Monday, 22 April 2013
Pregnancy, birth and parenting advice often has very little genuine scientific evidence behind it. Given that it has all been going on for quite a while now, this came as a bit of a surprise to me when I first became pregnant. I then found out that all too often the gaps in genuine scientific understanding are plugged up with hunches, pseudoscience and outright woo. It can be very difficult to determine what has real evidence behind it, lots of "experts" claim that their techniques are "scientifically proven" or "evidence based" but that proof can be rather shakey.
In this series of blog posts I will pick up on a few of the common examples of claims that sound nice and sciencey but don't really offer the definitive proof that they claim. That doesn't necessarily mean that the practises advocated are wrong, just that more evidence is needed for the sort of authoritative claims made. If "experts" and organisations are going to declare that they have the weight of science behind them, then I believe their evidence should be genuine, high quality and open to scrutiny.
So here is my first example of evidence that isn't:
1- A respected organisation says it's true so it must be:
Well, not always. If you want to quote a well known and respected organisation to back up any claims then WHO better than the World Health Organisation (can you see what I did there?). It seems entirely reasonable to assume that any advice they give out is based on good solid evidence but unfortunately it's not as simple as that. There are two bits of WHO policy that I see quoted a lot in parenting world:
First up: "The WHO recommends that caesarean section should account for no more the 10-15% of births".
The current UK C-section rate is about 24% so you can see why the WHO figure is widely quoted by advocates of natural birth and others who want to see a reduction in the caesarean rate. However, this recommendation is nearly 30 years old (issued in 1985). In the world of medical research that's ancient history. A lot has changed in that time, surgery has improved greatly so whatever evidence the statement was based on would be entirely out of date in 2013. Worse still, the figure wasn't actually based on any evidence anyway. The WHO acknowledged this and dropped the recommendation in 2010. It now says that "what matters most is that all women who need Caesarean sections receive them". Unfortunately the 10-15% figure is still widely quoted. I'm not saying that a 24% C-section rate is optimal, I'm not actually convinced that targets are a good idea at all, but if we must have them they need to be based on accurate, current information.
Secondly: The WHO says "exclusive breastfeeding for 6 months is the optimal way of feeding infants. Thereafter infants should receive complementary foods with continued breastfeeding up to 2 years of age or beyond." This bit of information is current, it's based on the best available evidence and it makes perfect sense. At least it does if you live in a part of the world where food is scare, water is contaminated and anything you give your child other than free, clean and nutritious breast milk, could potentially kill them.
Back in the wealthy world it's a bit more complicated. There is very little evidence of specific health benefits for breastfeeding longer than four to six months, the studies just haven't been done*. Of course there is absolutely no reason why a western mother shouldn't breastfeed for two years or more, so long as it's her choice and works for her and the child. But the vast majority can't or don't. Even for those who manage the six months, returning to work, having another child or just wanting your body back might bring about the decision to stop and it's highly unlikely that this will be massively detrimental to the child. So claiming that it's harmful in order to pressurise those who don't want to continue** is surely every bit as unfair as throwing freak comments at those who do?
Moral of the story? - These are just examples, if anyone (even someone important sounding) is advising you to do something that just doesn't work for you, don't panic - question their claims, are they up to date? Do they really apply to you? Or is someone being selective to fit their own agenda?
Next time - It's More Natural - So It Must Be Better
(Don't worry, I'll have cute pictures of the kids in between!)
*For more information on this and many other bits of pregnancy woo, get hold of the excellent Bumpology by Linda Geddes
**I can't actually find the quote given in this blog in the document it links to, the nearest was this quote in Appendix 1: Breastfeeding should continue with the addition of complementary foods throughout the second half of the first year. Breastfeeding beyond the first year offers considerable benefits to both mother and child, and should continue as long as mutually desired
Tuesday, 26 March 2013
This afternoon I found E at the top of the stairs, minus most of her clothes, leaning against the wall and striking a quirky pose while proudly waving a note left by the decorator.
Can you guess what the note said?
Of course you can...
|Some time later that evening...|
In case anyone thinks I'm getting a bit self- important after my last few posts, don't worry, the kids are onto it...
We've just got in from the park. It's roughly -103C outside, baby M is asleep and so well wrapped up that she may spontaneously combust within moments of entering the house, at the very least she'll wake up any second demanding a feed. E is sat on the stairs, her foot, still shod in a mucky boot, is held to her ear like a telephone:
E: Muuuum! Foot says you haven't got me my Tombliboo yet
Me: yes well let's get our coats off fi...
E: Muuuum! Foot says you've not put Dora the Explorer on yet
Me: yes, just get your co...
E: Muuuum! Foot says you've not made me a hot chocolate yet.
Me: Could you ask foot a question please?
Me: what should I do first? Fetch the Tombliboo, put on Dora, make hot chocolate or kneel down before you in a humble act of devotional worship?
E: (thinks for a second) Foot says Dora.
Wednesday, 20 March 2013
On Monday The Times published a letter* from Prunella Briance. It had been written in response to the Kirstie Allsopp articles that I mentioned in my last post. Briance claims to have proof that 97% of women can give birth with no medication or "interference". The remaining 3% are: "usually ill or damaged". My first caesarean was definitely unavoidable - I wasn't ill, does that make me damaged? hmm.
But why am I even bothered about the opinion of Prunella Briance? Frankly, she sounds like a conspiracy theorist (if there is a proven way to achieve a 3% C-section rate why on earth has it been hidden from us?). I'm bothered because in 1956 she founded an organisation called the Natural Childbirth Trust. It's now called the National Childbirth Trust (the NCT)** and is hugely influential on childbirth issues in the UK. It would be very worrying if this was still their opinion. The NCT haven't formally responded to Briance's letter, but Belinda Phipps, their CEO, did answer a question about it on twitter*** saying:
"Prunella NCT's founder 57 years ago - lots has changed since them (sic)".
Good. It's understandable that Briance holds strong, but outdated opinions. In the two decades prior to the foundation of the NCT the maternal death rate in the UK had plummeted thanks to various factors including antibiotics, and greater access to professional medical care. But unfortunately, for many women giving birth at the time, there wasn't a cheery east end Nun in sight. It was a clinical procedure and they were expected to just shut up do what they were told with no emotional support whatsoever. You can read about Briance's own traumatic experiences of birth in this interview from 1996. Briance blames the medical staff for what happened to her and, although I can't agree with her letter this week, there is no doubt that women today have a lot to thank her organisation for. So it was heartening to read that the NCT continue their good work, while putting aside the more dubious (and rather insulting) claims of the past.
I'd love to end there, but Phipps' tweet continued:
"Tho in the USA Ina Mays maternity service has a c section of 2%"
I don't know a great deal about Ina May Gaskin, but if you google her you will find no shortage of articles she's written and interviews she's given promoting natural childbirth. Her maternity service practices "spiritual midwifery" on a farm community in Tennessee and does indeed claim a 2% C-section rate. But what does that 2% mean? We're back to confusing figures again. To the best of my knowledge, my sitting room has a 0% C-section rate, but I very much doubt that watching The Killing and eating too many Kit Kats is the answer to ensuring natural births. The 2% means nothing without a few other numbers:
How many women are transferred to hospital and then need a c-section? Are they all included in the 2%?
Are planned "elective" C-sections included or only emergencies?
Can anyone give birth there or are only very low risk cases accepted?
If complications arise during the pregnancy are women discharged to another maternity service?
What is the rate of instrumental deliveries, or other interventions?
How does the rate of serious injury or death compare to the national average? - That one's quite important!
(the total number of births is also important but is stated on the website as "over 2000")
As I said, I don't know a great deal about Ina May Gaskin, perhaps she sees a wide range of women and genuinely only 2% go on to have surgical deliveries, I hope so. I hope that the NCT know more about it than I do, have answers to the questions above and will work hard to ensure that whatever Gaskin is doing becomes standard practice here. If not, if the questions haven't been asked, if the figures are a bit dodgy then I may not be ill or damaged but I am certainly concerned. The NCT is as important now as it was in 1956 - it needs to be working from the best possible data.
*Sorry for the lack of a link, The Times' pay wall is making this tricky, if you have a subscription it is in letters to the editor Monday March 18th 2013
**I expect that this debate will continue and so it is likely that I will be blogging about the NCT again. Many people have strong feelings about the organisation so let me be quite open about my own, they are very mixed:
I became a member in 2009, when I was pregnant with E and attended their antenatal classes. I got some great information, especially about breast feeding. I also met a group of other expectant mums who were utterly invaluable in the confusing early months of new motherhood. However our teacher strongly advocated natural and home birth. When we met two weeks after E's birth she asked how it had gone and I told her I'd had an emergency caesarean. She didn't ask what had happened, or what else had been tried, instead she wanted to see my hands. I can't remember exactly what she said after looking at them, but I left convinced that she thought that I hadn't really needed a c-section, I just hadn't tried hard enough. It seems ridiculous now, but at the time, when I still didn't fully know what had happened, it was crushing.
If I ever seem to criticise the NCT here it is because I really want to be able to support them. We absolutely need an organisation who will speak up for the rights of pregnant women (and their partners), perhaps never more so than now, with NHS reforms, budget cuts, soaring birth rates and midwife shortages. The NCT has done some really great work, ending the obligatory enema and shave, championing the role of birth partners etc. etc. They are consulted on government policy and are the go-to organisation for any journalist wanting someone to represent expectant parents. So it is vital that their work is based on accurate, unbiased data and that they represent all mothers - whether or not they live up to the current maternal ideal of natural birth and exclusive breastfeeding.
*** I have a screen shot of this conversation but out of respect for the person asking the questions, who to the best of my knowledge is not a public figure, I decided not to include it in this post.
Sunday, 17 March 2013
Well at least some of them...
I had a little flurry of excitement on the blog last week. My last post was written after seeing a tweet from Kirstie Allsopp about the Telegraph piece, so when I sent out a tweet about my post I thanked her for making me aware of it. I really really didn't expected she would do this:
But what was really nice was the number of comments and tweets that I got from Kirstie's followers who shared my annoyance with this kind of lazy and insulting journalism. I won't repost any of them here as many people shared their own experiences and may not have intended them to be public, but thank you so much, let's hope eventually we can ditch the ridiculous too posh to push stereotype. In the mean time, at least we know we're in good company!
This does leave me with an issue though, thanks to her tweet, that post has had far more readers than anything I've ever written previously (and I suspect far far more than any scientific papers I've published!). So now I need to come up with a really good follow up post. I have a touch of difficult second album syndrome here and also a chronic lack of time to research anything properly (not that that seems to worry some professional journalists).
So, rather than leave the blog bare for ages I've decided to cheat and offer you this piece from the (currently very pregnant) anatomist and TV presenter Professor Alice Roberts who deals with yet more dodgy uses of data: How can the findings of one study be used to both to warn against the risks of home births and to promote home births? Well quite easily, if you have an agenda to push. I also really wish her husband had been in my NCT class - you'll have to read it to find out why.
And finally, since she talks a lot of sense, and it would frankly be rude not to now, here is more from Kirstie Allsopp in The Times a couple of days ago* and in the Daily Mail. You can also read her own blog post on the related subject of how NCT antenatal classes deal with c sections. Now perhaps there's an idea for that difficult
second album next blog post...
PS. Ok one more thing - for those who only come here for cute pictures of the kids...
* The Times piece is annoyingly behind a pay wall, but you can get a 30 day free trial if you download their iPad app.
Tuesday, 12 March 2013
I've been AWOL from here for a while, small kids, very busy blah blah blah, but if one thing was going to get me back to the blog it would be shoddy journalism about C-sections. So, thank you The Telegraph, you've got me back in the saddle:
Here's the story: "Caesarian rates support 'too posh to push' theory". To summarise: Chelsea and Westminster hospital has a C-section rate of 33%, at King George hospital in East London it's 8%. Lots of posh people live in Chelsea, lots of poor people live in the east end, therefore the 33% are too posh to push. Also, C-sections cost the NHS "several times more than a natural birth" and mean the mother is "three times more likely to need a hysterectomy after their next pregnancy" while the baby is at increased risk of "death, blood clots and breathing problems".
On the face of it it's pretty damning. Posh women in Chelsea are risking the lives of their infants and draining NHS resources because they just can't be bothered to pop their babies out properly.
Except that's utter rubbish, and here's why:
Firstly it assumes that everyone in Chelsea is "posh". Certainly there are a lot of wealthy people there, the cheapest house currently for sale in the area is a 2 bedroom cottage going for £1,150,000. But there are plenty of "poor" people too, in council flats etc, London is just like that- who do you think is more likely to use an NHS hospital for the birth of their child?*
Secondly, 33% is the overall C-section rate, i.e. it includes emergency C-sections. I had an emergency C-section, after 34 hours of unremitting contractions - was I too posh to push then? Even after an hour and a half of, well, pushing? Ok, the writer also points out the the hospital has the highest rate of elective caesareans, with "16 percent of births performed by choice rather than as an emergency". But this is also misleading. There are only two types of c-section, emergency and elective. So those that take place because of e.g. a transverse baby that could not be delivered vaginally, or a severe heart condition in the mother that means she could well die in labour, are still "elective" although there is very little choice in the matter. The Chelsea and Westminster hospital has a high risk maternity unit, women with exactly these kinds of issues are referred there so it's hardly surprising that they have a higher than average C-section rate.
But what of the cost to the poor old NHS of all these C-sections? Well the Daily Mail re-hashed the Telegraph piece and tells us: "caesarean section costs the NHS about £2,600, more than double the £1,200 cost of a natural birth" Not exactly "several times more" and we're not told where those figures come from either. The only ones I've seen in the past put the cost of a C-section higher, but importantly don't include the costs of treatment and surgery for women who suffered damage during a vaginal birth, or the astronomical costs of a lifetime of care for those (thankfully rare) cases where a child suffers permanent brain damage after eg. shoulder dystocia leads to them being deprived of oxygen during a "normal" birth.
Ah - but C-sections are more dangerous for everyone we're told. I have no idea where the three times more likely to need a hysterectomy figure comes from, guess what - no reference! But even assuming it's true, it's still meaningless. Does it mean 60% of C-section mums need their womb whipped out compared to 20% of those who did it properly? It could equally be 0.0000003% v 0.0000001%. Show me the stats!
|What's more important? A Natural birth or a healthy baby?|
Where the baby is concerned, my consultant agreed that there is indeed an increased risk of breathing problems. But if the baby is delivered after 39 weeks (as is standard if there is no good reason to do it earlier), then that risk becomes negligible. And yes, more do die after a c-section, but not because of the c-section. The vast majority of those poor babies had developed serious problems before or during birth, they were delivered surgically as it was the best hope of saving them. They would not have survived a vaginal birth either but their mothers were brave enough to endure major surgery in the hope of saving them.
How dare anyone label those women too posh to push?
But finally, what about those brave, poverty stricken women in East London, delivering their babies by the Telegraph approved method? Well after five minutes on Google I discovered that the King George hospital maternity services are about to be shut down. The unit currently only accepts low risk women with everyone else going to the Queen's hospital, ten minutes away in Romford. No one choosing, or even needing a c-section would be sent to King George's, even women in labour there who need one unexpectedly are likely to be ambulanced to Queen's instead. To use their 8% C-section rate as a yet another slap in the face to C-section mothers is either lazy, callous or both.
This matters because the vast majority of women who have had C-sections didn't want them. They, we, endured major surgery because we genuinely believed it was the safest thing for our babies and for ourselves as the mothers who would care for them. Comparing the stats from different hospitals is meaningless to the unique situation of any individual mother and if those numbers are deliberately (or just lazily) fiddled, to produce clichéd headlines then they are not only meaningless, they are also deeply offensive.
PS. C-section mum Kirstie Allsopp responded to this piece too, you can read her letter to the Telegraph here
PPS. Neither the Telegraph or the Mail state where the figures come from, my best guess is here
*The hospital does have a private maternity service, but the article doesn't state if this was included in the figures, or if so, what proportion of the c-sections it accounted for.
Friday, 15 February 2013
It's a good while since I joined in with this and I've been missing it, I think we all need to count our blessings sometimes especially when you are at home with a small baby and life can seem very monotonous at times. So here are my three Reasons To Be Cheerful for today:
1- I've got rid of mastitis:
Uch, I've been feeling awful, last Saturday was F's birthday and despite starting out the day pretty well I ended up a shivery, aching mess on my mother in laws sofa. Roughly half of people with mastitis (a blocked/infected milk duct) also get the symptoms of flu - and I was one of that half. But, I think I have it beaten now thanks to lots of feeding, expressing and help from F and my Mum who came all the way up from Devon to give me a hand (thank you Mum you're a star).
2- Old friends, little girls and science:
An old friend who I met in the girl guides was visiting London this week, she has two children almost exactly the same age as mine and so I joined them on a visit to the science museum. It was a pretty manic day but E immediately made friends with the other 3 yr old girl and the two of them ran around furiously pretending to be aeroplanes, playing in the hands on launch pad area etc. etc. it was hard work keeping up with them but well worth it and of course I was delighted that E took such an interest (although she now thinks that all I do all day at work is shout in echo tubes). I was also impressed by a few little things at the museum that really made life easier as a parent. The baby changing room I used had a loo and space to take your buggy in with you, there were ramps and lifts everywhere and when we stopped for lunch we were given a table at the back with plenty of room for our buggies so we didn't spend the whole meal apologising and shuffling to make space. They aren't big things but they are much appreciated!
3- Getting out:
Sleep is pretty rare for me at the moment and has anyone ever actually managed to "nap when the baby naps"? So I'm keeping going by keeping going. I've just come back from a lovely walk with M which included a visit to our local cemetery If that sounds weird it's not as bad as you think. Nunhead Cemetery is an overgrown Victorian Gothic cemetery and on a sunny winters day it's magical. Think a walk in the woods where angels keep peeping out at you and there are great views over London.
PS: Why not have a look at some other cheerful blogs?