM developed the dreaded spots on Friday evening. This one is definitely a bad thing as we were all supposed to be going camping for the weekend. So what to do? All stay home and disappoint MissE? One of us stay home with MissM and the other go solo camping, to a festival, with a four year old? After tears from MissE and considerable indecision from me, F made the decision: I'd been on house arrest while MissE was ill, so I got to go camping and he would stay home with the poxy toddler (besides I'm better at putting the tent up than he is).

Which brings me to...

Solo Camping With A Four Year Old
My husband is very good at carrying stuff and telling me when I'm being irrational, he also produces a considerable amount of body heat and has a good sense of direction. These aren't his only qualities by the way, but they are particularly useful  when trying to go camping in a mystery destination with small children. I'll be honest, the thought of doing it all without him was pretty daunting, all the more so when I woke up to pouring rain, but I didn't want to let MissE down so I put on my best independent woman face, checked the directions 15 times and set off.

I'd gone the wrong way by the time I'd left our street. *face palm*

But all hail the sat nav (and the Lion King DVD that kept MissE happy), we were soon sailing through the traffic free streets of early Saturday morning London (love that), bombing along the motorway and then gingerly up the dirt track to the secluded Feast In the Woods site.

I'd been worried that this would be a bit stressful on my own, it actually turned out to be one of the most relaxing weekends I've had in ages. We parked up and then walked through the woods to a little clearing with a fire pit already on the go. MissE was directed to a little bridge, leading to a wardrobe in the woods. Stepping through the wardrobe she found a kids entertainment team with face paints and crafts all ready to keep her happy while I got on with pitching the tent (with a bit of help from some kind folks around the campfire). Before long MissE had found some new friends and bonded over a mutual love of Disney's Frozen. The little Elsa's and Ana's ran wild for two days, dangling from swings in the trees and toasting marshmallows on the fire but the thing that really amazed me was that the only screaming strop MissE had was when I wouldn't let her fling her (non-swimmer) self into a lake. 

MissE has never liked water. I sometimes joke that my natural birth plan only failed due to her horror at the birthing pool. While other babies love splashing in the bath, she wailed in terror at it for her first year and the baby swimming classes I'd so looked forward to were a total, expensive, write-off. Recently though, she has been having swimming lessons with a lovely teacher and after a day of rare physical bravery and having seen so many other kids in the water she actually begged me to let her go in too. So I donned my swimmers, took a deep breath and jumped.  After about two minutes of gasping for breath in the cold I pushed an inflatable crocodile over the MissE on the jetty and we splodged about in the water until I got cold again and had to beg her to get out. It beats the heck out of a festival shower queue for feeling refreshed though!

There was also great food, lovely cider, the endlessly amusing composting loos, pond dipping, ukuleles and at least an hour where I just sat in the sun reading a book while my daughter roamed free in the woods with her friends. Bliss.

By the time we got home I was filthy and exhausted, by the next day every inch of me ached from packing everything up on my own (then unpacking and re-packing it all because I thought I'd lost my glasses) but it was totally worth it, MissE and I both had a wonderful time and I actually feel pretty proud of myself for taking on something I was a bit nervous of. We've already booked for next year, hopefully we will all make it this time but if not, I'll have no worries about going solo again.


 PS. My photos don't really do the weekend justice but much more lovely ones can be found here:

Wednesday, 14 May 2014

A Few More Notes On the Nice Guidance

When I wrote about the new NICE guidelines yesterday I hadn't been able to find the actual document and was relying on the news stories about it (none of them seemed to link to the source, helpful!). Inevitably about 25 seconds after I hit the publish button I found the document. Cue hurried skim reading and even more hurried re-write.

I've now had chance to read at least a couple of the relevant sections and some of the many other blogs that have been written on the subject and I thought it was worth adding a few notes.

Firstly, for the most part I agree with the new guidance. It says:

Explain to the woman that she may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support her in her choice of setting wherever she chooses to give birth

But it goes on to say:

Advise low-risk multiparous women to plan to give birth at home or in a midwifery-led unit 

Advise low-risk nulliparous women to plan to give birth in a midwifery-led unit

(nulliparous women are those who haven't given birth before, multiparous have)

And it was that word - "advise" that concerned me. 

Low risk women should be advised that a midwife led unit is just as safe as an obstetric ward. It should be explained that these units have lower rates of interventions, and of the potential risks of these interventions. If that's done many more women will probably choose this option and I'd welcome that. 

But I don't think they should be "advised" that this is what they should plan. You're not giving someone a choice, if you then tell them what their choice should be.

For all their benefits there are a couple of down sides to the NICE approved options. Firstly, the transfer rate, especially for first timers is high. Women need to be aware of this and prepared for the very real possibility of a fraught ambulance trip if they aren't in hospital. Would that be better or worse for them than having medical intervention hovering in the background all along? It won't be the same answer for everyone.

The other snag is pain relief. If you really want the pain to go away an epidural is your best bet. It's very safe and I for one see nothing morally wrong with choosing to avoid the pain of birth. The guidance says:

If a woman in labour asks for regional analgesia, comply with her request. 

It also adds that women must be cautioned about the risks and benefits and, importantly that you can't have an epidural at home or in a midwife unit.

So effectively the new guidance is advising women to give birth in a setting where serious pain relief is not available to them. It's saying you have a choice, you can have this nice place where you won't have nasty things done to you but, if you want pain relief, you will have to give all that up and argue against your doctor or midwife's advice.

It also sends a very strong message that epidurals are somehow a wrong choice or at least unnecessary if you do this birth thing properly. 

Then there is the risk that we create a two tier system for birth. 

Already women choosing a home birth are likely to have better continuity of care throughout pregnancy, birth and the postnatal period. Rather than sharing one stressed out midwife with other women on the labour ward, a home birth Mum will have two who she may know already, all to herself. At the hospital where Miss E was born the facilities and environment of the midwife unit were sufficiently enticing to encourage women to choose it over the obstetric ward, even without information on interventions. Women should be able to choose between epidural or no epidural, not between pain relief or decent care.

What also seems to have been forgotten in all these debates is that not all women are low risk. Actually an awful lot aren't (and sometimes the judgement over who is and who isn't can be wrong, which is another issue). All these other women seem to have been swept aside in this debate, are we only interested in those who through dumb luck are able to have a choice? If we demonise obstetric units how will that make women feel when they are told that, for them, the people most in need of care and support, the "wrong" choice is their only choice?

Let's have midwife units available to everyone, ideally (in my opinion) on a hospital site so the transfers aren't too traumatic. Let's offer home births where it is appropriate and lets continue to make those environments as welcoming and stress free as possible. But let's do the same for obstetric units too and let's be careful not to place a moral judgement on pain relief.  Then we can advise women of the theoretical best option but not dictate a one size fits all "correct" choice.

For what it's worth I thought it may be helpful to explain my own experiences. Inevitably they influence my opinions. I was low risk for my first pregnancy, I chose to give birth in a midwife unit in a hospital. I was hoping for a natural birth, maybe water, I wasn't keen on epidurals and was confident in my ability to cope with pain and exhaustion but I also liked having the obstetric unit down the corridor just in case. I never expected to use it. At that point I thought that if all went well I might have a home birth for any subsequent babies. Basically my choices were exactly what the guidelines would recommend.

In the event things weren't straight forward and I had to transfer. When it became clear I was in for a long haul I had an epidural for a while. I let it wear off to push the baby out but unfortunately that didn't work out either and I had an emergency C-section. For my second child I wasn't low risk and I opted to have a planned C-section.

If I were doing it again, I would still opt for the midwife unit, I'd still want to avoid an epidural but I would perhaps try to be a bit more prepared for things not going to plan!

Tuesday, 13 May 2014

New Nice Guidance - The Correct Birth Choice

Well damn it all, looks like I was totally wrong when I said that there was no one "right" way to give birth and  women should have clearly presented evidence to make their own decision. Just look at the news today:

NHS Push For Home Births  - Daily Mail

This has all come from new draft guidance issued by NICE, the body who evaluate the effectiveness (and cost effectiveness) of NHS treatments. It uses the evidence from the Birthplace Study and, rather than saying all women should have a home birth, it says that all low risk women should be advised to give birth away from a hospital obstetric unit, in  midwife led unit or (if they aren't first timers) at home.

"Midwives should explain to the mother-to-be that she may choose any birth setting... and support her in her choice"
(Quote from Nice as it appeared in the Daily Mail piece above)

 The fact that many news stories have chosen to focus on home birth rather than midwife units is unsurprising. Its guaranteed to whip up arguments, there are plenty of evangelical supporters of home birth and a whole host of others ready to shout them down as hippies. In fact the guidelines themselves cover far more than just place of birth. But beyond the headlines the language is crucial here. Women should be given  unbiased, clearly presented information about the risks and benefits of each setting and they should be supported in the choice they then make. But the guidance states that women should be "advised" to give birth away from obstetric units.

There is a fine line between advised and persuaded and it's not far from there to coerced.

I for one do not believe that there is anything inherently wrong about wanting to give birth surrounded by 21st century doctors, medical equipment and pain relief. It is true that there is a greater risk of intervention in hospital and women must be made aware of this. Low risk women should not be forced into an obstetric birth if it's not their choice and they shouldn't be scared into it because they erroneously think it's the only safe option, but it should BE an option and there shouldn't be any judgement attached to that.

"To the woman he said, “I will surely multiply your pain in childbearing; in pain you shall bring forth children"
Genesis 3:16

I for one increasingly feel that there is far too much judgement.  A woman who gives birth with no pain relief or interventions is now somehow the feminine ideal, empowered yet a part of nature's great plan. To read some of the descriptions it sounds like a pseudo-religious experience, the ancient, biblical image of "mother " enduring pain as she's supposed to. Those who want to make use of modern medicine are portrayed as weak and selfish, giving in to the cold, artificial, masculine temptations of science and technology and missing out on the true wonder of what their bodies can do. Perhaps I'm getting carried away here, I feel like I should be throwing in the word patriarchy at any moment. But this isn't just coming from a male dominated media. News websites of course want to get people angry and commenting, but us women and the groups we trust to stand up for us are colluding in this and egging it on.

I listened to a bit of a radio phone in on this story, (before I got cross and turned it off). But the host raised an important point. What about pain relief?  At home or in a midwife unit you can't have an epidural. Of course many women won't want one anyway, but some will plan to use it from as early as possible, many more will plan not to but change their minds during labour (how many of us who have been through childbirth really knew what to expect?) One caller, though she tried not to, typified how judgemental we women can be of our own. She talked about her wonderful natural births and when asked about pain relief said that women in hospital were likely to use it, "just because it's there".  Basically she didn't use it, brave, strong, empowered her, so anyone who does must just be weak. It's the obstetric equivalent of raiding the fridge on a dull Tuesday evening.

 Inevitably Belinda Phipps of the NCT (and go to "voice of the mothers" for anything pregnancy and birth related) was also on the show.  She responded to a question about epidurals by warning of the dangers - the risk that they would lead to more interventions. When asked about women who didn't plan to use one and then changed their minds she dismissed the question, saying that even if you were in hospital there probably wouldn't be anyone around to do it in time.

Well, sorry sisterhood but I just don't agree with either of these women.

Yes there are potential downsides to epidurals, (more information can be found here) nothing in life is risk free, especially not childbirth. But there are advantages too, they make the very hurty thing stop hurting, they let you rest and maybe get something to eat when you've been pacing in agony for days and overall they are pretty safe (kind of like home birth really) it's a trade-off of risks and benefits so if a woman makes an informed decision to have an epidural, why is that not a perfectly valid choice? Certainly some women want epidurals and don't get them because of staff shortages, I can vouch for that myself, after 24 hours of unremitting contractions I waited several more before an anaesthetist was found, and drugs made up. But rather than dismissing epidurals because of this problem why aren't the NCT campaigning for more anaesthetists as well as for more home birth midwives?

As for the caller? Well it's great that her births went well, if she feels proud of herself for that, then good for her, she's been through a tough thing and come out the other side. But does she really think that her experience is typical for everyone? That anyone could have births like hers if only they were as brave? as strong? as "empowered"?  You can be all of these things but dumb luck has the final say.

The guidance may be trying to help women but much of the response to it does exactly the opposite. It's time we stopped judging mothers by how they give birth and we need to look to ourselves for that, not just the media. It's great that we have moved on from the 1970's where women were flat on their backs doing as the doctor ordered, I thank all the women who fought for that change. But we risk a new, self imposed oppression if we call for choice, then dictate that only one of those choices is right.

PS.  There is still time to vote for me in the Health category of the BiB awards! Click on the badge below and fill in the form (pretty please)


PPS.  I also feel I should apologise for begging for votes then not posting for ages - I'm currently on chicken pox lock down so although I've not left the house in days I have very little time to write!