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!