Wednesday, 12 March 2014

Making the case for independent midwifery: The Baby's Coming by Virginia Howes

Virginia Howes's book The Baby's Coming - A story of dedication by an independent midwife was published this week, just as the Department of Health announced that the government would not support independent midwives' proposed insurance solution, which means that when new EU legislation is implemented later this year independent midwives will become illegal. To anyone who has had any involvement, however remote, with independent midwifery - even if they've done no more than watch Virginia on TV in ITVs Home Delivery - this must seem like total madness: independent
midwives are highly skilled and offer choice and high-quality care to women with a wide variety of needs, relieve the pressure on an over-stretched NHS and save £13 million per year in costs to maternity services. You can read more about the situation facing independent midwives in this article in the Express, this blog by Angela Horler on the Huffington Post, or on the Independent Midwives UK website.

Reading The Baby's Coming this week, then, means that I have read it with an eye on the wider picture too. And, having read it, it couldn't be clearer to me that if independent midwifery is outlawed then we will have lost something of immense value, and outcomes for the women who would choose independent midwifery if they could will be less favourable as they are forced to birth in circumstances they wouldn't have chosen - either within the NHS or alone and unsupported.

Although the book is in many ways an entertaining read, packed with wonderful birth stories, moments of humour and everything that birth junkies like me love to read about - it's also profoundly political, stuffed full of clear demonstrations of where there is room for improvement in our maternity services. In a climate where choices in childbirth are becoming limited within the NHS, due to the suspension of home birth services, the closure of stand-alone midwife-led birth centres and fear of litigation - and all this despite a European law that enshrines a woman's right to choose the circumstances of her birth - it seems to me that we need independent midwifery more than ever.

I'm involved with the Positive Birth Movement, and at meetings we share positive experiences of birth and discuss how women can make their own choices and work with their caregivers to ensure their needs are met; in the process we often hear how difficult this can be and debrief previous experiences. Virginia's book, it seems to me, could be seen as almost a manual for mothers and their caregivers for how respectful, woman-centred maternity care should be delivered, whether in home or in hospital, within the NHS or outside it. There are 'scripts' in its pages that mothers (and midwives) could use to great effect and that's a real strength of these stories - they are an antidote to the 'am I allowed'/'will they let me' position that so many women find themselves in and they show how, even in difficult circumstances, you always have a choice about your care and your informed consent should always be sought.

I had all three of my children at home - with NHS midwives - and I love how the book, again through real-life birth stories, gives a truly realistic picture of what home birth can be, both when all goes well and when there are complications. (I absolutely loved the story of the parents who planned a home birth, went into hospital for monitoring, found all to be fine, then dashed back home again to have the baby in the pool as planned!) Parents considering home birth can read the book and get a sense of the 'back up' that's in place, whether the care is independent or NHS, and feel reassured. On the whole the book is immensely reassuring; it's a long way from the 'drama' of birth on television shows like One Born Every Minute. Even through the (admittedly very unusual!) story of a breech birth that took place in a moving ambulance in a snowstorm there is never a sense of panic, more a sense of wonder that birth can often unfold spontaneously even in the strangest of circumstances. I also relished the moments where traditional (yet evidence-based!) birth wisdom - so easily overlooked in more medicalised births - was in evidence: Virginia describes how something as simple as getting out of the pool could slow down labour enough to give her time to arrive to be with a nervous father worried about having to catch the baby, and how labours that are progressing well can be stalled by people coming in and out and talking to the mother, or turning on the lights. She often talks about the subtle signals women give about what is happening in their labours, without the need for vaginal examinations or calculations of 'rates of progress'. There's valuable knowledge here that we would all do well to take note of.

It's probably clear by now that I loved this book (I've ordered a few copies for my mobile book stall so I'll be spreading the word...) And I'm with Virginia in hoping that it doesn't become a historical document in the near future: if you can join in the campaign to save independent midwifery, please consider doing so. You can go to the IMUK website and take it from there - lobby your MP, donate to the fighting fund, sign the petition.

Finally, I wouldn't be an editor worth my salt if I didn't flag up the fact that there a few proofreading errors in the book, and that some of the dialogue sounds a bit clunky (that's down to the fact that someone decided not to use any contractions - strange, given the subject matter! - so instead of 'I'll' 'I'm' or 'We're' these are spelled out in full). These are minor niggles, didn't spoil my enjoyment of the book and can no doubt be corrected in future editions (of which I hope there are several, revised and updated to include many future birth stories!)

I received a review copy of the book from Headline; my opinion of it is, of course, my own!

Thursday, 27 February 2014

New breastfeeding research: approach with caution!

You may have seen this article in the Daily Mail, with the provocative headline:
"Breast milk is 'no better for a baby than bottled milk' - and it INCREASES the risk of asthma, expert claims". Having done some digging, including reading the abstract, extended abstract, press release and the full text of the scientific paper (Colen, C.G., Ramey, D.M., Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons, Social Science & Medicine (2014), doi:10.1016/j.socscimed.2014.01.027. - available via ATHENS, or to purchase online) that this article is based on, and other reports, it's clear that the findings of this study should not be dismissed out of hand simply because they appear to contradict what we think we know about the long-term impact of breastfeeding on child health.

I recently heard scientific research described as 'like a jigsaw puzzle, except that there are no straight edges, and no picture to follow on the box' and thought that this was a useful way of thinking about it. Each new piece of research fits in somehow, but the how and where of it can take a long time to unravel. What's interesting, and what moves our understanding forward, is continuing to delve deeper, and, instead of dismissing results that we instinctively feel are 'wrong', asking 'How did the researchers obtain these results? Are their methods sound? Why did they get the outcomes they did? Are there clues in their work about other things we need to know before we can draw a sensible conclusion? Should we be acting to alter our recommendations or behaviour based on this research, or not?'

Of course, the above has nothing to do with the poor reporting of the research in the media (for interest, compare the Daily Mail article with this one for an illustration of how different two reports based on the same press release can be). My hackles rose at the line 'The NHS recommends that mothers breastfeed for around six months' - it doesn't, it recommends exclusive breastfeeding for around six months and continued breastfeeding alongside other foods after that, with no maximum duration specified. That the most basic of fact-checking hasn't been carried out makes me suspicious of reading too much into the Mail's slant on the story (that, and past experience of the Mail's anti- breastfeeding/anti-breastfeeding supporter agenda). Looking closer at the piece it follows the press release fairly closely, except that in certain telling ways it exaggerates the impact of this study, despite the authors taking care in their discussions to take a fairly moderate view. Something as simple as the Mail choosing to include a bullet point beneath the headline that reads "Dr Cynthia Colen says the benefits of breastfeeding are exaggerated", when in fact the press release says "A new study comparing siblings who were fed differently during infancy suggests that breast-feeding might be no more beneficial than bottle-feeding for 10 of 11 long-term health and well-being outcomes in children age 4 to 14." (my italics) serves to overstate the importance of this one study in the context of all the research into breastfeeding, artificial feeding and maternal and child health that is currently being carried out. Characterising Dr Colen as a generic 'expert' is another case in point; she's a sociologist, and an assistant professor - but what does this tag of 'expert', as applied by the Mail, mean? That she's more expert than other breastfeeding researchers? That she's the 'best expert' on breastfeeding that there is? There are plenty of other intelligent, committed, qualified researchers into breastfeeding currently working on research that may or may not support the findings of this paper - but the way the Mail uses the term 'expert' here suggests to the reader that this particular paper is somehow more important than others. I've talked before about the danger of believing that each new research paper moves everything 'forward' and it's helpful to remember it here - there are countless blind alleys and twists and turns in the quest for knowledge, and avoiding hyperbole when reporting new research would be a good start in making this more generally understood.

I've read the full paper and, I've got to confess, I am no statistician, so I am not best-placed to comment on whether the methodology is robust. At first glance, as an interested lay-person, it seems like a useful study, carefully designed to address some of the difficulties of previous studies, with some interesting results. The questions that immediately sprang to mind as I read it, which I would love others to examine in more detail, were the fact that the sample size of the differently-fed siblings was small - could it be that the numbers aren't sufficiently powerful to show statistical significance? I also wondered about breastfeeding duration - the researchers asked whether breastfeeding was initiated, and how long (in weeks) it went on for, but I couldn't find any numbers for this in the paper - what was the mean duration of breastfeeding in these families where one child was bottle-fed and one child was breastfed? If we are talking about the difference between two months or less of breastfeeding and bottle-feeding from birth, I would expect the results to show less of a difference than if we were comparing six months, or a year of breastfeeding against bottle-feeding from birth (based on the research I've read that shows a dose-response effect of breastfeeding on infant health). I found myself wondering about the scenarios in which one child in a family is breastfed and the other bottle-fed and how those might appear in these statistics - a common scenario in our culture of infant feeding in the UK, which I come across regularly as a breastfeeding peer supporter, is that a mother tries breastfeeding with her first baby, stops early due to a lack of support, then doesn't 'put herself through all that again' with subsequent children. I also wondered about whether the results of this study could be extrapolated to the UK or other Western cultures - the Mail certainly seems to think they can, as it was very unclear in their article that this was actually a US study (despite it being clear in the title of the paper itself). Differences in the racial and socioeconomic profiles of our respective societies might be important (indeed, the researchers note that one of the features of the differently-fed group is that the racial profile is different from that of the other two comparison groups, with the highest proportion of black/Hispanic families - although they urge caution in attaching too much significance to this).

Something else that was interesting to me is how the authors of the paper position themselves in terms of the research and debate surrounding infant feeding. In the introduction the authors write:
"Scientifically, disparities in infant feeding practices raise the critical question of the degree to which unobserved heterogeneity between children who were breastfed and those who were not may be driving the frequently noted positive association between breastfeeding and a wide variety of childhood outcomes. If this is the case, a well-intentioned, narrow emphasis on breastfeeding promotion would, at best, fail to realize positive benefits and, at worst, be a source of oppression for women who do not nor cannot breastfeed." (my italics)
This all sounded familiar to me and there's a reason for that, which becomes clear at the end of the paper:
"A truly comprehensive approach to increasing breastfeeding in the U.S., with a particular focus on reducing racial and SES disparities, will need to work toward increasing and improving parental leave policies, flexible work schedules and health benefits even for low-wage workers, and access to high quality child care that can ease the transition back to work for both mother and child. Hopefully, this multifaceted approach will allow women who want to breastfeed to do so for as long as possible without promoting a cult of “total motherhood” in which women’s identities are solely constructed in terms of providing the best possible opportunities for their children and the risks associated with a failure to breastfeed are drastically overstated (Wolf, 2011)." (my italics).
I think this at least sets the paper in context (for more, see my previous post about Joan Wolf). I should have guessed from the clue in the title of the research paper, 'Is Breast Truly Best?', which itself echoes the title of Wolf's book.

Let me be clear - I'm not dismissing the results of this paper. But just as its authors urge caution about overstating the benefits of breastfeeding in order not to oppress women, I urge caution about the importance we attach to the findings reported here, and suggest that we view them instead as one small piece of a very large jigsaw, and as a point of departure for asking further important questions.

Tuesday, 28 January 2014

Doctors and breastfeeding - a follow-up post

Sometimes blogging completely takes me by surprise. Last week I posted about GPs and breastfeeding. Compared to some of my posts, hardly anyone read it - which is, of course, fine - but those who did then engaged in such fascinating and lengthy debate, on Twitter, on Facebook and by email, that a follow-up post is the result. I guess sometimes you just have to put things 'out there' to get to the heart of the matter.

(I should probably say that I was in two minds about even posting last week's piece. I have enormous respect for doctors, the standard of their training and the work they do in tough times for the NHS. On the other hand, I think that when we're considering an issue as thorny as how to raise breastfeeding rates in our society, we have to look critically at everything that might be having an impact and wonder about how changes can be made. Sometimes we'll be barking up the wrong tree. Sometimes new insights will come.)

One point that I don't think I made well enough last week was actually about breastfeeding supporters (I include myself) and how we respond to articles in the media or comments by individuals. While I think it's right that misinformation be challenged, I can't help feeling that there's an irony in the fact that we can Tweet and blog up a storm - in what is sometimes quite an aggressive way, if only due to the sheer volume of complaints - in response to a media doctor's quote in a magazine, but have no meaningful way of addressing the same misinformation when it's dished out to women one-to-one by a GP or other health professional.

Some of the comments by doctors in response to my post took me to task - rightly - for calling for more training for GPs when their time and budgets are so sorely stretched, and when every other 'single-issue' group thinks the same about their area of interest. It was pointed out to me that if a GP must do 50 hours of CPD each year, and the breastfeeding training takes half an hour, then that means that breastfeeding must be in the top 100 things the GP considers that year (and that's assuming they all take half an hour; some will obviously take longer. Some topics GPs are contractually obliged to cover). When you start to consider the list of things that GPs need to be abreast of (!) you can see why breastfeeding doesn't automatically push itself to the top of the list, particularly in areas with low breastfeeding rates where GPs see very few breastfeeding women, or in areas where there are reasonable breastfeeding support services away from the GP.

Something that came out of this discussion for me was the idea that there is work to be done in increasing awareness among GPs, possibly via representation to the Royal College of General Practitioners, of the public health aspect of increasing breastfeeding rates and the potential beneficial impact on GPs - the cost implications of fewer appointments for ear infection, gastroenteritis and lower respiratory tract infection are outlined in this UNICEF report. I would love to see a case study showing this in practice.

Another point that was raised, and which I found fascinating, was the degree to which GP services vary across the country. I mentioned some of our local frustration with tongue-tie referrals via GP - and discovered that in North London tongue-tie referrals can be made by a midwife or IBCLC at a drop-in group, rather than by the GP, and that in Bristol, although four people across the city can snip tongue-ties, one is off sick and thus waiting times are around four weeks (a long time in the context of a troubled breastfeeding relationship). In some GP practices in the south-east parents can self-refer to an in-house GP for tongue-tie cutting, although the long-term availability of that service can't be guaranteed. Is there anything that can be done about this variability? It was suggested to me that breastfeeding supporters engage with CCG pharmacists and educationalists to discuss issues of prescribing for lactating mothers and best practice in treating breastfeeding women and infants, and I wonder if there's an opportunity - somehow, for someone - to do that work.

Finally, some really interesting ideas surfaced from the discussion. These included finding ways to have more IBCLCs working in or alongside the NHS, perhaps in larger GP practices or rotating between several practices, and the idea of increasing the numbers of peer supporters by offering them a £200 voucher incentive (as opposed to the mothers themselves). I also loved this link about innovative ways in which breastfeeding training is being delivered to busy doctors and nurses in the US.

In the end, it's a problem with no easy solution. But another common theme of the discussion was frustration with the way things are - on both sides. Perhaps we (and by we I mean anyone with an interest in breastfeeding) can start by broaching the subject with our own GP practices - we might at least open a dialogue that could be beneficial. Some great resources for doctors are Wendy Jones's book Breastfeeding and Medication and Dr Thomas Hale's Medications and Mother's Milk. The Breastfeeding Network's factsheets are another excellent source of information for GPs.

Thanks to all those who contributed to the discussions of the original post.