Category Archives: Scientific Fact

08 May

Book review: Mixed Up – Combination feeding by choice or necessity, by Lucy Ruddle

There is no doubt that a book on mixed feeding is very much needed, particularly here in the UK where we have the lowest breastfeeding rates in the world, and the most common way for babies under six months to be fed is to have a combination of breastmilk and formula.

If baby feeding is a subject area that often seems to parents to be mysterious and inaccessible, combination feeding is the most mysterious and inaccessible of all. It is often (mis)understood that breastfeeding is an all or nothing activity, an idea that certainly works out well for the formula manufacturers. We have plenty of books that include information on both breastfeeding and formula feeding, but few that address the question of doing both.

This is a good start, with some really excellent ideas such as the “quick glance alternatives” and “things to be aware of,” which are nicely phrased ways to help parents explore how things might work for them. It is written with kindness and an in-depth knowledge of feeding babies, and there are plenty of stories from real parents if you like that sort of thing.

I’m not a sleep-deprived new parent, and I did find it difficult to navigate the book. Headings are not very distinct from subheadings and the lack of an index made it difficult to find things that were referred to in early chapters such as paced bottle feeding, but not explained until much later in the book. It doesn’t feel logically organised to me; I really wanted to cut it up and put it back together in a different order. The information is solid and the tone is lovely, so it was frustrating that even with a good understanding of the subject, I couldn’t easily find my way around.

I would definitely use this book for my own reference, and given that there I don’t know of another book for parents that covers combination feeding to this extent I would also suggest it to parents, but my feeling is that this particular market niche is not yet saturated.

30 Mar

NCT courses: a clarification

This Guardian article today tells you that NCT courses “can set you back by £400.”

NCT is, by the way, a charity. Not a profit-making enterprise. Surplus from courses goes into charitable work such as campaigning for better services and support for new parents, and providing that support, usually completely free of charge to parents, whether they are NCT members or not.

This page shows very transparently the hourly rates for NCT courses.

This page shows that NCT discounts courses by up to 90%.

None of these pages explain the level of training (minimum two years, currently a foundation degree), assessment and CPD that NCT Practitioners undertake, nor the fact that NCT Practitioners are specifically trained in facilitating adult learning (unlike most midwives). NCT courses don’t just transfer information into passive vessels, and most people come out with tools and strategies as well as knowledge. Oh, and the “bought friends,” of course.

If you’re spending that much money (or not), you might want to look into the qualifications and ethos of the organisation you are spending it with.

20 Jul

How bottle manufacturers undermine breastfeeding and evade UK advertising rules, a guest post by Megan Stephenson

If you’re on social media, and you have had a baby recently, you’re seen as a feast of insecurities for many predatory companies. Most are fairly innocuous, they’ll cost your family money, but not have an impact on your babies health. But some, in particular the bottle manufacturers, are aiming to reduce the amount of breastfeeding you do. Since many of the health impacts of not breastfeeding are dose-responsive (that is, the more you do the more impact they have) this is not just about money any more.

The particularly egregious examples are the ones where they claim that they won’t have an impact on breastfeeding (how can this be? Surely every time the baby is having a bottle, they are not at the breast), that baby can’t tell the difference, and that you can switch between breast and bottle easily. This is actually against UK advertising laws because they have no solid evidence (this means properly conducted research trials, “my friend said” is not enough). So, how do they get away with it? I hear you cry. Well, easy, the company isn’t saying it, they are sharing real life reviews. Of course they are paying the social media companies to share them with you, so it’s still advertising.

If it IS possible to switch easily between breast and bottle (and I’m not convinced that anyone has proved that any bottle makes this easier than any other) how does this impact on breastfeeding? Does it mean that when a mother breastfeeds in a public place, she is no longer protected? Because she could have used a bottle for public and breast at home. How about breastfeeding as babies get older? Well, you could use a bottle and still breastfeed at night. What about maternity leave – why not go back to work at two weeks, leaving a bottle for day time and breastfeed at night? Once again, breastfeeding is consistently undermined.

Megan Stephenson is an NCT Breastsfeeding Counsellor

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.

13 Nov

Birth Plan Prompt Sheet

Birth planning is a vague science; some birth workers now refer to “birth preferences” instead, and some prefer to avoid this sort of planning altogether. I’ve found a few resources online including this comprehensive tool from the NHS, and cobbled together a list of prompts so that my clients and I can go through it together and make something that is completely tailored to their needs. I’ll be taking several copies with me to the birth!

Birth Plan

Early labour – where?

Where to give birth – MLU/delivery suite/pool etc

Who do I want to be with me?

Equipment I plan to take with me

Intermittent/continual monitoring of baby during labour

Keeping active during labour

Positions to adopt

Trainee midwives/doctors in the room

Immediate skin to skin

Pain relief preferences

Episiotomy

Third stage – active/managed

Breastfeeding

Vitamin K

Any special requirements

06 Oct

Dear Doctor

Views expressed here are my own, and do not represent the views of NCT.

This weekend, Dr Ben Goldacre stood on a stage in front of hundreds of NCT Practitioners, volunteers and staff, and told us that we “push” breastfeeding. “Because you do,” he said, with a cheeky wink. “You’re the breastfeeding nazis.”

There was a sort of silent stunned gasp, followed by a burst of laughter; it was the funniest thing, a great ironic deconstruction of the name-calling rubbish (with acknowledgement to my colleague Kerry from whom I pinched that description). It was funny the second time he said it, too. After a while I was much reminded of my eight year old son and how he repeats the joke until you have to sit him down and explain that we’re really over it now.

We were treated to Goldacre’s standard comedic romp through the Daily Mail’s war on cancer, his low opinion of Gillian McKeith, and a selection of amusing headlines that can be achieved by cherry-picking statistics. Lucky us, we got a little extra bit on research statistics, and then a worked example using Brion et al’s 2011 article entitled What are the causal effects of breastfeeding on IQ, obesity and blood pressure? This study does contain flaws, and I wondered if Goldacre had also read this commentary, though on reflection if he had read it, its conclusion might have helped him to write a conclusion of his own:

Although the collective evidence suggests that breastfeeding—initiation, longer duration or exclusivity— may very well exert a modest protective effect on childhood and adolescent obesity, it no longer appears to be a major determinant. Nevertheless, because breastfeeding also reduces infection and allergy-related outcomes and probably increases IQ, World Health Organization recommendations for 6 months of exclusive breastfeeding remain a just and justifiable policy around the world.

By the umpteenth repetition of the breastfeeding nazi joke, I had the impression that Goldacre did not quite understand what NCT does, and while I have no evidence for this assertion, I’m pretty sure he hasn’t read our excellent Infant Feeding Message Framework [pdf]. Reading through the reasons women give for stopping breastfeeding, it would appear that for mothers, the evidence itself is not the highest priority when it comes to evaluating the experience, and that is where NCT comes in, to support parents in the situation they are in: non-judgemental, respectful support where support is asked for.

Ben Goldacre told us he doesn’t care about breastfeeding, he cares about misuse of evidence, and nobody in the room would have disagreed with that. But I would have liked him to have been a bit more thorough in his own research and understanding of how NCT supports parents.

02 Sep

Every child wanted

“Abortion is very, very ordinary and a mark of civilisation – liberty for women and every child wanted.”

I had written and scheduled yesterday’s post about my abortion before I saw Polly Toynbee’s article in The Guardian. In fact I wrote it quite a while ago, in response to a request from the BPAS for case studies to debunk the myths that people who have abortions are reckless teenagers, or that they are somehow scarred and regretful for the rest of their lives.

As Toynbee points out, the media still treats abortion as a back street business, a dirty scandal, a secret we must never share. The storylines that end in miscarriage before the fateful decision is made tell us that as a society we are very confused about unwanted babies. We know it’s better for them not to exist, but we don’t want to admit that. Certain saintly (often childless) people may take the view that their god’s creations are all sacred and we mere humans don’t have the right to deny them life, but it is questionable just how relevant this is to the majority of women who find themselves in the position of having to make the decision.

I want abortion to be talked about in terms of a woman’s right to have control over her own body, not a shameful thing that we mustn’t mention in polite company.

20 May

Tropes about homebirth

I like Alice Roberts, she is interesting and clever. Some of the things she has written about birth have given me plenty to think about, and it’s good for me to think. This evening twitter drew my attention to an article in which she claims to take a “scientific approach to having a baby.” The article may be a year old, but it is relevant in the light of new guidance from NICE recommending that more women should give birth at home.

This of course has flushed all the extreme advocates of both hospital and homebirth right out of the woodwork, so here’s trope number one:

We all have to be for one thing and against the other.
Surely it’s a little more nuanced than that.

And it’s those nuances that make up the rest of the tropes.

Human birth is difficult and dangerous.
Except, not for everyone. Where does this information come from? What’s the evidence for that statement, as made by Roberts in the above article, and followed up by this statistic: “about five per 100,000 women die in childbirth and four per 1,000 babies” So, we’re not dropping like flies. And yes, in some cases that’s because modern medical intervention improves outcomes. But it’s also because in many cases, women’s bodies are apparently surprisingly good at giving birth. Up to date medical knowledge, high standards of midwifery training, and modern cleanliness are also factors, but these things are not exclusive to hospitals.

A healthy baby is the only important outcome.
Postnatal trauma is a real thing. Where the risk of a poor outcome to the baby is very small, maternal satisfaction with the birth process is actually highly relevant. The “healthy baby” trope buys into the patriarchal system where women must be compliant and put her unquestioning trust in the doctors; furthermore she should be grateful that they “deliver” her healthy live baby, no matter what they did to her, often without fully informed consent, in order to achieve that. The draft NICE guidelines acknowledge the importance of maternal satisfaction with the process; this is not the same as prioritising the process of birth over the goal of a healthy baby; it is simply stating that birth is a process. Giving birth is a huge physical and psychological event, and to reduce women to precious vessels whose only role is to produce live offspring is patronising at best.

A high proportion of women planning a homebirth end up transferring into hospital, so why bother?
Roberts quotes a 45% transfer rate for first time mothers, 12% for subsequent births. Of course, nobody goes into hospital before actually going into labour unless they’re suffering some severe condition such as pre-eclampsia. This is not an argument against labouring at home, and does not necessarily mean that those mothers who transfer in have less satisfaction. If we could take the value judgement out of home vs hospital, we could look at this as encouraging women to labour at home and only go in if necessary, rather than framing it as failure to birth at home.

If you need intervention, it’s instantly available in hospital.
Not true. You may have to wait a couple of hours for an anaesthetist to be available, or for the previous woman to move out of theatre. So plenty of time for that transfer.

Well duh, of course there’s a lower risk of intervention at home, because you can only carry out intervention in hospital.
This still isn’t an argument against homebirth, and it is one of the main reasons women might choose to birth at home. Yes, obviously, the tools are not available. If an intervention is necessary, then a transfer is going to be needed. But an intervention is less likely to be necessary where women give birth in a calm home-like environment. Statistics demonstrating a lower incidence of intervention in planned homebirths include those who transferred and then experienced intervention, because that happens.

Homebirth advocates present the research findings with the wrong priorities because they have An Agenda.
And by “wrong priorities,” we mean priorities that differ from hospital birth advocates. From Roberts’ article:

look up “home birth” on the National Childbirth Trust (NCT) website, […] the findings are laid out in exactly the opposite order to that in the original research paper and the RCOG’s statement: women having a home birth are more likely to have a “normal birth” without intervention; home births are safe for women having a second or subsequent baby; lastly: home birth increases the risk to the baby for first-time mums. The main outcome investigated by the study is the last to be mentioned.

What NCT are doing here is normalising straightforward birth. It’s all semantics, innit? If you do follow Roberts’ link to NCT, you will see that the risks are clearly mentioned. In fact, it took me several attempts to replicate Roberts’ results by searching NCT’s website; the first few articles I came up with were clearer, more accessible, and included links to relevant information from The Birthplace Study and the NHS.
I would argue that hospital birth advocates also have An Agenda.

Homebirth is unethical and dangerous
In January The Independent headline claimed that homebirth was “as dangerous as ‘driving without putting your child’s seatbelt on’.”
The always excellent NHS Choices website responded to this with the conclusion:

A case could be made that rather than discouraging home births, we should instead be improving the levels of support to women who choose to home birth and so reduce the risk of complications.

Perhaps that’s where we should leave it. This isn’t about our different choices making us good or bad people, or our different experiences making us successful or failures. It’s about informing and supporting families, even those whose priorities aren’t the same as yours.

Views expressed here are my own, and do not represent the views of NCT.

04 Apr

The science of birthplace

My work now includes talking to parents-to-be about where they choose to give birth, and so this subject is of increasing interest, particularly since the skeptics I hang out with suck their teeth a little when we get on to the subject. To be quite frank, I suck my own teeth. It’s very hard to weigh up the pros and cons of a subject in which even the most scientifically minded get rather emotionally invested. I will conclude, perhaps, that we all give different weight to different outcomes, and that’s parenting for you, which means that I am as usual chasing my tail and asking “why can’t we all just get along?”

This is a complex and emotive topic, and few people seem able to write about it without their passion leaking through. So let’s state upfront that my passion is to support parents to make their own informed decisions, decisions they will have to live through, and live with, about an event that is in many cases earthshattering in the experience itself, and in its ramifications. Giving birth is a very big deal. Yes, it’s a normal physiological process and women’s bodies are well-adapted to perform it; but let’s bear in mind two very important provisos here:

  • It’s 2014. We give birth in very different conditions than those to which our bodies are adapted; and
  • Birth is safer in England than it has ever been, and this is down to a range of factors including modern techonology and hygiene.

But giving birth is not simply a physiological process. It is a profound life event affecting our bodies and our view of our bodies, affecting our families and other relationships, affecting us in social, financial and psychological ways that cannot possibly be accounted for in a simple birthplace study. Therefore birthplace studies tend to base their conclusions on measurable outcomes, usually neonatal death, injury, or oxygen deprivation to the baby. Some studies also consider some physical outcomes for the mothers, such as whether she experienced medical interventions or whether she went on to breastfeed. Very few studies consider birth trauma as an outcome.

Which? Birth Choice has a very clear set of tables comparing outcomes for hospital obstetric units, midwife-led birth centres, and homebirth. This is based on the 2011 study Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study BMJ 2011;343:d7400. If you click through to the tables in the report you find risks for ALL births reported as 4.3 adverse outcomes per 1000 births. This is then broken down to show the differences for first births (5.3/1000) compared with second or subsequent births (3.1/1000), and broken down still further to show risks according to place of birth. As has been reported, the risk of an adverse outcome at a planned homebirth for a first baby shoots up to 9.3/1000. As has not been reported, the risk of an adverse outcome at a planned homebirth for second or subsequent baby drops to 2.3/1000. The study concludes that “The incidence of adverse perinatal outcomes was low in all settings.” The headlines, meanwhile, focus on the relative risk: 9.3/1000 is more than twice as high as 4.3/1000, therefore homebirth is twice as dangerous as hospital birth.

Parents need to be given these numbers along with a little bit of information about how to make sense of them, which is where the Which? page is useful. But they also need the opportunity to consider what other outcomes are important to them, given that the absolute risk of adverse outcomes is so low. The Which? page gives information about the likelihood of intervention in various settings, and parents may want to consider this as a factor in their decision making.

Meanwhile, all this pitting of hospital birth against homebirth results in Birth Centres being overlooked. Birth Centres are intended to offer a home-like setting, with midwife-led care. They are often located within hospital settings, so the obstetric facilities are on hand. Our birthplace study referenced above shows that the risk of adverse outcomes is comparable to an obstetric unit, while the likelihood of intervention such as instrumental birth or caesarean birth is lower. A 2012 Cochrane Review of Home-like versus conventional institutional settings for birth by Hodnett et al supports this:

Home-like institutional birth settings reduce the chances of medical interventions and increase maternal satisfaction, but it is important to watch for signs of complications.

One thing that is important to beware of is using data originating in the US, since the model of midwifery care in the US is very different to the UK. This perhaps is a subject for a later post, and probably not by me.

Finally I want to come back to the definition of an adverse outcome, where once again women are reduced to the precious vessels, solely charged with but not entirely trusted to bring this baby to the world unharmed and perfect in every way. What about outcomes for mothers? I have heard Sheila Kitzinger speak on the subject and read some harrowing accounts of childbirth:

one reason why many women have low self-esteem and cannot enjoy their babies is that care in childbirth often denies them honest information, the possibility of choice, and simple human respect…..

Studies from 2003 and 2004 found that up to 6% of women show full PTSD symptoms following an experience of birth where they felt scared, helpless and vulnerable. While all the focus is on outcomes for the baby, women’s lived experience is belittled and ignored as a decision-making factor. This is why parents need to be given all the information, and not frightened into seeing hospital birth as the only safe choice for their babies, regardless of how it will feel for them; and the information given needs to include more than just the risk of adverse outcomes for the baby.