Thursday, 22 January 2015

Some Important Lessons From Disney - About Measles and Vaccines




This will be quite a quick post as I am short on time and a lot has been written on the subject already (by much better and more important bloggers than me, see below). But it's a news story that has had very little attention in the UK* so I wanted to share it: Over the Holidays there was an Outbreak of Measles at Disneyland in California, the disease is still spreading. To date at least 70 people are known to have caught the disease and that number is growing all the time (It was 57 when I started drafting this post). Understandably this isn't big news over here but it is a story that provides us with a few valuable reminders about why we have vaccination programs:


1- Measles isn't a mild disease.
The most recent stories I've seen about the Disney outbreak say that a quarter of those infected have had to be hospitalised. Mild diseases do not put 1 in 4 people in hospital. However, I don't want to put too much emphasis on that figure as I'm not sure how reliable it is. I could quote all the well established stats about the risks of death, brain damage pneumonia etc. but you can find them in plenty of other places. What I'm going to do instead is give you one of those totally unscientific anecdotes:

I had measles as a small child. It was f***ing hideous.

Thankfully I don't remember it in detail and I came out with no long term harm. But I do recall being in bed, feeling hot, miserable and covered in spots, with my even littler sister ill beside me. My Mum says she had to put sunglasses on me and darken the room as my inflamed eyes couldn't bear any light**. Even if none of the victims of the current outbreak suffer any complications, that's still 70 people going through that misery needlessly, if the reported hospitalisation rate is true then things are much worse.

2- Measles is really really contagious.
Someone incubating Ebola but not yet showing symptoms could spend days at Disneyland and they wouldn't pass it on to anyone. It's a terrifying disease but you can only catch it by direct contact with the body fluids of some already suffering (or dead) from it. Measles, by comparison is a world champion at spreading itself about. You can catch it from someone without ever even meeting them. If someone incubating measles, but showing no symptoms sneezed in a room and then walked out, you could go into that room two hours later and catch the virus from droplets still hanging in the air. So it's hardly surprising that it has been passed on in a theme park crammed full of thousands of kids, many of whom are from the local area which has a high rate of-guess what? Middle class parents who read some stuff on the internet and now won't vaccinate their kids. Looking at it that way, the only surprise is that it didn't happen sooner.

3- This isn't just someone else's problem.
It would be pretty easy to think: "bloody stupid Californian hippies, risking their children by not vaccinating." Then move on, feeling comforted and probably a bit smug that it doesn't effect us, we're smart, we vaccinate our kids, our kids are safe.  Certainly most of those involved in the outbreak were unvaccinated (or hadn't had both doses) and most of them were unvaccinated because of their or their parents choice. Most, but not all. Disney attracts young children and with young children often come even younger siblings. Several of the victims are babies who were simply too young to have been vaccinated yet. There are also a few fully vaccinated people who have just gotten really really unlucky.

The MMR vaccine is very effective, with 2 doses 99% of people will be fully immune. But that does leave that little 1% who for some reason don't produce a good, long term, immune response. If everyone has the jabs that doesn't matter at all, the virus won't be able to spread and will never get anywhere near that 1%. But put 50,000 vaccinated people in an amusement park with one unvaccinated carrier of a disease as contagious as measles and you don't need to be all that great at maths to figure out what might happen.



So yeah it's a long way away and my kids are fully vaccinated, but that doesn't mean I can just ignore it. I feel really sorry for all those suffering the measles right now. Even, perhaps especially, those kids whose parents' grasp of biological reality is so poor that they left their little ones exposed to a potential killer. But I'm also angry that those same parents got to choose what happened to other people's kids, to those babies and that 1%. I'm angry that it could happen here, where my kids are and that somewhere, at some point, there will be another pointless, preventable death.

Ok so that wasn't very short and it got pretty ranty at the end there, as I said, it makes me angry. If you still want to know more about this, here are a few good reads from over the pond:

Tara Haelle in Forbes
Tara Again ('cause she's ace)
Orac at Science blogs
The NY Times Motherlode

SBx

*Of course while I was writing this the Guardian beat me to it.

**It's not entirely clear why I wasn't vaccinated, this was before the MMR was introduced but there was a single jab available (I'm not that old!). My parents are lovely and not anti vax conspiracists, so my best guess is that it got missed in the confusion and worry caused by a big scare over the whooping cough (pertussis) vaccine that was going on at the time.

NB: Disney seem to be responding very responsibly to the outbreak. Several staff were among those infected and they are now taking steps to ensure all staff are vaccinated and immune. They are also telling unvaccinated kids to stay away.


Saturday, 17 January 2015

Caesareans, Sex Lives and the Good Old Daily Mail.


I was wondering what to write next on this blog, I had a couple of posts in mind before Christmas that I never got time to write, but they are hardly topical now. However, thanks to the NCT twitter feed I have something new to be cross about:



It's a startling figure, I knew the C section rate in the country was high but 52% of women choosing major surgery just because of worries about their sex life? That's pretty incredible, so I did a bit of digging and it turns out there were some recent news articles I missed about this. The main one (and do sit down for a minute as this may come as a shock) is from that great defender of truth, reason and equality - The Daily Fail Mail.

I'm just going to call this as I see it right here; the Daily Mail piece is inaccurate, misleading, sensationalist, racist and deeply misogynistic.

First let's deal with the facts, or rather the torturing of them. The 52% figure is the overall C section rate in Brazil. Unless every single Caesarean performed there is due to fears about future sex lives then then the Daily Mail headline is clearly utter nonsense:

More than half of pregnant Brazilian women choose Caesareans over natural birth 'to protect their sex lives'

(Also, on a slightly pedantic note, 52% of births isn't the same as 52% of women, but anyway)

Even with this explained though, the 52%  figure is still quite misleading as it hides a huge disparity in the mode of birth between those using the state system and the millions of women in Brazil who have private health care. In state funded hospitals about a decade ago the caesarean rate was comparable to the current UK rate of about 24%. But since then it his climbed and some figures put it as high as 40%. But even this seems low when compared to the staggering 84%* of births that happen by C section in private hospitals. 

This disparity between public and private is important as it hints at another reason for the extreme number of surgical births in the country: Hospitals can make more money out of C sections. They require more people, more equipment and longer stays than a straight forward vaginal birth. They can also be scheduled to occur during office hours and the hands on bit for the doctors is usually pretty quick. No doubt this isn't the only reason behind the high levels of c sections but it makes rather more sense than most Brazilian women caring more about their sex lives than their babies birth! 
*****Edited to add: for more on this see the comment below by Eloisa, who had first hand experience of this in Argentina which has a very similar health system*****

So where did that claim come from anyway? Was there a big national study of women's attitudes to birth which turned up the huge numbers basing major decisions on concerns about getting a bit, *ahem*, stretchy? Nope, as far as I can tell the whole thing comes from a comment made to a newspaper by one individual, Vera Fonesca, Director of the Brazilian Federation of Gynecological Associations who said that: 'The Brazilian woman is concerned with her sexuality and fears that giving birth will alter the perineum, which is a myth.' 

Oh and since we are on the subject of myths, contrary to what the Mail article says: - 

THERE IS NO WORLD HEALTH ORGANISATION RECOMMENDED CAESAREAN RATE! 

There used to be one, until they admitted that some bloke just made it up and there was absolutely no evidence for it! - They dropped this rate in 2009! For how many more years am I going to have to say this?

and breath....

Actually, no, lets not calm down, lets get onto the racism and sexism that weaves it's way all over this story. 

First off, the Mail must have been so very pleased that this is happening in Brazil! Try to think of a stereotypical image of a Brazilian woman- most likely she is gorgeous. Tanned, toned, with enviable breasts covered in the tiniest of beach bikinis or sparkling samba costumes. She oozes sex appeal, she's a feisty, passionate lover. So of course all Brazilian women are like this, and it's not surprising that for more than half of them, the biggest concern of impending motherhood is getting back to all that wonderful sex, right? I wonder if the Mail would be so interested in the C section rate in Belgium?



Here's another question - Why is it inherently wrong for a mother to be concerned about her own sex life anyway?

Certainly if the sole reason for a huge number of c sections is false fears about  future sexual enjoyment then that is a problem. But in that case caesareans aren't the cause of that problem, they are the symptom. The problem certainly won't be fixed by demonising those who choose surgery. Those fears aren't entirely false anyway. Vaginal birth usually causes no major, lasting, harm to the mother. But there may be reasons for some women worrying about how a vaginal birth might effect their future sex life. Many women suffer a torn perineum during birth and that could cause difficulties in the short term (although bravo if you feel like having sex at any point in that "short term" anyway). In rarer cases vaginal birth can lead to longer term harm and/or issues with incontinence, which could impact on a mothers sex life. These things are rare but they exist and it's perfectly reasonable to consider them. 

Sometimes the damage isn't physical. Some woman experience considerable psychological trauma during birth and go on to develop PTSD. Where the traumatic birth involved a lot of internal examinations and interventions, especially if the woman feels she was forced into these and didn't truely give her consent, then future intimacy can become a huge trigger, sending the woman straight back to the stress and terror of the birth and leading her to avoid sex altogether. 

On a related note, women who experienced sexual abuse earlier in their life may well want to avoid a vaginal birth and all that can go with that so as not to dredge up old traumas, something which could also effect their future sex life too.

All of those are reasonable excuses, but why do we even need excuses?

Let's think about a completely different decision, one that involves only men's bodies for a change. If a man is found to have early signs of prostate cancer he can have surgery or other treatment to reduce the risk of that cancer progressing. But the cancer may never progress anyway and the treatment can damage a mans sex life. So some men decide to avoid the surgery and accept the increased risk of cancer rather than the risk of those side effects. I'm yet to see a headline declaring that "Men Risk Cancer To Protect Their Sex Lives". Why should there be? It's a perfectly reasonable decision. Prostate cancer mostly occurs in older men, most of them will have children already but that doesn't mean they don't still want to have a sex life - so why doesn't the same apply to women? Our society has mostly moved on from the idea that young men should "spread their wild oats", while women save themselves for their wedding night, but mothers as sexual beings still doesn't seem to be something we are entirely comfy with. Mothers are supposed to exist in a constant state of grateful self sacrifice for their offspring. Still wanting to be able to have a decent shag with the kids Dad doesn't really fit in with that.

So does the Mail think that 52% of Brazilian women are so dim witted and sex obsessed, that they would still choose needless major surgery, even if they had accurate information about how unlikely it is that a vaginal birth would harm their sex life? Or are they just plain horrified at the thought of a woman, a mother, making that a consideration at all?



None of this means that I think a c section rate of 84% or even 52% or 40% is fine. Speaking as someone who has had two C section and a very long labour I know from bitter experience that the surgery is not an easy option! I really don't believe that huge numbers of Brazilian women would choose a C section without a good reason, if they were actually given decent information and not put under pressure by hospitals. 

But (like the WHO) I don't think there should be any ideal caesarean rate. Contrary to what some of the news stories are saying, modern caesareans are very safe for both mother and baby. Especially when they aren't done in a rushed emergency. So if a woman looks at all the evidence and decides she wants one, even if her reasons seem frivolous to some people, you know what? Her body, her choice.

Mostly I'm annoyed with the Daily Wail, but the paper seems to actively troll it readers, so they are probably pleased about that. But what about the NCT tweet that got me into this rant in the first place? I really want to give them the benefit of the doubt, best case scenario it was a poor choice made by an individual manning the twitter account and in need of something topical. But the NCT has often been criticised (and not just by me) for being anti caesarean and propagating unevidenced nature-knows-best type beliefs. They always counter that they support all parents' choices and give only evidence based advise but if that is the case why promote a "news" story that is so very lacking in evidence and which is sexist, anti choice and sensationalist too? As I say I'm inclined to go with the best case scenario that it was just a silly mistake, but at worst it suggests that some of those old judgmental attitudes and beliefs still linger in the organisation. Come on NCT, you can do better than that.

SBx

*I've actually seen a variety of figures for both public and private in various newspapers but I'm going with the most commonly used, which is also the highest as I haven't been able to find a good original source - if anyone has one, please let me know!

Thursday, 8 January 2015

Postpartum Hypothyroidism, Pregnancy and Being a Bit of a Divvy

This will make it two personal(ish) and non ranty blogposts in a row!

I made a classic error over the Christmas holidays and ran out of my thyroid medication. Given that it was my own fault for being a divvy and not checking sooner I didn't feel I could justify a GP appointment to get more the same day. So I ordered a repeat online, and assumed I'd be ok to go without for a few days. From this I learned two things:

1- Always check you have enough meds for the holidays and order repeats in plenty of time.

2- I'd forgotten how miserable having untreated hypothyroidism actually is.

I did write about my thyroid condition way back in 2010 but I've learned some new stuff since then, especially through having another pregnancy. So now I have my pills and I'm out of the "thyroid fog" I thought it was time for another blog post on the subject.

***NOTE: I'm going to refer to postpartum thyroditis in this post, but technically that's not what I have, I'll explain that a bit more as we go along!***

Part One: The Basics 
or: Stuff your GP will probably know

What Is Postpartum Thyroiditis?

The thyroid is a little organ in your neck responsible for a variety of hormones which need to be produced in the correct amounts. But sometimes it goes wrong and starts producing too much (hyperthyroidism) or too little (hypothyroidism) of these hormones. This can happen because of all sorts of things but postpartum thyroiditis happens after pregnancy and can involve either hyperthyroidism, hypothyroidism or, often, both, one after the other. Fortunately in the majority of cases it sorts itself out and may never need any treatment.

What Causes it?

During pregnancy, the immune system gets turned down a bit, to prevent it from attacking the baby. Once the baby is out the immune system is allowed to bounce back again but sometimes it gets a bit carried away and starts attacking the mother's own thyroid. There then ensues a bit of a hormonal slanging match as the hormones produced by the thyroid and those that control it all scream at each other about what they think the thyroid should be doing. Ok clearly that isn't an entirely accurate, technical description, but the upshot is the poor thyroid ends up getting it's hormone making all wrong. In the case of postpartum thyroiditis this usually means it starts off making too much and ends up making too little.

What Are The Symptoms?

This is one of the really tricky things about this condition. The major symptoms are tiredness, aching, depression, mental slowness and weight gain (there are quite a few others too, see here for more info).

Basically it makes you feel like cr*p. Ordinarily you would probably notice that, but what if you've just had a baby? Aren't you supposed to feel like cr*p anyway?

*****
When I was pregnant for the first time there seemed to be no end of people who gleefully told me I would never have a good nights sleep again, my body would be ruined, my social life destroyed etc. etc. Throw in the epic labour and the c section (which I'd been taught should be avoided at all costs because of the hideous recovery) and it simply didn't occur to me that there was anything wrong with me. I felt utterly awful, but perhaps this was just what it was like to be a Mum? I'd surely be laughed out of the room if I went to the GP and complained that ever since I had a baby I felt tired and fat? I looked on in wonder as other mums lost the baby weight, got out and about and actually did stuff. It didn't look that hard for them so why was it for me? Were they all just putting on a show like I was, pretending they were coping or were they genuinely better at it all and I was I just being a bit pathetic. I failed to do the birth thing properly after all, perhaps I was just wasn't very good at being a Mum? 
*****

How Is It Diagnosed?

Thankfully this bit is more straightforward. Usually postpartum thyroiditis gets better on it's own and the mother may never realise she had it. But if it goes on and she actually plucks up the nerve to speak to a doctor then there is a simple blood test which can figure out what's going on. It looks at the levels of the hormones produced by the thyroid and at something called TSH (Thyroid Stimulating Hormone).  When the thyroid isn't producing enough hormones it's TSH's job to tell it to work harder so a high level of TSH in the blood test means the thyroid is under active (hypothyroid).

The other thing that can be tested for when a thyroid problem is suspected is antibodies against the thyroid. Again, this is a simple blood test but if the antibodies are present then it is a good indication that there is a problem even if the other tests are a bit borderline. Unfortunately testing positive for the antibodies also means the condition is more likely to stick around permanently.

How Is It Treated?

If the thyroid is over active (hyperthyroidism) then it will probably resolve itself quite quickly and won't need treatment. So from here on in I'm going to concentrate on hypothyroidism (but if the hyper version lingers I believe a short course of beta blockers should sort it out). Hypothyroidism (under active thyroid) is also quite easy to treat with Thyroxine pills. These basically replace the missing hormones and hopefully, once you find the right dose (which may require more blood tests) should alleviate the symptoms and side effects are very unlikely.  Most cases of this will sort themselves out in about a year but in some cases (like mine unfortunately) this doesn't happen and those little white pills become life long companions at which point it isn't technically a postpartum problem anymore!

Me, pre diagnosis. Looking back on this the eyes are more honest that the smile and the baby weight was clearly going nowhere.



Part Two: Hypothyroidism In Pregnancy
Or: Important stuff your GP might not know


*****
My thyroid condition was managed entirely by my GP for a couple of years. But when we came to thinking about baby number two I happened to listen to a podcast which mentioned the problems hypothyroidism can cause in pregnancy my GP didn't seem to know much about that so I asked to be refered to a specialist. Perhaps other GPs are more knowledgeable about this but none of the ones at my surgery seemed to be.
*****

The Risks

Untreated hypothyroidism can be a big problem in pregnancy, it seems to increase the risk of all sorts of bad stuff including miscarriages, low birth weight, premature birth and pre-eclampsia. In some cases it may also impair the baby's intellectual ability. Clearly avoiding all these things is pretty important.


 - MASSIVE CAVEAT ALERT - 
I'm not a medical doctor and the treatment advice I was given will not be appropriate for everyone. If you have or think you have hypothyroidism and are planning a pregnancy don't just follow what I say here, go see your GP,  if they are as hopeless as mine, go see a specialist!! 
(here endeth the caveat).



Treating Hypothyroidism in Pregnancy

Normally hypothyroidism is monitored with occasional blood tests to check those TSH levels. So long as they stay below about 5 (there are units, but this is complicated enough already) then the patient is probably on an ok dose of thyroxine. In pregnancy this isn't good enough (something my GPs had no idea about until I told them).

In pregnancy, especially in the first trimester, the TSH level needs to be lower, I was told by the specialist that mine needed to be below 2.5. There is obviously a problem if GPs aren't aware of this as it is quite normal in the UK not to see any other medical professionals during the first trimester if all is going well. Yet this is the most critical window.

Luckily for me the specialist had told me what to do in advance, he had made a small increase to my thyroxine dose and as soon as I got a positive pregnancy test I increased it again then checked the new dose with a blood test a week later.

Monitoring

With the right dose of thyroxine on board, hypothyroidism shouldn't cause any problems for the rest of the pregnancy but I was monitored very closely anyway. I had blood tests every 4 weeks to check my TSH levels were staying low and I also had ultrasound scans every 4 weeks to check the baby's size - although given that my first was a hefty 9lb 10oz (4.4kg) I wasn't too worried about this one being smaller! I was initially also having separate appointments with both the Obstetricians and midwives every 4 weeks but thankfully the docs decided that was a bit OTT and scaled back their appointments!

So there we go! There are a few potential problems for mums that I heard a lot about while I was pregnant, post natal depression and incontinence being the main ones. But I had no idea about postpartum thyroiditis until a medical student friend spotted a very slight lump in my neck (another symptom) and suggested I see my GP (see not all doctors are bad and said med student is now training as a GP herself). I also have friends who've developed other immune system related problems after having a baby yet there seems to be little awareness of these conditions and I wonder how many other mums are just putting up with them, not realising treatment is available? No one wants to turn pregnancy and motherhood into an endless warning list of what can go wrong, except perhaps the "you'll never sleep again parade". But I'd like to see a little more awareness of these things even if just among GPs, midwives and health visitors. I pretty much pay no attention to my condition now, but my little visit back to the cold, tired fog I was in for the first months of MissEs life was a reminder of just how much those little white pills improved my life - and in future I'll try not to run out of them!

SB




Sunday, 4 January 2015

2014 In Pictures


I've deliberately been writing less about my kids on this blog this year, focusing on the health stories and bad science that far fewer "mummy bloggers" write about. I guess I'm finding a niche as all those how to be a blogger posts tell you to.  But I've really enjoyed putting together a few memories in past years and I often return to those posts again and again. I take so many photos, it's easy with a camera phone to snap away all the time but I rarely get the chance to actually comeback to those images and remember all the great times we have in between all the ordinary business of work, school, and general life. So here are a few, though by no means all, the best bits of 2014.


January 
A trip to see the butterflies at RHS Wisley




February
At half term we visited Greenwich. While other parts of London were packed with tourists, it was strangely quiet, if very cold, and MissM, on the brink of walking, explored the famous painted hall.




March
A few little firsts: My first attempt the at the dreaded World Book Day costume came out pretty well, MissE got her first proper bike and Me and F had out first night away since MissM was born as we celebrated our wedding anniversary at a little boutique hotel in Margate. (Where I learnt that, even without kids to wake you up you still can't get a good nights sleep if you are not used to drinking any more and have a Bellini, half a bottle of wine and an espresso Martini with dinner! fool)



April
We headed off to Coombe Mill farm in Cornwall for another wonderful week, I think this was our fourth year and it gets better every time. MissE was rather taken by the train driver, and MissM got thoroughly wet and sandy on a nearby beach.





May
In May the dreaded Chicken Pox struck us, which meant that poor MissM was stuck at home with Daddy while me and MissE headed off for some Mummy-Daughter time under canvas at the lovely Feast In The Woods Festival







June
On a glorious June day we celebrated the wedding of one of the girls (many) Aunties. Which gave me the perfect excuse to dress them up in matching frocks!





July
The Summer really kicked off in July when we headed out on the recently invented ancient Nunhead festival of Beating The Bounds.


The end of MissE's first year of school meant her first ever sports day




And once the holidays were underway we got a chance for a day out with just the two of us being totally touristy





Next we headed off to Spain for a small amount of walking, a fair bit of splashing and a heck of a lot of eating!






August
In August we were back in our trusty tent again, this time at the Just So Festival (I can only imagine how cold mermaid lady must have been!)





And it was MissE's birthday which meant magic tricks and of course the obligatory Frozen costume




September
In September we celebrated my parent's Ruby wedding anniversary at center parcs and of course it was back to school for year 1






October
October half term couldn't come soon enough and we headed to Devon to hit the beach (well wrapped up!)



With Grandparents on tap to babysit F and I even got chance for a long walk on Dartmoor. We could barely see, but it was worth it to remember how much we enjoyed walking together before we were doing it pushing a buggy and stopping to say hello to every individual ant!





November
Astonishingly MissM is now 2! Time is just flying but I love this age, even if she has mastered the terrible twos tantrums already!





December
Both girls had a really wonderful Christmas this year. We started to get into the spirit by visiting Father Christmas at the museum of London





We also had a trip to the museum of London docklands, where MissM had a go at being a builder




As the big day drew nearer we kept tabs on father Christmas with the NORAD Santa tracker




And of course there was plenty of cooking and eating!





So that's that for 2014. Thanks to everyone who has continued to read my blog this year and to all the new people who have found me one way or another! Thanks also for all the comments, shares and retweets for what I write, it's always much appreciated. I hope you all have some good memories of 2014 too and even more to come in 2015!



Happy New Year from the SouthwarkBelle family!



Monday, 29 December 2014

7 Reasons Why Giving Birth In A Stable Definitely ISN'T Better Than A Hospital


How did Mary and Joseph know that baby Jesus was 7lb 6oz?
They had a weigh in a manger.

Boom-tish (and thanks to the NHS Epsom and St Helier twitter feed for that cracker standard joke)




I saw a link yesterday to THIS Article by homebirth advocate Milli Hill which claims that Mary was probably better off giving birth in a stable 2000 years ago than she would be in a modern obstetric unit.

I was er, a little surprised, and assumed it was a joke.

It wasn't a joke.

I could now do a big ol' post about the likely levels of maternal and infant mortality 2000 years ago, the high risk of obstetric fistula that would have been faced by a very young woman giving birth for the first time etc. etc. But Hill seems to have skimmed over that part, after all the most important thing when talking about birth is to say nothing that is in any way worrying to the poor little ladies. lest we cause The Fear. (It's perfectly ok to make hospitals sound utterly terrifying though BTW). So lets not worry about little things like death and permanent injury. Here are my other seven reasons why giving birth in a stable would have been sh*t.

1 The Sh*t Hygiene
Hill contends that hygiene is one reason why giving birth in a stable is better than being in a hospital (honestly, I'm not making this up). Because er, kids who have pets may be healthier and kids born vaginally at home might have different microbiomes (friendly gut bacteria) to those born in hospital. I've blogged about microbiomes before, it's a very interesting field but poor Mary is closer to securing a room at the Bethlehem Hilton Spa hotel than we are to understanding enough about the microbiome to base important decisions on it. Besides, even if there were proven microbial benefits to a vaginal home birth in a 21st century semi-detached, I'm not really sure how that equates to it being a good idea for a vulnerable newborn to enter the world surrounded by dung?

2-Birth Attendants.
There were no midwives in the school nativity play. Hill therefore assumes that Mary was attended by a skilled and caring local woman plus her team of Doulas. All of whom would remain awake, sober and competent for however long it took for the wee son of God to make his entrance (thus avoiding the horror of, gasp, a shift change). Maybe, I hope so for Mary's sake as the other explanation is that there were no skilled attendants, just livestock and Joseph. So basically poor Mary had to accept that the first time her intended future life partner would get a look at her virgin lady-bits, they would be pushing out the head of another man's child.

3-No Bed
We know that Jesus was laid in a manger in swaddling clothes, thus contravening any number of modern health and safety recommendations. But at least he got somewhere to sleep. Hill sees the lack of a bed for Mary as a good thing, encouraging (well basically forcing) her to keep moving in labour. Ok, movement in labour helps a lot of women but what about afterwards? After a straight forward hospital birth many women are now home within hours but Mary was in that cow shed for days. Labour is tiring, so it breastfeeding a newborn. Surely the poor woman deserved more than a hay bale smelling of goats? On which subject...

4-Clearing up the mess
Birth is a messy process, there will be blood and most likely poo and vomit too. At least in a hospital birthing room the bodily products are likely to only be from the mother, or a member of the same species at any rate. They also tend to get cleared away pretty sharpish by the staff. There are no staff in the stable. I can't imagine that the nausea many women experience in labour would be eased by watching a goat chow down on your freshly produced afterbirth.



5-Visiting hours
Postnatal ward visiting hours can be very problematic, especially if partners are kicked out but the stable sounds like a total free for all! First there was the huge gang of blokes in dresses, singing and blaring trumpets right over where poor Mary was trying to get some kip on the aforementioned goat stinky hay bale. Then some random local agricultural workers arrived for a good stare. Oh but at least they brought a lamb, because obviously if you are in a cattle shed the thing you most need is more bloody livestock. Finally, just when things seemed to be calming down a bit, three dodgy looking old men turned up, and banged on about how very wise they are before giving the baby some funeral incense. Hardly a relaxing environment to bond with one's new born deity. When I had my babies my family brought me Brie sandwiches and tons of fudge. Those are wise gifts, Myrrh? Not so much.

6- No Modern Medicine
For Hill this is another good thing about the stable, there is no modern medicine, no machines, no pain relief, and nothing to speed up a long labour. All of which works wonderfully for a lot of women who choose that route but Mary had no choice. Some mothers want pain relief, some feel more relaxed knowing medical backup is close at hand and some decide they want it all over and done with as quickly as possible. There is nothing wrong with any of that.


*****
Yes, this post is intended to be a bit tongue in cheek, but to be serious for a moment Hill's article annoyed me. I support home birth. I absolutely support the move away from the doctor knows best, lie on your back and do as you're told, childbirth of the past. But that doesn't make it OK to spread fear about hospital birth unless you have rock solid evidence and Hill doesn't. There are many problems with hospital birth, but to suggest that you would be better off 2000 years ago in a shed full of livestock than in a modern western hospital is plain inaccurate and and does a huge disservice to the many women who want or need to give birth in a hospital. Their fears are every bit as real and their choices every bit as valid as those for whom home birth is the best option. To propagate excessive fear of hospital birth does absolutely  nothing to further the goal of genuine informed choice for everyone. At the risk of sounding like a broken record, there is no one right way to give birth.
*****


7- The Smell
Sure hospitals can have a certain whiff about them that isn't all that nice, but personally, I'd prefer that to the stable which most likely reeks of Bull Sh*t.


SBx

Wednesday, 10 December 2014

Breastfeeding: Not Glorious, Not Grotesque, Just Ordinary


So, inevitably, as soon as the media have finished telling us all how to give birth it's time to start instructing us on how to feed those born as they should be babies.

There were two main stories in the news this week about breastfeeding and a third which touched on it so, as this is my blog, I'll be starting with the sciency one:


On first look it's tempting to assign this to the yet more breast is best propaganda pile, but the study is actually quite interesting. One thing the headlines don't make clear is that the study doesn't call for more women to breastfeed, but for more support to help those who want to to do it for longer. And while the cost savings headlined are just estimates, what's interesting to me is that they are based on all the factors proven to be effected by breastfeeding in the UK. These are - certain infections in young babies, breast cancer risk for mothers and  - and that's it.

Contrary to all manner of claims, there is no good evidence that breastfeeding increases IQ, reduces obesity or improves social skills*. True, there have been individual studies which suggested all these things and got many column inches in response but they all suffered from one major flaw: Overwhelmingly in the UK women who breastfeed are well educated and well off (hence the recent dubious voucher scheme) so these studies aren't just comparing breast v formula fed babies, they are comparing rich v poor. Was it the breastfeeding that made the difference? It's possible, but it could also be the better diet, reduced smoking, better housing, less stress, etc. etc. etc. Basically, if you are born relatively privileged in this country then you will most likely do better than your poorer peers, however you are fed as an infant.

Before I go on I want to be quite clear - I'm not anti breastfeeding, far from it. I near as damn it exclusively breast fed both my girls for at least 14 months each. At times it was exhausting and excruciating but ultimately I'm very glad I did it. Even if all the health benefits were removed it is still cheaper than formula, less faff than sterilising bottles and you can't forget to take a boob with you when you go out for the day. I absolutely agree that there should be more, better and more consistent support for mothers who want to breastfeed. But I also think that support needs a reality check sometimes. If trying to breastfeed is placing a huge strain on a mothers physical or mental health then there are times when it is better for everyone, especially the baby, to say that bottle would be best.

This last point came to mind last week with the tragic story of a Mother in Bristol who walked out of hospital one night with her newborn baby, both were found dead the following day. The press suggested that she had stopped taking medication for mental health conditions so that she could breastfeed. I have no idea if that is true, whatever happened it's a heartbreaking story and the causes were no doubt complex, I really don't want to speculate further than that. But as the news came out that day a number of people on twitter began to relate their own experiences of being advised or coerced into stopping important medication so they could breastfeed. Sometimes with terrible long lasting effects for their whole families. The self-abnegating mother, sacrificing her own health for that of her child is a nice romantic story, but in reality the health of the mother is utterly interwoven with that of the child and when all we're talking about is the potential for a few less infections for a few months, in a country where we have access to antibiotics and top quality medical care, sometimes, breastfeeding just isn't worth it.

So we have a tricky balance to make. How do we encourage those who want to breastfeed without stigmatising those who don't or can't? Well perhaps we could start by normalising breastfeeding, by just making it completely and utterly ordinary.



And that brings us nicely to the whole  Claridges-Napkin-Farage-#Ostentatiousbreastfeeding media opinion-fest.


For the benefit of my non-UK readers, Claridges is a very swanky hotel. Recently a woman breastfeeding her small baby in the restaurant was told to cover up with a large napkin. She posted photos on twitter, people got cross. Then the ever hideous politician Nigel Farrage, weighed in to criticise "ostentatious breastfeeding" and suggest feeding mothers should sit in the corner because some older people found the sight of them uncomfortable. And lo was born a very amusing #hashtag.

Frankly, in my little corner of South London, you are more likely to get a dirty look if you are caught bottle feeding a baby, and at least one local friend was praised by an elderly woman for public breastfeeding, something the woman wished she could have done when a young mother herself. But I appreciate that the sight of a breastfeeding mum is a bit uncomfortable for some people. But why? 

This uneasiness isn't the result of some natural aversion to an unsanitary act. In an stroke of stunning hypocrisy the Sun newspaper actually likened public breastfeeding to urination on it's front page (UK readers will be well aware of what is on page three**). But the only reason we feel unnerved by breastfeeding is because it's not a common sight. In our culture, breasts are purely sexual objects, and as such decent people shouldn't get involved with them, at least not in public. But this is our own invention. The day after MissE was born I shuffled along to the obligatory breastfeeding workshop, taught by a wonderfully frank, loud and hilarious African midwife who told us all:

 "You women here are all afraid to get your breasts out because you think it's all sexy! But you all walk around in your short short skirts with your asses hanging out! Your breasts are for your babies, not for the men! Put your asses away and get your breasts out!". 

Seriously, she was the only good thing about that hospital stay.

She was also completely right (well maybe not about the skirts). If some people feel uncomfortable at the sight of a woman breastfeeding then I am sorry for that, but the best way to cure that sexy-lady-things-feeding-baby-AHHH cognitive dissonance isn't to hide breastfeeding, it's to normalise it, to make it ordinary. People used to freak out at the sight of woman in trousers or a tiny flash of ankle, even UKIP are probably ok with that now, because we see it every single day, it's not special and it's not shocking.

The bottom line (covered by a nice long skirt for the benefit of that midwife) is that there are benefits to breastfeeding, but in the context of a developed nation they aren't huge. If women want to breastfeed then it's worth the NHS investing in helping them but it's also important that women know it's not that big a deal. It's lovely for the individual mum and baby, for the rest of society - meh. The problem is it will always be a big deal when any hint of a breast being used for something non-sexual is splashed across the press and open season for idiot commentators (I'm aware I'm perhaps putting myself in that category right now). It will also continue to be a big deal if we go on haranguing mothers with piles of unproven claims about the wonders of breastmilk and holding it up as some magical, perfect act of motherhood. If only women could breastfeed in public without comment, and do the same with bottles, if only it was just as ordinary as changing a nappy or giving your toddler a hug when they fall over, then perhaps we could stop damning women whatever they do. Breastfeeding is neither glorious nor grotesque, it's an ordinary everyday thing, or at least it should be.

SBx

*The other often quoted benefit of breastfeeding is that it aids bonding of mother and baby. I've not included this as I've never seen any research either way on it. If anyone has some please let me know. Personally I'm doubtful that the mother-baby relationship really suffers because of bottles. I also have to admit, when breastfeeding I rarely spent all those hours staring in dewy eyed adoration at my babies. With a good arrangement of cushions or a sling, breastfeeding is almost hands free, so I was generally on twitter/facebook and/or watching boxsets of Downton Abbey. Not terribly bondy but it got me through the utter tedium of it all. It was the times I used a bottle that I actually concentrated, that seems to require about 3 hands!

** For the benefit of non-UK readers the Sun is a national newspaper which has a daily, topless," page three girl".

Wednesday, 3 December 2014

Home Birth, Hospital Birth and Not So NICE Advice



I've written previously here and here about the draft guidance from NICE on where women should give birth, but (as you'll have noticed if you were anywhere near UK media this morning) the final version is now out. The headlines mostly read something like this (From the Mirror):

Mums-To-Be Warned "Have Your Baby At Home, It's Safer" By Health Chiefs


An awful lot has been written on this subject today but, having looked at much of it and at what the new guidelines actually say I think there is a fair bit of confusion and a lot that annoys me too. What follow is long, be warned, but I hope it will clarify things for people or at least vent my frustrations. (Also fyi, it's not as well checked over as normal because I also have a sad, snotty two year old on my arm).

The Confusing Stuff


It's not all Mums
Firstly, this advice doesn't apply to all Mums-to-be. It is solely for low risk mothers who have already had at least one baby. The guidance also covers low risk first time mums but it does not say that home birth is safer than hospital for this group as there is a slight increase in risk to the baby with home birth. I'll be coming back to this.

The Meaning of "Safer"
What do you think of when you hear that word related to child birth? Is a safer birth one where mother and baby are less likely to die or suffer lasting harm? Well yes but these reports also consider a birth safer if there are no interventions such as emergency caesareans, forceps deliveries (so far so sensible) and epidural pain relief. I'll be coming back to this too.

There is no, single "right" place to give birth
Crucially, the NICE guidance itself doesn't actually say that there is a single best option for where women should give birth. Here's what it actually says midwives and doctors should do:

  • Explain to both multiparous and first-time mothers that they may choose any birth setting (home, FMU, AMU or hospital obstetric unit), and support them in their choice of setting wherever they choose to give birth.

This is the first point in the "Key Priorities" section of the document, and it doesn't say "tell all women to have home births" it says, tell those who are low risk that they have choices, then respect those choices.

Here's my fantasy headline:

NHS Told "Women are Intelligent Individuals, Facilitate Their Informed Decision" By Health Chiefs

Well, I can dream.


The stuff I'm coming back to


To be clear, I am not against home birth. I am certainly not against birth in a midwife led unit - it's what I chose myself first time around. The thing that is bugging me is the headlines which suggest there is one, best, safest, correct way to give birth. I just don't believe that. No two women are the same, our, bodies, minds, life experiences and social situations make each and every birth utterly unique. 

What about the "other" women?
The fact that this guidance doesn't apply to all mums anyway is very important and it's something the media has pretty much overlooked. What about all those women who aren't low risk? Who are told that for them, the best/safest/correct way to give birth isn't an option, they have to be in the dangerous hospital with it's terrifying interventions. Firstly, these stories only add to the fear and stress of those whose situations are the most difficult to start with. Then, after the birth there is the lingering guilt that many feel for having failed to give birth properly. For more on this see this post over at Headspace Perspective

My safe or your safe?
The recommendations published today are based mostly on the Birth Place Study, which I covered in  (much) more detail here. It looks at how likely it is a baby will suffer one of a list of adverse outcomes and how often women have a range of interventions but (as I say in the post) how you interpret that risk is a very personal matter. What is more worrying a very small chance of something dreadful happening to the baby at home or a greater chance of having to endure interventions in hospital? There is no right or wrong answer to that. It's a personal, individual choice.

One thing that really bugs me is the inclusion of epidurals in the intervention list. While I doubt that anyone would want a forceps delivery or an episiotomy, there are perfectly good, intelligent, valid, reasons for choosing an epidural, - it's the best way to make the very hurty thing stop hurting being the main one and the risks are very low. So I don't think having one should be a measure of a bad or unsafe birth. 


The Stuff That Just Makes Me Cross

In a home birth no one can hear you scream give you an epidural
This is a real biggy for me and I say this as someone who didn't want an epidural and, were I magically a low risk pregnant mum again, still wouldn't want one: 

There is nothing wrong with wanting pain relief in labour.

You can't have an epidural at home or in a midwife led unit. If you plan to have one in advance then your only choice on place of birth is an obstetric unit. Women need to be made aware of this.


Transfer Rates
Something else that very few of the media reports mention is the transfer rates. The Birth Place study grouped women according to where they planned to give birth, not where the birth actually happened in the end. For first time Mums, a whopping 45% of those who planned a home birth ended up in hospital (It's only 12% for those who've done it all before). Again, it is vital that Mums have this information and are realistic about the possibility of a transfer. How would that feel? - Is it worse to be surrounded by the trappings of medical birth all along or to be bundled into an ambulance in the full throws of labour? No right answer, personal choice.


Why Are there more interventions in hospital anyway?
There is no clear answer to this, it's generally supposed that women are more relaxed at home or in a midwife only unit and that this helps labour progress better, though the evidence for that is sketchy. and of course some women find it reassuring to have modern medicine on hand. Another possibility is that doctors are overly keen on interventions, they see the rare cases that go bad and so over medicalise everyone to avoid them (and the ensuing law suits). I suspect it's also likely that most women having home births (only 2% of UK births) are very committed to it. So they are less likely to agree to eg. a drip to speed up labour if it comes with an unplanned ride to the hospital and the abandonment of all their carefully worked out plans. If many more low risk mums started out at home, would it always be the same story?

It's probably a combinatinon of many reasons, but whatever it is we should be finding out and doing something about it. Simply telling women to give up and go home is fine for some but it does nothing to improve care for the many women who want or need to be in an obstetric unit.

The Care Factor
Where I live there is already a two tier system for midwife care. If you are lucky enough to be in a certain area, be low risk, planning a home birth and well enough informed to contact them early, then you can have a caseload midwife. She will look after you throughout pregnancy birth and the postnatal period. She'll come to your home for some of your appointments and take time to get to know you. She'll also ensure that you have chance to meet the other members of her small team in case they are on call when you go into labour. If you aren't so lucky you may see a different person every time for rushed appointments and give birth with complete strangers then be looked after by whoever turns up, if they turn up. Why shouldn't women going to hospital have this standard of care too? It's probably one of the reasons why there are fewer interventions at home - women are supported. You shouldn't have to choose between an epidural or good care.

Midwife Units
The media and admittedly me too, keep talking about this as home v hospital, but what the NICE press release actually says is that Midwife led units are safest for straightforward births. They offer both the low risk to the baby that comes with hospital birth and the reduced intervention rate of home birth, so why aren't we cheering these on more?

Well for one thing,  not everyone has access to one and when there is so little money about do NICE really think NHS trusts will put in the massive capital outlay to build them? 


 Women's bodies


But what's the other reason why the media aren't talking about midwife units? It's because no one is all that passionate about them. Women choosing them aren't  ****ing hippies risking their babies for bragging rights about their orgasmic home births. They aren't cold, too posh to push bitches, so removed from what is right and natural for a mother that they have their poor babies surgically removed at a convenient time. They aren't even the terrified masses, strapped to a bed by an unfeeling doctor because they watched Eastenders too many times and were afraid to be anywhere other than hospital. In short (which will be a first for this post) they are women making reasonable, informed decisions about their own bodies* not caricatures to be judged and vilified, and for some reason, that is something our society and the media that reflects and feeds it, still struggles with. 

I'm going to shut up soon, I promise.
What the NICE guidelines actually say is that low risk women should have a choice of home, hospital or midwife unit. They should be informed of the pros and cons of each choice and they should be supported, whatever their decision. Well done NICE, now can the rest of the country catch up please?

SBx

*as indeed are the vast majority of women who choose, home, hospital or even C sections!