Tag Archives: pregnancy

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?

15 Jan

Book Review: Bumpology, by Linda Geddes

Bumpology is an attractive and accessible book with a very clear and logical layout, which compensates for the lack of an index. It is as easy to dip into as it is to read from cover to cover; I know because I did both.

This is a marvellously comprehensive collection of research evidence and occasional comment upon the lack of research evidence, for all the advice and received wisdom relating to pregnancy, birth and early parenthood. As Geddes says, the science is out there, but it often takes some digging to find it.

Geddes looks at the big issues such as place of birth, breastfeeding, and all those things you’re told you can’t eat during pregnancy; as well as bringing in some colourful sections on how the growing baby develops in the womb, what senses function from birth, and the role of newborn reflexes. This in itself is a useful part of learning to empathise with the baby, and might influence parenting choices.

I am used to reading far more dogmatic books (from all over the birth and parenting spectrum), so this measured tone is very refreshing. Research in this area on the whole appears to be very thin, often studies are very small or based on the behaviour of lab animals. The book does not offer many definitive answers, but its general message is not to take advice for granted, since much of what we are told from the moment we even start to think about having a baby has no basis in fact. This very important point was made by Octavia Wiseman in a recent Midirs article (July/August 2012:p22), pointing out that much health advice is risk-averse, undermining parental choice, and that “explaining to women the limitation of our evidence base is the first step to take when asking them to make ‘informed’ choices.”

It is lovely that the text is scattered with anecdotes about the author’s personal experience, but for the most part this book is about facts not feelings. It largely ignores ‘soft’ aspects such as how parents feel about risk, and how mothers experience birth and early motherhood. Statistical comparisons of different aspects of birth look at outcomes and define those in terms of health of the baby and mother, taking little account of how women feel during and after the experience. For example lying down or being mobile during labour may make no difference to the outcome in statistical terms, but different women may experience these scenarios as more or less positive. Lying down in a room full of medical staff may feel disempowering; a woman being made to walk around may feel bullied. Working with parents both antenatally and postnatally, I know that scientific evidence may not always be the most important factor when making decisions. A good example of this would be the decision to share a bed with your baby: whether, according to various studies, this increases the risk of cot death; or whether it increases your child’s self-esteem, are less likely to influence the decision to bedshare than the fact that it might just be easier not to have to get up in the night. This does not, of course, detract from the fact that parents can and should be made aware of the evidence in order to make an informed decision; and to be fair, Geddes does not set out to explore the qualitative aspects of parenthood, but to present the facts and figures, and bust the myths: a very worthwhile mission.

I would recommend Bumpology to anyone expecting a baby, but I think it is also essential reading for anyone working with parents, antenatally or postnatally. It is so important for us to get our facts right, to counter the myths and enable parents to be confident in their decision making. Very few of the books I’ve seen are so robustly evidence-based, and an awful lot of people working with parents will repeat advice without giving any critical thought either to the evidence behind it, or the effect it might have in an individual situation.

Bumpology Blog
Sense About Science
Linda Geddes on Radio 4’s Today Programme with Belinda Phipps, CEO of NCT

28 Sep

Where’s the evidence?

Louise Timlin is a Health Economist and mother of two.

When I was pregnant with my first child I was often asked about baby-brain. A colleague or friend would smile indulgently and share a story about how they left their laptop on the train, or their wife put their socks in the fridge while pregnant. I smiled politely whilst I thought to myself, of course no non-pregnant person has ever made such a mistake. One day at work, when I was about 6 months pregnant I inadvertently sent out two invites for the same meeting to the same colleagues but for different days. Oops, I thought and shared my error with my boss who was one of the invitees. He laughed heartily and jokingly referred to my “baby-brain”. On my return to my desk I noticed that everyone invited had accepted both meetings without question, yet none of them were pregnant.

I am sure that baby-brain is simply another example of finding evidence for something if you look hard enough. For example I believe that some people are labelled “forgetful” who are probably no more forgetful than anyone else but every time they make a small mistake it is pounced on as evidence of their intractable forgetfulness.

And apparently I am right, according to a study conducted by Dr Helena Christensen from the Centre for Mental Health Research at the Australian National University. The study, published in the British Journal of Psychiatry, followed a representative cohort of women and measured cognition before, during and after pregnancy. No significant differences in cognition were found, leading to the conclusion that previous studies were flawed or biased.

Dr Helena Christensen said, “Part of the problem is that pregnancy manuals tell women they are likely to experience memory and concentration problems, so women and their partners are primed to attribute any memory lapse to the ‘hard to miss’ physical sign of pregnancy. Not so long ago, pregnancy was ‘confinement’ and motherhood meant the end of career aspirations.”

It may be that pregnancy shifts a woman’s focus away from work, and who wouldn’t forget where they’d left the remote control whilst chronically sleep deprived from looking after a new-born baby. But come on girls, give yourselves a break, you are not cognitively deficient and don’t let anyone tell you otherwise.

Having spent 12 years working in the highly regulated field of clinical research I am not a big fan of “alternative therapies”. Don’t get me wrong, I am a big fan of the placebo effect, just don’t kid yourself it is anything else. If it’s not backed up by evidence from a series of well designed, placebo controlled, regulatory and ethically approved clinical trials then you would do well to be sceptical.

The 1023 group concur. They staged a demonstration at 10.23am on 30th January in which more than 400 homeopathy sceptics took a “homeopathic overdose” in protest at Boots continued endorsement and sale of homeopathic remedies. Homeopathic remedies are hugely diluted substances. They are commonly sold at strengths labelled 6C. This means there is 0.0000000001% of the active substance in them.

There are people who are certain that homeopathy works for them. This is why the most rigorous clinical trials are placebo controlled. In clinical trials for antidepressants, up to 40% of patients taking placebo report a beneficial effect. A paper published in the Lancet in 2005 and the Cochrane Collaboration concluded that homeopathy is nothing more than a placebo effect. Proponents will claim that at worst it does no harm. However even this claim should be treated with scepticism. If patients delay seeking proper expert medical advice whilst using homeopathy to treat their condition, they could risk their condition degenerating. By all means go ahead and try it, but don’t forget, we have medicines that have actually been proven to work; why not give them a go at the same time?

Originally written for the Wokingham NCT Newsletter
Views expressed here are my own, and do not represent the views of NCT.

14 Sep

Massage for pregnancy and postnatal care

Linda Cook is a massage therapist, NCT Antenatal Teacher, and NCT Birth Companion.

Would you like to feel pampered and nurtured?  A massage during your pregnancy will provide you with time to relax, unwind and connect with your baby.

You may also be aware of your body’s changing shape and you may be experiencing one or more of the discomforts associated with pregnancy:-  headaches, sinus congestion, stretch marks, oedema (puffiness) in your hands and/or feet, sciatica, back, neck or shoulder discomfort, cramp, insomnia, anxiety….

Massage can help alleviate these discomforts by releasing tightness in the muscles around your neck, shoulders, upper and lower back which can cause headaches, sinus problems and possibly sciatica too. Oedema in your feet and hands can be uncomfortable and massage can help to reduce the fluid retention. Carpal tunnel syndrome can be caused by the oedema in your hands and I can show you exercises to minimise the discomforts you may be experiencing with this condition.

Massage improves skin tone and elasticity whilst helping to minimise stretch marks. Gentle massage will improve your circulation, helping oxygen, nutrients and waste products more efficiently to and from your own body tissues and your baby’s placenta.

On your first appointment we will spend some time getting to know each other and discuss your general health and also how you’ve been feeling during your pregnancy. Whether you are in the 1st, 2nd or 3rd trimester the massage treatments will be gentle and adapted specifically for your needs on the day. For your comfort and to allow for your growing baby, various positions may be used whilst supporting your changing body with pillows.

Postnatally, massage can be very helpful whilst you adjust to your new life as a mum as it is still important that you find time to rest and relax. Massage is very beneficial at this time to minimise and prevent any discomforts that you may be feeling. On an emotional level, massage may help to alleviate any feelings associated with postnatal depression.  Babies are very welcome to join you for any postnatal session as they also find it a comforting time relaxing and bonding with their mum.

As a massage therapist I enjoy working with mums and babies as I feel it’s a very important time in a woman’s life. My experiences as an NCT antenatal teacher and birth companion have enhanced my skills, providing me with additional knowledge and tools to share with you within your session.

If you would like any more information or would like to have a chat about how I may be able to help you, please call Linda on 0118 9697461

Celtic Touch