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.

20 Apr

Book Review: Your No-Guilt Pregnancy Plan, by Rebecca Schiller

I’ve been waiting for this book for years – since my own pregnancy, in fact.

Rebecca Schiller, director of Birthrights, has created a manual for pregnancy, birth and the early weeks of parenthood, that is mother-centred and evidence-based, and achieves that incredibly difficult feat of getting the right tone when balancing those two things.

Your No-Guilt Pregnancy Plan – A revolutionary guide to pregnancy, birth and the weeks that follow skips the “your baby is the size of a walnut/pear/skateboard” theme that most writers on this subject consider to be mandatory, and focuses on what is happening to the woman: how she might be feeling, how her body is changing, how the pregnancy/baby affects her world. It includes exercises and checklists to help women reflect on their goals and enjoy the experience; and is kept completely up to date with an accompanying set of links to further reading and support on Rebecca’s own website.

As with most such books, there is a chronological approach. However some things you will not find in most such books are a clear emphasis on the rights of women, on the basis that when women are well cared-for and respected, outcomes improve for them and for their babies. It’s a very realistic book, and a fine example of giving information without advice. With one or two small exceptions, this book is about the reader, not the writer.

And so we come to the breastfeeding section, which you know I looked at first. It’s good. It covers the basics of milk supply and positioning, some of the early challenges, and where to go for help. This sits alongside clear guidance about formula feeding, and not a lactation cookie in sight.

The final chapter of the book helps the reader to refer back to relevant sections of the book, in order to create a personalised plan for pregnancy, birth and afterwards, including a going into labour checklist, and a ‘little black book’ of support for the early days, so you don’t have to figure it out when you need it.

This is the most realistic, practical and informal guide I have seen, and goes straight to the top of my pile of recommendations.

[Disclosure: I received a free review copy of Rebecca’s book.]

29 Aug

Book Review: Growing Up Pregnant, by Deirdre Curley

I sat up in bed and admired all the women in the room. All of us had different birth stories, and we each realised how lucky we were to have healthy babies. Although we were all at different stages in our lives, we were all going to be going through the exact same transition into motherhood. (p184)

Deirdre Curley is pregnant and 19. She is surrounded by a supportive family and a loving partner. She really wants to be an actress, and she isn’t at all sure she wants to be a mum.

In Growing Up Pregnant, she tells the story, not just of pregnancy and birth, but all the things that bring her to this point. And then in detail she takes us through the months of her pregnancy, and the reader witnesses her maturing from good-time girl to “the most beautiful pregnant lady” one waitress has ever seen. When she and her partner make up their minds that they will be parents, they commit to the changes they need to make, even when it’s hard to adjust to the loss of old pleasures and still-partying friends. It’s so interesting to read about their mixed feelings as they adjust to this new lifestyle, and the strength and positivity they bring to it is admirable.

Deirdre pauses between each trimester to give a little rundown of what a pregnant woman might be experiencing, how her baby is developing, and any preparation she might consider doing. This includes the most down-to-earth “what to buy” lists of any pregnancy book I have read. She refrains from too much specific detail about pregnancy and birth, but gives a useful overview that would be relevant to a pregnant woman of any age.

This is a properly grounded book, both reflective and informative, and does as good a job as any (and better than most) of getting across what it’s really like to be pregnant and to have a baby. Although the focus is on pregnancy as a young mum, most of the feelings Deirdre expresses are pretty universal: what is happening to me? Will my body ever be the same again? Can I rely on the support of my partner? Am I going to be a good enough mum? Women twice her age think the same things.

I enjoyed taking this journey with Deirdre and her partner Gary, as they put down roots and prepare for the baby. The birth itself is well-written, and early motherhood is covered with both wistfulness and joy. It is a very realistic description and I would certainly recommend this book to pregnant women, whatever their age.

[Disclaimer: I was sent a free review copy of Growing Up Pregnant. You can order yours from Pinter & Martin, with a 10% discount at the checkout if you use the code SPROGCAST]

16 Mar

Book Review: Why Hypnobirthing Matters, by Katrina Berry

This interesting little book explores the development of hypnobirthing as an approach to childbirth, from its origins in the thinking of Grantley Dick-Read, to its modern usage in situations from freebirth to caesarean and beyond. Author Katrina Berry points out what a useful coping technique it can be for early parenthood and for life in general.

The book goes on to explain how hypnobirthing works, and its relevance for birth partners and midwives. It does not claim it as the province of one particular type of birth, but does emphasise its role in increasing the likelihood of a straightforward birth, and offers information to empower women to make their own choices in any situation.

It finishes with a useful comparison of the different hypnobirthing tribes, in their own voices. This gives a real flavour of the slight changes in perspective from one programme to another.

Parents-to-be or practitioners with an interest in hypnobirthing can use this book to learn about what it is, and then decide which path will help them on their own journey.

[Disclaimer: I was given a free review copy of this book by the publisher Pinter & Martin. You can buy it here, with a 10% discount using the code SPROGCAST at checkout.]

24 Feb

Book Review: How to grow a baby and push it out, by Clemmie Hooper

Clemmie Hooper is the new Mark Harris: the midwife all the talk shows want, popular on social media, and with a new, slightly different book about pregnancy and birth. Sorry Mark.

How to grow a baby and push it out‘ is a colourful, cheery book, with lots of pictures (mainly of Clemmie herself looking pregnant and glamorous). With a heavy emphasis on what to buy and how best to treat yourself (“Find a really, really lux hotel to stay in.” p101) and an assumption that you will “buy friends” by doing NCT classes, this really is the yummy mummy’s handbook.

I would have quite liked this book during my pregnancy ten years ago. In between the slightly vapid chapters about shopping, it covers a lot of topics, including how to massage your perineum, what to consider when choosing a place to give birth, and different options for coping with pain. With its bite-sized chapters and clear explanations, it is more accessible and less gloomy than the book I did have, ‘What to expect when you’re expecting.’

Reading it now, I would like to see more on consent and informed choice; Clemmie is in a good position to talk about building that kind of trusting relationship with Health Professionals, but at the end of the day she is working within a medical model, and that’s what comes across. The information given about breastfeeding is scant and inadequate, starting with a list of its benefits, omitting any discussion of how it works, conveying the message that it is always difficult and usually painful, and then admonishing readers not to pay attention to pressure about how long to do it for. This could have been done so much better.

I liked the positive tone of the book, although in places the chumminess gets annoying; and I liked the focus on active birth, and the signposting (other than in the breastfeeding section) for readers who would like to explore the many topics in greater depth. It’s a nice starting point for mums-to-be who like a guidebook, but doesn’t really replace good quality antenatal education, where there will be more for partners, and lots of opportunities to discuss what might happen and how you might feel, rather than just be passively told about it all.

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.

01 Sep

On having an abortion

[10 years ago]

It’s 4.30am. I’m sitting on the side of the bath, watching as the moisture seeps up the stick. A line appears, dark pink, just as it should. The instructions said five minutes, so I continue to watch, and slowly, beside it, a second pink line appears, such a pale ghost of the first that I could almost kid myself that I am dreaming it. But definitely a line.

I’m stunned. This is an experience I never expected to have. Of course there is no question of me having a baby right now, I know that straight away; but I still feel strangely pleased and positive. It’s shattered my fundamental assumption that I can’t conceive, and that’s a huge deal. I feel sad that this is very much the wrong time, but completely astounded that I do have the option, after all.

My marriage ended a year ago, and I’ve been with my boyfriend for a few months. We’ve just made the big decision to reduce the 100 miles between our homes and live together. We have so much fun, so much in common, so many possibilities. We’re not ready to bring a baby into this relationship, there just isn’t room, yet.

I see my GP who points out that I’m 33 and it’s taken me months to conceive; what if I have an abortion and then never conceive again, won’t I regret it? But my priority is my relationship, and what if I go ahead with the pregnancy and the relationship doesn’t survive? I currently have no maternity rights and no savings, and I’m happier than I’ve ever been in my adult life.

Do I have a moral obligation to have the baby? No. I have a moral obligation, when I make a positive decision to have a baby, to be prepared. To have a body free of alcohol and antibiotics, a secure roof over my head, and a few more years to solidify this relationship, to give a baby a stable family. This is not a difficult decision, but nor is it one I make lightly.

*

I have to endure Christmas through morning sickness and hormones and a strange stab of conscience with every glass of wine I drink. In early January I am sent for family planning counselling, expecting to be judged or dissuaded, but none of that happens. It’s all very practical and I feel a bit scared, mainly of how I might feel after The Procedure. I notice that none of the professionals seem to use the word “abortion.” They tell me that there will be a lot of blood.

My boyfriend and I book a Friday off work and I spend a miserable night and morning feeling nervous and not allowed to eat in advance of the anaesthetic. The clinic looks like a large house on a residential street, inside and out. I’m taken to a bedroom with two other women, and the nursing sister talks to us all together about what will happen. We put on surgical gowns, then we wait for a bored, tense hour, to be taken through. We don’t chat.

I am the last of the three to be taken away. The staff are pleasant and efficient; it’s so clearly all in a day’s work. They check my temperature and my blood pressure, and give me a hairnet. The anaesthetist and the surgeon introduce themselves to me. I am not particularly bothered that they are men, but younger girls might mind, I suppose. As I lie on the bed being wheeled through to another room, a voice asks “is this our last one this morning?” It makes me feel like I’m being processed on a conveyor belt, and frankly the impersonal touch is exactly what I need.

I lie looking up at the lights, just waiting for the anaesthetic; at this stage, I really don’t want to know any more about it. I want to be out, I want that moment before unconsciousness, where I’m certain that the next thing I know, it will be over. They take an age to get the needle into my hand and I panic that for some reason it might not work. The last thing I remember before the feeling of numbness starts to creep through my veins, is them fixing stirrups to the side of the bed, a moment of knowledge that my pregnancy is about to be sucked out of me, and then nothing.

*

I wake in post-op, where a nurse is watching for me. I try to speak and my words sound slurred. I say I can feel terrible cramps, and the nurse tells me that’s my womb clamping down, and it will stop soon. I’ve been given painkillers and antibiotics but they haven’t kicked in yet. I gather myself up, and someone walks me back to my bed in the waiting room.

I lie down feeling tearful and lonely, wanting to be able to let my boyfriend know I’m alright, wanting to go to sleep, wanting a cup of tea. That wish is granted about twenty minutes later: tea and biscuits, and I sit up and feel a bit better. The cramps fade. I listen to the other women chatting quietly. One already has three children, she didn’t want to go through it all again. The other woman is Irish.

Finally I am allowed home, and I can spend the weekend feeling a bit delicate but on my way back to normal. It takes a little while for the hormones to seep out of my body. I still have this strange feeling of sad-happy acceptance of the situation, that I’ve had from the moment I took the pregnancy test. This is something I needed to do for me, for us, at this time. It was weird to be pregnant, without being a mum-to-be, and over the weeks I was pregnant, I did let myself form an odd detached attachment to my little clump of extraneous cells, knowing that I would have to say goodbye soon. I thought of it as a little bundle of potential which I was putting on hold until the time is right.

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.

06 Jun

Precious Vessel

The media week started well, with the heartwarming story about Finnish baby boxes, which I’ll write about later. And then it all went downhill with the release of an amazing report from The Royal College of Obstetricians and Gynaecologists on Chemical exposures during pregnancy.

The RCOG “encourages the study and advancement of the science and practice of obstetrics and gynaecology.” On this occasion, they have taken this to an extreme, by advising women to avoid any possible exposure to chemicals, which may or may not have a harmful effect on their developing baby. While they do explicitly state that none of these harmful effects are proven, this is not how it comes across in the media. Dr Michelle Bellingham, co-author of the report, goes a step further on Radio 4 by asking what harm it does to follow this advice, to err on the side of caution.

So what harm does it do, to tell women not to use cleaning products, shower gel, or make up; not to buy new furniture (presumably including cots and car seats); not to eat any processed or packaged food? Astonishingly, this is presented as “practical” advice. The message it sends is that women themselves are of little importance compared with the package they are carrying. Our job is to breed, and we had better do it well, and if this means no deodorant for nine months, suck it up. In a world where we are made to feel uncomfortable using our breasts for their original purpose and we are expected to glow throughout pregnancy; we are now expected not to wash.

And as the report itself states, there is little or no evidence that any of these items actually do any harm, so this controlling advice is utterly spurious, and the idea that it is supposed to be in any way helpful to women is disingenuous.

Meanwhile any useful evidence-based guidelines are more likely to be ignored by women overwhelmed with conflicting and impractical instructions. On the one hand: good, we are grown-ups, we can make up our own minds. On the other hand, this is a real fail for those of us trying to provide evidence-based support during pregnancy and early parenthood.

Further Reading
The NHS’ excellent Behind The Headlines series takes the report apart here.
Sense About Science dismisses the usefulness of the report and the media coverage here.
Fran Yeoman responds as a new mother, in The Independent.
Risk Sense asks Is everything a risk when you’re pregnant?