research | Motherworldly

02 Dec

Book review: Biological Nurturing, by Suzanne Colson

On reading the second edition of Biological Nurturing, I am reminded of what a powerful influence the first edition has been on my work as a breastfeeding counsellor, both in terms of how I talk about positioning, skin to skin, and the transition from womb to world in antenatal sessions; and how I support mothers with breastfeeding after the birth.

Suzanne Colson has vast clinical experience and research experience of what is now widely known as her method: biological nurturing. Biological nurturing is far more than just laid-back breastfeeding; it is a deep understanding of the needs and abilities of the breastfeeding dyad, almost a philosophy of positioning. It is a mother-centred process, using gravity and both parties’ instinctive behaviour, to achieve comfortable and effective breastfeeding.

It could be argued that this is simply a rediscovery of ancient behaviour: the way women breastfed long before male experts took over all the thinking and management of it, to spare our pretty little heads. Colson describes some of the social and cultural movement away from instinctive breastfeeding, using her own science to show how wrong those 18th and 19th Century men of science were about what we do. As she tells us, “you cannot teach mothers to do this,” (p158) because it is instinctive behaviour, highly dependent on the hormonal environment. So the role of a breastfeeding supporter is to enable that environment to be right for the mother and the baby, and to have confidence that this innate behaviour works.

Colson has a great deal of research to support her work, presenting it here in detail, and yet with accessible language and even QR codes so that the reader can access video clips. She is critical of the deeply entrenched, prescriptive ways that some midwives manage early breastfeeding, and this might be a difficult – but essential – read for those who work in that way. It is a fascinating and useful book for anyone supporting breastfeeding, and for mothers who are interested in a much deeper level of knowledge than they will get from your average book on breastfeeding.

[Disclosure: I was sent a review copy of Biological Nurturing. You can obtain yours, with a 10% discount when you use the SPROGCAST code, from Pinter & Martin].

29 Nov

Book review: Informed is Best, by Amy Brown

This afternoon I opened the latest copy of MIDIRS, and a couple of inserts dropped out of it. They are training modules, one on infant skincare, and one on breastfeeding challenges. I browsed the latter for a moment, noticing a paragraph mentioning a Cochrane review on the treatment of nipple pain:

However, the latest Cochrane review (2014) found insufficient evidence to recommend breast milk or any other intervention for treating nipple pain.”

So I looked up the Cochrane review, and here’s what it actually says:

Currently, there is not enough evidence to recommend any specific type of treatment for painful nipples among breastfeeding women. These results suggest that applying nothing or expressed breast milk may be equally or more beneficial in the short-term experience of nipple pain than the application of an ointment such as lanolin.

The picture above shows who produced this document: Lansinoh. A company with a vested interest in selling an ointment such as lanolin.

With this in mind, I picked up my copy of Amy Brown’s latest book, Informed is Best, a book which purports to help the reader fight their way through the tangle of misinformation, opinion, and hidden agendas that gets deeper and deeper as you wade into pregnancy, birth and parenting. This is a very useful and important book, and is more important than ever in an era of fake news, limited attention spans, and a distrust of experts – as the book itself explains in glorious detail.

What I find amazing about Amy’s writing is her ability to gather so much information, and distil it into meaningful and accessible writing; in fact she quotes a study where a mother describes wanting “mom-level detail from an expert” (p226) and this is exactly what we have in this book. Amy sets the context, looking at how the media, social media, and the patriarchy shape our access to good quality information. She explains different types of research, and even gives us a quick blast of how to understand statistics in a way that didn’t actually make me want to poke my own eyes out. The text is wonderfully seasoned with examples, including unpicking many twisted media reports of research; and presented in her marvellously offhand-but-serious-really style. For a book about research, it’s just such an enjoyable read.

One thing I especially love about this book is her exploration of her own bias, along with sections that really should make the reader reflect on their personal biases. The Dunning-Kruger effect really gave me pause for thought. How often do I dismiss someone’s work because of a connection with something I didn’t like reading or hearing? It definitely happens.

Each chapter ends with a practical list of ways to keep informed, summarising the detail within. My favourite is: “To any female expert reading this, I urge you to have the confidence of a mediocre White man.” (p124). Oh yes indeed.

If you want more, I interview Amy about the book in episode 56 of Sprogcast. To get your copy of the book, use our 10% discount code SPROGCAST at the Pinter & Martin checkout here.

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.

22 Nov

Book Review: Testing Treatments

Testing Treatments by Imogen Evans, Hazel Thornton, Iain Chalmers & Paul Glasziou asks the crucial question, how can we ensure that medical research effectively meets the needs of patients? It is a crucial question because all over the world, resources are wasted on poor quality research, research that only meets the needs of drug companies, and on unproven, disproven, or unnecessary treatment.

The authors state that medical research is ‘everybody’s business’ (p.114) and suggest that if patients, doctors and researchers worked as a team, the testing of treatments could be more effective, precise and useful. The BMJ famously bans the phrase ‘more research is needed,’ and Evans et al, who comment ‘do less… but focus the research on the needs of patients’ (p114) clearly agree.

A useful complement to Ben Goldacre’s Bad Science and Simon Singh’s Trick or Treatment, Testing Treatments clearly lays out the principles of robust research, defining what makes a fair test, and explaining the importance of setting a study within the context of existing research. In itself, these principles do not sound particularly challenging, but the authors go on to show how the waters are muddied by vested interests, patient pester power, paternalistic clinicians, and inexcusable poor practice.

Finally, they set out a strong blueprint for a better future, asking for patients to be treated as equal partners, both as individuals requiring treatment, and as groups participating in research.

The manifesto is laudable, but for this to work, people need to read this book and get on board; and not just other academics. There is an obvious effort to make the style of the book accessible to the wider public, and indeed it is, as I read it in two days despite the company of a bored five year old. I found the slight dumbing-down of some of the terminology (words like ‘menstrual’ and ‘cardiac’ explained in parentheses) slightly patronising; and the over-simplified diagrams lacked much meaning. Boxed quotations are scattered over almost every pages, which breaks up the flow of the text without adding very much in terms of content. However the chapters are very clearly laid out and richly illustrated with anecdotes and examples. It was impressive that the entire chapter on statistics managed to avoid using the word ‘statistics.’

I would definitely recommend this book to my colleagues and to some of my more sciencey friends, but this is why I feel that it will mainly preach to the converted. Those paternalistic GPs who are certain of their infallibility, those focus groups desperate to prolong precious life, those politicians in the pockets of big pharma: they should be forced to read it!

I took away from Testing Treatments, a much enhanced understanding of the arguments against routine screening, and an appreciation of the need for greater regulation and better-informed consent for treatment outside the context of clinical trials. I enjoyed reading what could potentially have been a heavy-going book, but was in fact, as Ben Goldacre says in the foreword, ‘interesting and clever.’ (p.xii)

***

To order Testing Treatments with a 25% discount, just follow the link and use the discount code KH25 at the checkout.