29 Feb

Maternity Review: Informed Choice and Personalised Care

Yesterday’s publication of the 2016 Maternity Review, glossily titled “Better Births,” gave rise to a mixed response in the press. The 126 page document is a fascinating compilation of statistics and feedback gathered from parents and health professionals, much of which tells an all-too-familiar tale about disconnected care, conflicting advice, families feeling unsupported, and midwives and other health professionals working within the confines of a complex high-pressure environment.

The main recommendations of the report were:

  • Personalised care, with genuine choice, informed by unbiased information;
  • Continuity of carer;
  • Safer care, with professionals working together across boundaries, and a culture of safety, with rapid and transparent investigation of mistakes;
  • Better perinatal mental healthcare;
  • Community hubs so that women can access a range of care from different professionals, including local midwifery practices;
  • Reform of the payment system for maternity services.

Mainstream media were quick to focus on the proposal that women should have a £3000 budget and a choice of birth places and carers. The Times describes this as women being “handed £3000 by the NHS,” a scenario which seems as unlikely as its tone seems dismissive of women’s abilities to think straight if presented with such quantities of money.

In what I will call the “birth press,” the response was more mixed, with much applause for the focus on personalised care, continuity of carer, and genuine informed choice. Doula and founder of Birthrights Rebecca Schiller wrote in The Guardian of her expectation of “the inevitable barrage of scepticism about whether we can handle the weight of responsibility for our own health.”

Jane Merrick in The Independent
immediately obliged:

Do all expectant mothers really want personalised care plans, as proposed by the National Maternity Review? […] Although there is no cost to the individual, placing the burden on mothers, with a price tag attached, is yet more pressure and yet another thing for pregnant women to worry about.

There was a widespread response that, since homebirth is generally cheaper than birth in a hospital, the focus on cost efficiencies would see health professionals encouraging more homebirths, even, according to Kim Thomas, author of Birth Trauma, when this is not clinically appropriate. Many birth workers will be reading this with a raised eyebrow; experience suggests that the interests of the baby always trump the interests of the mother, and it would take a huge change of culture for homebirth to be routinely recommended even when it is clinically appropriate.

Another undercurrent in the response among the birthy people is that the report, and particularly the recommendation of the birth budget, opens up the door to privatisation of maternity care, as well as the use of NHS funds for non-evidenced forms of care. The report itself tells us that parents want to be able to make informed decisions:

Many women expressed frustration over receiving conflicting advice from different healthcare professionals throughout their care. Women and their families told us they need to be able to access
appropriate information to enable them to make genuinely informed decisions about their care and where to give birth. They wanted information to be evidence-based and available to them in a range of
formats, including online.

What this report is calling for is a huge cultural upheaval, as well as a change to the infrastructure of birth in the UK. To be able to offer genuine choice of birth place, we would need more midwife-led birth units and more midwives able to support homebirths. Health professionals across the board would need training to bring about a shared knowledge of the evidence base as well as an understanding of the different perspectives they bring to maternity care. I think perhaps the body of the NHS may be willing, but the purse strings are held too tightly by people who do not have this knowledge or understanding.

Cross-posted from Huffington Post.

25 Feb

Why are twins double trouble?

From conception onwards, having twins seems to raise the bar. Through pregnancy and birth, mothers having twins are viewed as twice as delicate, with their precious double burden, placing a pressure on babies and parents that impacts on the birth as well as the early days and weeks of the babies’ lives.

Google “having twins is” and autofill offers the options of “hard” “so hard” “a blessing” and “a nightmare.” It must be difficult to focus on the blessing when society is so hell-bent on telling you you’re in for double trouble. “The way the majority of people turned my twin pregnancy into a negative really surprised me,” says mother of twins Jen. Another mum Mally adds “It makes you feel incredibly isolated. People are incredibly arrogant to think that they are much better off with ‘just the one’ (at a time).”

Having twins is increasingly common in the UK, partly because the overall birthrate is increasing, and medical advances means that more twins survive when born prematurely. In addition, women tend to wait a little longer to have babies, and over the age of 30 the likelihood of releasing multiple eggs, and therefore having twins, increases. Assisted conception through IVF and fertility drugs is another contributing factor. And more twin pregnancies means more opportunity for little old ladies to hover over your bump or your pushchair, giving advice and telling you what hard work it’s all going to be.

Kate, who has triplets, says: “Apparently it’s perfectly fine for the first question out of the gate to be ‘are they natural?’ Or ‘How were they conceived?’. What difference does it make? But it always feels like a loaded question to me.” It is loaded: with the assumption that you couldn’t have managed this all by yourself, and therefore that you cannot possibly birth, feed, or generally manage these babies all by yourself.

Most mothers who are having twins give birth to healthy babies. Some complications are more common in twin pregnancies, and modern medical practices mean monitoring for high blood pressure (a sign of pre-eclampsia), gestational diabetes and anaemia, all of which can usually be managed. For the babies, the complications that are likely to arise are a result of prematurity or low birth weight.

Giving birth to twins without medical professionals hovering around like cats on hot bricks seems unlikely. Even in the most uncomplicated twins pregnancy, it can be a challenge to avoid being channelled down the high-risk route and straight into theatre for a c-section. The effect of this is that skills and confidence in giving birth to twins without intervention are gradually eroded, and this is self-perpetuating.

I had the lady serving me in the post office say ‘twins? Poor you!’ the other week. I was so shocked I just stared at her. She then said ‘so you’re done now then’. I thought about her comments all day and got more and more upset. (Marie-Claire)

Once the babies arrive, the focus switches to all the things you surely cannot manage to do with two babies: breastfeed, sleep, get out of the house, retain your sanity. Most of the time I talk to singleton mums who tell me that all of those things are difficult; I’m not convinced that they are twice as difficult with twins, and one thing I know is that twins mums are a little better at recruiting the help they need. Life with any number of new babies can be hard work, and it’s hard to define “more” sleep-deprived when you’re as sleep-deprived as it seems possible to be.

Society needs to stop feeling sorry for mothers of twins; it’s a judgement they probably don’t need, and they get twice as much of it.

Thanks to members of Reading & District Twins Plus Club for their input. We’re talking about having twins in the next episode of Sprogcast.
Cross-posted from Huffington Post.

11 Feb

My complaint to the BBC

Dear BBC

I wish to raise a complaint with regard to the choice of Clare Byam-Cook, who was represented as a “breastfeeding expert,” a “breastfeeding counsellor,” and a “lactation consultant” on Woman’s Hour on Monday morning. With respect, she is none of these things, and I am deeply unimpressed that BBC researchers were unaware of this, despite complaints every single time she appears.

The information given out by Byam-Cook about tongue tie, milk supply, and the baby’s latch at the breast were fundamentally incorrect. Since the purpose of this piece was to explore the reasons why women feel unsupported and do not breastfeed for long in the UK, I am surprised that this misinformation was perpetuated without comment. This is negligent of the BBC.

Byam-Cook was also allowed to talk about her video and book, and mention that she is available for private consultations. I understood that the BBC was required to adhere to certain standards about allowing advertising. If this had been advertised on ITV I would be making a complaint to the ASA, since her book contains many factual errors that would undermine the breastfeeding experience of most women.

Please do not bother to send me your standard response, as I have read it. I take issue with the statement that ” Unlike other breast feeding counsellors, she doesn’t believe that breastfeeding is the be all and end all.” As a Breastfeeding Counsellor, I am very well aware that breastfeeding is one part of the complex experience of becoming a parent, and I have supported parents in many different situations, making many different decisions. The word “counsellor” should convey to you that we listen and support individual mothers, without an agenda. Nonetheless, breastfeeding is an important public health issue, as shown in last week’s article in the Lancet; and the BBC has a responsibility to give out correct factual information, as well as the helpline numbers from the four reputable organisations whose counsellors are trained to support women in an evidence-based, parent-centred way.

Kind regards
Karen Hall

11 Feb

How not to talk about breastfeeding on the radio

On Monday, BBC Woman’s Hour had what they described before the programme as a “ding dong” about breastfeeding. Ironically I missed the first fifteen minutes because I answered the phone, just as the programme started, to a mother who was concerned about her milk supply. Then I tuned in and cringed to hear the brusque tones of Clare Byam-Cook, a self-appointed “expert” on breastfeeding, telling listeners all about her magic techniques for getting babies to feed, and explaining where we, the trained breastfeeding supporters, are going wrong.

I have issues with the BBC allowing this person to promote her book and simultaneously undermine the work of the breastfeeding counsellors who criticise it. I’ve read her book and it’s hard to see how anyone could have much chance of breastfeeding for long, following its guidance. Callers to the show spoke of pressure, conflicting advice, and not being listened to. Byam-Cook dismissed the issue of tongue tie as “just a trend,” thus dismissing the experiences of thousands of mothers who have struggled to feed their babies precisely because of this. Estimates vary, but it seems that tongue tie affects 5-10% of babies, many of whom will be able to breastfeed, and some of whom are so badly tongue tied that they cannot drink from a bottle. Because it can be hard to identify a tongue tie, and midwives are not universally trained to do so, many mothers struggle with long or painful feeds, and many give up in despair. This is not a positive decision for them, and to hear that it’s a non-issue that doesn’t need to be resolved must hurt in so many ways.

Her fundamental lack of understanding of the way breastmilk is produced is shocking (“it is absolutely not true” that the more you feed, the more milk you produce). The well-established, basic principle is that milk removal creates milk production, therefore the more effectively a baby feeds (that is, on cue, for as long as he/she wants to, without discomfort for the mother), the more effectively the mother produces milk to meet that baby’s needs. Yes it is true that sometimes a baby feeds more (for longer, or more frequently) because the feeding is not effective; breastfeeding is complex, and breastfeeding counsellors are trained to listen to mothers and try to understand the situation so that they can offer appropriate support.

Listeners were also treated to her description of how to get a baby to latch on and feed (“mouth to nipple and squeeze the breast.”) Breastfeeding counsellors all over the country must have been banging their heads on the desk at this point; how many painful feeding experiences have we witnessed, where a woman has been told to squeeze her breast and force the baby on to it? No one-size-fits-all approach can ever be appropriate when we’re talking about human bodies, but there are strategies involving comfort, closeness, and biological reflexes that can make things much easier for both mother and baby.

I understand exactly why BBC Woman’s Hour invited Byam-Cook on to the show: a discussion between two International Board Certified Lactation Consultants about the shocking lack of support for new mothers would not have made such exciting radio. Or would it? As Dr Pat Hoddinott pointed out, the media has to share responsibility for the low breastfeeding rates in the UK, and shows like this are very much part of the problem, not part of the solution.

If you are a new parent and need some support with breastfeeding, there are several helplines run by women trained in listening, and with evidence-based knowledge about how breastfeeding works, including the NCT Breastfeeding Line 0300 330 0700 open 365 days a year, 8am-midnight. We talked about breastfeeding support in our very first episode of Sprogcast, which you can find here.

08 Feb

Book Review: Helping your baby to sleep, by Anni Gethin and Beth Macgregor

Helping your baby to sleep is a book about being kind and gentle to your baby: a persuasive philosophy in anyone’s book. It is divided into two sections: the science of responsive parenting, and the practice of gently encouraging a baby to sleep. Its starting point is very much the argument that “bringing about change by causing a child to be distressed can never be considered a success.” (p.xxi)

Like many, many such books, authors Gethin and MacGregor explain the mechanisms of sleep: cycles of sleep, survival needs, and what exactly does “normal” mean, anyway? Each chapter has a nice summary of key points, useful if you are reading this as a sleep-deprived parent.

Having laid out the scientific support for responsive parenting, the case against sleep training in chapter four makes complete logical sense, if somewhat distressing reading in places.

Moving on to the practical section, they offer a range of “slow fixes” for helping babies to settle and parents to get a less disturbed night, appropriate for different ages and situations, as well as a chapter addressing most of the common sleep difficulties that parents experience.

The book finishes with a helpful section on self-care and support for parents, which really needs to be threaded throughout lest parents give up reading while it all still sounds rather onerous. Of course parents want to be gentle and responsive, but attachment parenting books can appear to ask a lot of parents at a challenging time in their lives. It really helps to have the science of brain development and attachment so clearly laid out, alongside quotations and ideas from other parents. The cartoon on page 130 seems very apt. Buy it and see for yourself!