03 Jun

Book Review: Inducing Labour: Making Informed Decisions, by Dr Sara Wickham

Sara Wickham’s new book Inducing Labour: Making Informed Decisions aims to explain the process of induction to parents and to professionals. It very clearly covers the how and why, and comprehensively goes into the risks and benefits of the most commonly encountered scenarios. Wickham argues strongly for women’s bodily autonomy and individualised care, and the whole book is set firmly within the evidence base. Her discussion of the evidence was for me (and unsurprisingly!) the strongest point of an all-round excellent book, and I was prompted to reflect on her point that we all interpret the evidence according to our existing biases.

This is a book written for women, addressing “you” the pregnant mother, but without holding back any technical points or difficult statistics. It is also an important read for antenatal teachers, midwives, and anyone supporting women to make decisions about their care. There are, for example, some useful points that a woman can use for agreeing a “due date” with her midwife or consultant, and some questions that are helpful to ask in order to ensure care is personalised rather than simply following a protocol. Above all, there is really clear information about the impact of induction in a number of different situations, and a good breakdown of statistics for example on the risk of stillbirth in older mothers, and how likely it is that earlier induction would make much difference to these stats (answer: not very likely).

In fact the message that comes across most clearly is to trust women and to trust women’s bodies. The evidence that induction routinely improves outcomes is simply not there, and anyone needing to argue that point with a clinician would find this book a really useful resource. In a culture where the baby’s safety is prioritised over everything, it is good to read a practical, straightforward discussion of why intervention is often not the best way to do no harm.

I was sent a free review copy of Inducing Labour. You can get more information here, and your own copy from here.

08 Dec

Book Review: Breastfeeding Uncovered, by Amy Brown

Before reading Amy Brown’s book, I became aware of a highly critical review of it, written by someone who admitted to not having read it. She felt pretty strongly that the world doesn’t need any more books exhorting women to breastfeed.

Having actually read it myself, I get the feeling that Amy Brown would agree with that sentiment; and while Breastfeeding Uncovered: Who Really Decides How We Feed Our Babies comprehensively demonstrates the importance of breastfeeding for babies, mothers, and society, this is not a book telling mothers that they must breastfeed, but rather one that explains the complex range of reasons why so many of us don’t. It’s not even a book that is explicitly aimed at mothers, since it isn’t a how-to-breastfeed manual; and it is likely to be useful to a wide range of readers including new fathers, grandmothers, health professionals, and anyone supporting a breastfeeding mother. It also might be a helpful read for mothers who have stopped breastfeeding and perhaps have mixed feelings about that decision. And one final demographic: I’d recommend this to policy makers, politicians, budget holders, and anyone involved in public health promotion – these are the people who can really use this information to protect and support breastfeeding in a society that just doesn’t seem to get it.

Breastfeeding Uncovered addresses social, cultural and political issues; examines the impact of transition to motherhood; and talks about the reality of breastfeeding for modern families. There are some lovely clear explanations, for example the SIDS statistics in relation to bedsharing; and I found myself trying to memorise certain facts and phrases for use in my own work.

Amy Brown’s voice comes across very clearly, and initially I wasn’t sure if I would find the occasional sarcasm a bit annoying. But she uses it to make such good points that it’s pretty hard to get annoyed. She really just tells it like it is.

If I had to find gaps in this thorough work, I would like to see a little more mention of highly qualified volunteer Breastfeeding Counsellors such as those trained by NCT and ABM, who occupy the space between Lactation Consultants and Peer Supporters. There is also a vast network of support now available on social media and websites like Netmums, but perhaps that’s scope for the next book.

The real strength of Breastfeeding Uncovered is its firm grounding in an absolute wealth of evidence, both from the author’s own research and from many other reputable sources. Haters gonna hate, but they can’t actually argue that Amy Brown is wrong, or that she doesn’t understand the complexities of infant feeding, or that she is exhorting mothers to do things her way; to do so would indicate that they too have not read the book.

You can get a copy of Breastfeeding Uncovered here, with a 10% discount if you use the code SPROGCAST at the checkout.
Disclosure: Pinter & Martin sent me a free review copy of this book.

18 Mar

The value of breastfeeding in pounds, pence, and Brazilian dollars

This morning we are hearing on the news about a study from Brazil that demonstrates an economic value to breastfeeding, evidenced through measuring IQ, educational attainment, and income at the age of 30. It’s a fascinating study with a large cohort, followed up over 30 years, and of course it is causing the usual furore.

Here is the paper in full: Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age and I would recommend actually reading it before you commence your ranting, since I have seen on social media this morning so many straw man arguments standing up against it.

This research set out to examine the claim that “breastfeeding can also increase individual income, and thus contribute to economic productivity,” as previous studies have not demonstrated this. Inevitably detractors will argue that there is more to life than economic productivity, with which I would certainly agree. However the value of a study like this is in providing evidence of a real economic value to breastfeeding, which could sway policy makers into increasing funding for breastfeeding support and education. We already have plenty of evidence that breastfeeding rates would increase if effective support was more widely accessible; surely some fund-holding decision maker somewhere can join the dots?

What this research does not set out to do, is to judge individual women for their feeding decisions. And yet that is the strongest reaction I have seen today: this kind of report makes women feel guilty. Self-appointed and unqualified “expert” Clare Byam-Cook called the research controversial on TV this morning. The controversy is in this kind of response to it, not in the research itself. The research does not say that you are a bad parent if you don’t breastfeed, and it does acknowledge the many other factors in both nature and nurture that contribute to the outcomes measured – but the researchers did control these variables quite thoroughly and still demonstrated a correlation.

As a breastfeeding support worker who scrapes a living and works mostly in a voluntary capacity, I appreciate anything that might influence future policy making, and I rail against society-imposed guilt imposed on individual mothers who make hard decisions in difficult circumstances, when effective support has not been available to them.

29 Dec

Tongue Tie: the other side of the divide

Recently I read a blog post about one mother’s experience with her baby’s tongue tie. It was a familiar story: the tongue tie was not picked up for several weeks, during which time breastfeeding was painful and the baby fed ineffectively. By the time the tongue tie was divided, the mother’s milk supply was severely compromised because of that ineffective feeding, and shortly afterwards, she took the decision to stop breastfeeding completely. She feels angry and let down by the health professionals who did not diagnose the tongue tie sooner, by the NCT for not telling her about tongue tie in the antenatal breastfeeding session, and by society for insisting that breast is best, and making her feel like a failure.

I have heard this story so many times, and after reading it I spent quite a lot of time reflecting on why I find it so painful to read, and also on just why it is such a common tale.

What is tongue tie?
Definitions of tongue tie vary from source to source, but all seem to agree on the basics:

Tongue-tie is a problem that occurs in babies who have a tight piece of skin between the underside of their tongue and the floor of their mouth. – NHS Choices.

UNICEF adds that this tight piece of skin stops:

the tip of the tongue from protruding beyond the lower gum. It varies in degree, from a mild form in which the tongue is bound only by a thin mucous membrane to a severe form in which the tongue is completely fused to the floor of the mouth.

Note the varying degree. When a tongue is bound by a thin mucuous membrane, this is usually visible even to the inexperienced practitioner, as you can see it at the tip of the tongue, and it often causes the tip of the tongue to be heart-shaped rather than pointed. “Completely fused” would probably also be obvious. However, there are all the degrees in between these two, which are much harder to spot, harder to diagnose, and harder to resolve. Most practitioners agree that an assessment of the function of the tongue is actually far more useful than making a diagnosis on the basis of what you can see in the baby’s mouth. There is a good tool for assessing both; however I feel that this still misses out a hugely important factor: the mother’s experience.

Suspect and Signpost
As a Breastfeeding Counsellor, my remit with regard to tongue tie is to suspect, and to signpost. I’m not clinically trained, nor am I insured to feel about with my fingers under a baby’s tongue. I do have a number of years’ experience in supporting breastfeeding mothers, and it would appear that there is absolutely no situation where it’s completely obvious what to do. In the last few years I have seen a tongue tie so severe that a Lactation Consultant later said that the baby would not have been able to bottle feed, never mind breastfeed; this was not picked up by the hospital midwives or paediatrician. I have seen clumpy little tongues on babies who pile on weight regardless, owing to their mothers’ robust milk supplies. I have seen mouths with every appearance of a a tongue tie, which on referral to the NHS clinic have come back with the diagnosis ruled out. I have witnessed a midwife dismiss tongue tie as “definitely not,” and gone on to support that mother to finally have it divided six weeks later. I have seen babies whose tongues look completely normal, but on listening to the mother’s story I hear familiar warning bells; and having tried everything we can think of to improve positioning, there is no improvement. I can suspect tongue tie all I want, but if the clinicians to whom I signpost parents disagree, then mothers are left with very little they feel able to do.

So if tongue ties are so variable in both appearance and impact on function, what sort of clinical training would grant me the apparently magical ability to diagnose consistently and reliably, and send mothers and babies to get the treatment they need? So while I am, in theory, supportive of NCT’s ongoing campaign for better services for babies with tongue tie, I have some reservations about how this might be done. In fact, as usual, I feel that it would be helpful to campaign for better services to support parents of newborn babies, full stop.

In conversation with one of the lead breastfeeding midwives at a local hospital, she expressed irritation at the number of referrals she gets where tongue tie ends up being ruled out. In accordance with NICE guidelines, she would prefer conservative management of tongue tie, and better help with positioning and attachment for all mothers. It seemed that she felt the people providing breastfeeding support in the community should be doing a better job. Apparently this is a widely-held view among health professionals and parents alike, so here I’d like to point out that most of our work is done on a voluntary basis, nor do we get paid for the time we spend doing training, and in many cases we pay for our own training.

As one of those who works in the community providing breastfeeding support, I do have the advantage of being able to spend time listening to a mother and observing her baby feed. If I suspect a tongue tie then I will always explain this to the mother and inform her of her options. I don’t make the decisions for them, and I do explore positioning and attachment, and other things that might improve breastfeeding for both of them. The options I inform her of will always include a referral to someone who can rule tongue tie in or out, but frankly anyone who is 100% certain that they can rule a tongue tie in or out at a glance needs supervision.

The NHS is not in a position to grant every midwife the specialist skill of identifying tongue ties, and the experience to do so, overnight. The voluntary organisations even less so. This is simply impossible, never mind the cost, the fact that tongue tie division is an invasive procedure, and – I’m afraid – the lack of clinical evidence to support it. Here is the NICE guideline on that:

Current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve breastfeeding. This evidence is adequate to support the use of the procedure provided that normal arrangements are in place for consent, audit and clinical governance.

Hindsight
Once I fractured my wrist. Initial x-rays showed no fracture, but six weeks later as it had healed, the x-ray clearly showed where the fractured bones were knitting together. Mothers who realise later on that their babies have or had a tongue tie can look back and understand why they had such difficulty breastfeeding, and this can only feel bitterly disappointing, on the basis that if it had been diagnosed and treated, everything would have been fine. In fact not all tongue tie divisions are successful; some regrow and some are just not completely divided. Many babies seem able to breastfeed despite a tongue tie; and many retrospective diagnoses are probably just plain wrong. This brings us back to increasing support for parents, training midwives not just in identifying tongue tie but in effective all-round breastfeeding support, and supporting the voluntary breastfeeding organisations to do more.

Because it’s true that health professionals and parents may focus on the suspected tongue tie to the exclusion of any other breastfeeding issues, particularly improving positioning and attachment, which could sort things out much quicker and – if it really isn’t a tongue tie – more effectively.

I can completely understand the anger that mothers feel when their breastfeeding experience has been disappointing or unhappy, and I understand why those mothers may feel that their experience is universal and if only the NHS and breastfeeding supporters could learn from it, we’d all do a better job. And I agree that we need to keep on listening to mothers and not focus solely on diagnostic tools. But I don’t think tongue tie is something that either we just don’t understand, or want to keep secret. It’s simply more complicated than 1. spot tongue tie; 2. divide tongue tie; 3. all is well.

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

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.

19 Jun

Book Review: Optimal Care in Childbirth, by Henci Goer and Amy Romano

This dense and fascinating book presents a huge amount of evidence and a highly articulate argument for a physiological model of birth, starting from the premise that pregnancy and birth are healthy, normal experiences for the majority of women, and only where risk exists, does medical management become appropriate.

This approach fits nicely with my own philosophy of pregnancy and birth, and is well-supported by short analyses of the research in each chapter. Other reviewers have pointed out that the evidence is somewhat cherry-picked, as is always the way in the context of books on birth. It seems to be categorically impossible to have a truly objective reading of the evidence on this subject, and few people with any real knowledge seem to occupy a middle ground on the spectrum from hardline birth skeptics who can only allow the medical model, and advocates of straightforward physiological birth. Both groups tend to be very blinkered about research that contradicts their point of view.

Optimal Care in Childbirth gives a good insight into the source of this deep opposition between the two philosophies. Within the medical model, pregnancy and birth are presented as intrinsically dangerous and difficult. The historical background to this assumption is well documented. In the 21st Century western world, overall levels of risk, particularly to the mother, are very low; and this results in a narrow focus where almost the sole positive outcome to be achieved is a live baby and mother. Strategies are therefore devised to minimise the maximum potential risks, and preventative procedures become routine. This leads to an assumption that the medical approach is the norm, which has a knock-on effect on the research available. The more women who give birth by caesarean section, for example, the greater the belief in the medical community that birth is difficult and dangerous, and the more deskilled midwifery becomes.

There is no doubt that childbirth is complex, variable, and human; and the outcomes of childbirth are soft, complex and variable too. Goer and Romano define the optimal outcome as:

“the highest probability of spontaneous birth of a healthy baby to a healthy mother who feels pleased with herself and her caregivers, ready for the challenges of motherhood, attached to her baby, and who goes on to breastfeed successfully.” [p21]

However since the language and thinking of research is based in the medical model, the basic assumption is that non-intervention in childbirth equals risk, rather than the other way around. Optimal Care in Childbirth recommends reserving medical intervention for those women who would genuinely face greater difficulty without it, rather than protocols that offer it routinely in order to reduce risks that are already small.

The chapters of the book cover all the main topics of relevance to anyone working in childbirth (it is probably not a book aimed at pregnant women, who might get similar but more accessible information from Ina May Gaskin’s books). The chapters cover caesarean birth, induction of labour, care during labour, birth, postnatal care, and midwifery practice. Each chapter includes a mini-review of research and strategies for optimal care. It is a very practical book and an important resource for midwives, obstetricians, doulas and antenatal educators.

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.

04 Feb

Evidence is overrated!

As a confirmed skeptic, my title is deliberately provocative, but reflects the tail-chasing propensity I have to apply skepticism to skepticism. I absolutely have to be evidence-based in my work, and I’ve completed a BA module in understanding and using research, but I still worry that I’m as guilty as the next person of cherry-picking it to suit my own views.

When it comes to birth and parenting, the quality of evidence available is not great. Much of the subject matter is undefined or too complex to boil down to a testable hypothesis, and RCTs on babies are ethically difficult. On top of that, parents being such a super marketing demographic, there are an awful lot of vested interests.

Most people working in this area are emotionally invested in some way, and not all the organisations supporting parents have a rigorous reflective practice and supervision structure, allowing them to debrief to the extent that they don’t carry any value judgement at all into their work.

This muddies our use of evidence.
There is some research on how hard it is to adopt new learning, when prior knowledge is deeply embedded. Hence out of date practices and misinformation propagated through on the job learning. If new evidence is not a good fit with what we already ‘know’, it is difficult to re-align oneself. We see this with adherents to scientifically implausible theories for example within alternative therapies, where belief is very much stronger than evidence.

There is also research [pdf] suggesting that GPs often base their breastfeeding advice on their own experience or that of their partners. In fact this rule applies to most people: if it worked for you, you may well suggest it to someone else, especially since the urge to problem-solve may be overwhelming. One GP spoke to me at length about something that she called “yeast mastitis.” A yeast infection of the breast (thrush) and mastitis are two entirely separate conditions, with different (but sometimes related) causes and different treatments. This is fairly basic stuff.

Parents are certainly titled to evidence-based information, and there are some good sources such as NHS and NCT websites; but this should include information about the limitations of the evidence, and where professionals supporting parents are unsure, untrained, or inexperienced, they should be clear about their boundaries and limitations. More damage is done by the supportive making up of answers than by handing over a reputable helpline number.

Evidence can be used as a stick to beat parents with (perfect example: “breast is best”), and then on the other hand it really is overrated as a decision-making factor compared with pressing lifestyle issues and social influences. Science journalist Linda Geddes, a busy parent of two who knows the evidence behind exclusive breastfeeding to six months, still chooses formula milk for her four month old when it is more convenient to do so. She weighs the risk, according to the evidence, but also in the balance are the fact that her two children are “simultaneously clamouring for their dinner and I don’t have time to sit and breastfeed.”

This is not a value judgement, but an excellent illustration of the way evidence is balanced and sometimes negated by parents’ lifestyle and needs, when making decisions. For me, it’s the evidence about sending a six month old to daycare that makes uncomfortable reading.

Working with parents is about providing evidenced information and decision making tools and confidence in themselves as parents. Evidence does not make something right or wrong when it comes to parenting, and we absolutely cannot use it either to dictate or to judge what parents do.