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!