02 Jul

Book Review: Expecting Better, by Emily Oster

This book has come across my radar a few times, so I finally got round to picking up a copy. I think my lateness to the Emily Oster party may be because I didn’t much enjoy Linda Geddes’ similar book Bumpology, so let’s put that one to bed straight away; this is much, much better than Bumpology.

Expecting Better is well written, with a personal but not annoyingly chatty tone, while also explaining very clearly how to understand some quite complex research, and incorporate that into one’s decision making. It is aimed at parents-to-be and its chronology starts with trying to conceive, and to my disappointment ends at the birth, although I now see that there is a follow up, cleverly named Crib Sheets, which I shall be purchasing as soon as I finish typing this.

The consequence of the book ending with the birth of Oster’s daughter is that I cannot apply my usual test, of checking the tone and accuracy of the breastfeeding section. I have had, instead, to apply my more shallow knowledge of pregnancy and birth, to decide how good I think Expecting Better is.

Oster uses her introduction to explain that, as she is an economist by trade, she likes to make decisions using data. Her model of decision making is to take the data, and combine it with your own personal set of pros and cons. This, then, is how she has set out her book; and while it would be impossible for her to have researched every possible issue that a pregnant woman might face, it’s clear that she has written mainly about those decisions that she personally had to make. So we get almost an entire chapter on caffeine, and two paragraphs on restricted growth and related decisions. However, that is not to say that she doesn’t cover enough; the book is comprehensive, obviously well-researched, and thoroughly referenced., and key points are summarised at the end of each section for when you don’t feel like reading every nuance of the different antenatal screening options.

Language and some content has been edited for UK publication, however Oster is in the USA and this does skew some of what she feels she needs to know about, and her general attitude to birth. She touches on the role of midwives, but knows that a doctor (and a doula – hooray!) will be present at her birth, and she will certainly not be allowed to eat during her labour. The research she looks at are mostly USA, UK, Australian and European, with some cultural comparison as well. The induction methods discussed are definitely american, and there is limited discussion of any pain management options other than epidural.

The implicit message of this book is that informed consent is not possible for the majority of parents-to-be, as the necessary information is not easily accessible. Oster clearly makes up her own mind on a number of issues, after being given scant or even incorrect information by her own healthcare professionals; interestingly she doesn’t seem to question routine vaginal examination, and she is certainly working from an all-that-matters-is-a-healthy-baby point of view.

I sound critical but I did enjoy this book, learned some interesting things about caffeine, and was reminded that I haven’t read so much detailed information on food poisoning since I took my Intermediate Food Hygiene certificate, a quarter of a century ago. Emily Oster is a one-woman systematic review, driven by her own need for evidence to support her decision making; and the book she has produced will undoubtedly be useful for other parents, albeit with the caveat about some of the information being less applicable in the UK.

17 Mar

Book Review: The Psychology of Babies, by Lynne Murray

Lynne Murray is a Professor of Developmental Psychology at Reading University, and this is her second book. Her first book, The Social Baby, is an essential tool for most antenatal teachers, and really useful for parents too. The Psychology of Babies is a very detailed text on psychological development from birth to the age of 2, richly illustrated with photographed sequences showing interactions between babies and their parents.

Subtitled “How relationships support development,” the central focus is on how sensitive parenting supports a range of developments in the areas of social understanding and co-operation, attachment, self-regulation and control, and cognitive development. The book provides an academic level of information and is extremely well-referenced. It would certainly be useful to anyone studying child development or working with families and children. It may well also be interesting to parents, however there are more accessible texts such as What Every Parent Needs To Know, which I would be inclined to suggest as an alternative.

As a general read, I found it a bit heavy, and would be more likely to dip into particular sessions. In some places the photographs are too small for any useful detail to come across, although they are all captioned with explanations.

The chapter on self-regulation covers infant sleep, however there is a real contradiction in the way Murray writes about attachment, promoting sensitive parenting (see pages 74 and 78, for example), and the advice to discourage reliance on the parent when it comes to bedtime; and she fails to address the “ethical questions of whether it is acceptable to leave babies to cry for any length of time” (p164), in any meaningful way. It’s clear that despite her comments in the Independent interview linked above, she subscribes to the notion that babies shouldn’t rely on their parents to settle at night.

There is a very interesting section on supporting babies to settle into childcare settings, which could be useful and reassuring for parents in this situation. This includes discussion of research into the effects of childcare on social and emotional development, and the importance of high quality care.

The section covering the introduction of solid foods is disappointing, with its limited focus on spoon feeding, starting from five months, and nothing on developmental signs of being ready for solids, which arguably would fit the remit of this book.

The final part that I want to mention is the pages covering TV and books in relation to cognitive development. This is something that could be usefully and effectively shared with parents, particularly in light of the huge force of commercialism pressuring parents to buy Stuff to entertain and educate their children.

I enjoyed leafing through this book, and will take some ideas into my work, but it would not be the first book that I recommended for new parents to read.

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?

08 Oct

Trick or Treatment

Trick or Treatment: Alternative Medicine on Trial
By Simon Singh and Edzard Ernst

Cheekily dedicated to HRH The Prince of Wales, Trick or Treatment is an investigation of alternative therapies, using scientific methods to determine whether any of them work.

Between them the authors have medical and scientific backgrounds, and Prof. Ernst has also practised homeopathy and other alternative treatments. They argue that this places them in a strong, objective position from which to investigate these therapies.

The book specifically examines over 40 complementary therapies, from aromatherapy to yoga. The authors have critically reviewed the available research, and drawn conclusions about whether the therapies are effective, and for what sort of conditions they might be beneficial.

Whole chapters are devoted to four of the therapies: acupuncture, homeopathy, chiropractic and herbal medicine. Within these chapters, the authors give detailed descriptions of the history and development of the therapies, and discuss the theories behind them. In valuable addition to the discussion of the therapies themselves, these chapters include colourful explanations of research methodology, and concepts such as bias. For this reason I strongly recommend the book to anyone who wishes to understand how clinical trials are conducted, and what factors can affect the results.

The chapter devoted to the placebo effect considers the ethics of promoting ineffective treatments for conditions that might respond to conventional medicine.

Singh and Ernst conclude that homeopathy and acupuncture are at best benign placebos, but can in fact be dangerous quackery. Chiropractic treatment is shown to work for a limited number of conditions, but the financial and physical risks to patients are high, and it is no more effective than conventional treatment. Some herbal medicine is shown to be effective, but the paucity of the research leaves a muddied picture.

The conclusions reached about most of the other therapies are that they are largely ineffective, although some, such as yoga, may have a short-term calming or de-stressing effect. Most are shown to be expensive, not founded in actual scientific knowledge, and may be dangerous, particularly when used instead of an effective conventional treatment.

The book is extremely readable, with hundreds of memorable examples, such as the death of George Washington being caused by his doctors’ practice of bloodletting. The tone is amusingly scathing, occasionally strident, and the authors pull no punches. The book would not be enjoyed by believers in or practitioners of alternative medicine but ought to be required reading for anyone considering using it, for their own good.