Friday, 28 November 2014

BabyFriendly 2014: a conference report

I've just got back from the UNICEF BabyFriendly Conference in Newcastle. I'm full of thoughts, ideas and inspiration and wanted to mention a few points before I get caught up in other work again.
Dr Kasja Brimdyr speaking at BabyFriendly conference

Breastfeeding and politics are never far apart, and the opening address was a reminder of that. Dr Dan Poulter, MP is the Parliamentary Under Secretary of State at the Department of Health and the Conservative MP for Central Suffolk and North Ipswich. He spoke about the vital importance of the first few years of a child's life in terms of development, health and longer-term outcomes, about relationship-building supported by the BabyFriendly standards, and he talked about increased numbers of midwives in training and money that's been invested in improving the environments of maternity facilities.

Unfortunately for Dr Poulter, I wasn't really in the mood for his carefully-worded speech. Earlier in the week I'd read this article about Newcastle - the host city - which explains the utter hopelessness of the city's financial situation and the impact cuts are having on family services (spending on children and family services, via Children's Centres, has been cut by 40%). When asked how much worse it will get, the city council leader replies '[With cuts to] transport for kids with special educational needs and disabilities. That is in the pipeline.' The day before conference I had read this article too, about how families with disabled children are being forced into grinding poverty - the article itself is hard enough to bear, but read the comments for many more real-life examples. Closer to home I've been filling in consultation documents about cuts to family services in my own area. As volunteer peer supporters affiliated to the Children's Centres we deliver our breastfeeding groups, hold our training sessions and support families there. Recently I've also been supporting Cambridge Breastfeeding Alliance's campaign to secure funding to continue their incredibly valuable breastfeeding drop-ins, the victim of cuts to children's services in Cambridge, as well as the RCMs campaign for fair pay for midwives (Dr Poulter told us - again - that more midwives are in training, but - again - didn't address the question of whether there would be jobs for them when they graduate...)

He went on to talk about breastfeeding statistics - another area of concern for me: I've been emailing the Department of Health, writing to my MP and signing this petition to contest the decision to cancel the Infant Feeding Survey 2015. This survey is of immense value to anyone working in breastfeeding as it gives detailed information about national breastfeeding rates, introduction of solids, continued breastfeeding, use of formula milk and so on. Many of the conference speakers referenced the survey in their presentations. According to Dr Poulter the government will be improving the quality, quantity and timeliness of breastfeeding statistics at targeted local level - I'm not sure how, or how the national picture will be monitored, and he didn't elaborate.

So far, so depressing... fortunately, the rest of the conference was a genuine celebration: of 20 years of the BabyFriendly initiative, of accreditations across the country, of the hard work and dedication to supporting mothers and babies that underpins the whole thing, and looking ahead to how the achievements of BabyFriendly can be made sustainable into the future. It's hard to pick out my personal highlights, but I particularly loved Dr Nikk Conneman's presentation about gentle, baby-centred neo-natal care that fully involves the parents: when asked how he handled ward rounds in his unit (when parents are often asked to leave their baby's bedside), he replied 'I don't do ward rounds' and the audience broke into spontaneous applause: I think because it's so refreshing to meet someone so prepared to change the system if it isn't working for the babies and parents. Laurel Wilson's engaging talk about the emerging new science of epigenetics and breastfeeding was described by someone sitting near me as 'mindblowing'; we now know that how a baby is fed can influence the way their genes are expressed, and that breastmilk is packed with genetic material (the only way that this can be transmitted other than through sexual reproduction). It's a topic I can't wait to read more about, and it's closely linked to the work that's going on into the microbiome.

Dr Kasja Brimdyr talked about skin-to-skin in the first hour after birth - there was so much in her presentation that I found fascinating, particularly her observations about the effect of epidural fentanyl on infant responsiveness in the first hour (which ties in with a post I wrote about the effect of epidural on breastfeeding). The fentanyl (a commonly used epidural drug) delays the stages a baby must go through to find the way to the breast and latch on. It doesn't mean they won't or never will, but it may take longer, and those babies need even more skin-to-skin time to facilitate it. She cautioned against paying 'lip-service' to skin-to-skin; it shouldn't be interrupted or hurried if at all possible. Kerstin Uvnas Moberg touched on epidural too - explaining how it blocks the release of oxytocin, causing subtle changes that may affect breastfeeding behaviour.

There's so much more I could mention, but my take-home message was one of positivity and belief that the work we're all doing in breastfeeding really matters. One delegate asked how, given the daily pressures on midwives and breastfeeding supporters, we could give mothers and babies the best possible care? It's a frustration we all share at times, and the answer Sue Ashmore gave was simple but inspiring: keep doing your best, keep trying, keep the BabyFriendly standards at the heart of what you do, and it will be good enough. We don't need to be perfect to make a difference.

Were you at the conference? I'd love to know what your personal highlights were. Leave a comment below...

Thursday, 13 November 2014

Exciting times...

My desk today.
I've not written as many blog posts as I'd like over the last few months. It's not for want of material - there's always plenty to comment on in the world of birth and breastfeeding - but other projects have been taking up most of my work time (which is squeezed in around the demands of the three small people in my house). But now, as the the pile of work on my desk grows ever higher, I can reveal what I've been up to.

I've done quite a bit of work for Pinter and Martin in the last couple of years, in my freelance editorial capacity - editing and proofreading some of their most recent titles. Earlier this year Martin Wagner asked me to go a step further and commission a new series of books: to be called the Why It Matters series. So I've been hard at work finding and talking to authors, finalising titles and overseeing the first few books in the series, and it's now starting to come together. A formal announcement, and new website, will be coming from Pinter and Martin very soon - but for the eagle-eyed the books are already listed (albeit without jackets) on both the Pinter and Martin site itself and other bookselling websites.

The first three books in the series are Why The Politics of Breastfeeding Matters by Gabrielle and Palmer and Susan Last (eek!), of which more below, Why Doulas Matter, by Maddie McMahon, and Why Hypnobirthing Matters, by Kat Berry; these will be published in March 2015. The next three, to be published in summer 2015, are Why Pre-conception and Pregnancy Nutrition Matters, by Michael Walne (of Your Nutrition Matters), Why Breastfeeding Matters, by Charlotte Young (aka The Analytical Armadillo) and Why Baby-Led Weaning Matters, by the pair of them working together. I am so excited to be working with all these wonderful authors, each one passionate about the vision of the series - to provide evidence-based, clear information that will genuinely help new parents, and anyone involved with them, to make properly informed decisions. More titles are planned for next autumn and beyond... watch this space!

The manuscript for one book has been delivered, the second is well advanced... and I find myself, as joint author of Why The Politics of Breastfeeding Matters, with Gabrielle Palmer, with a lot of work still to do on my own manuscript. In fact I've realised that I've been procrastinating about getting on with it and I've had to address a whole heap of doubts: about my ability as a writer/editor, about my time management skills and about whether I actually know enough to do justice to Gabrielle's work - it has been hard to buckle down. I hope I've turned a corner with it... let's see. It would be ironic if I failed to deliver my own manuscript on time, given that I've spent a good proportion of my career coaxing authors through the writing process! I need to take my own advice, I think, and just get on with it. Please feel free to nag me.

Another project I've been involved with is Laura Dodsworth's fabulous photograph/interview book Bare Reality - which you may have seen in the press or online as she ran a phenomenally successful Kickstarter campaign in September. I'm editing the text of the book and am delighted that Laura has actually now linked up with Pinter and Martin to publish and distribute the book - the jacket has just been announced and it looks amazing.

As if all of the above wasn't enough, I'm thrilled that Milli Hill's book Water Birth: stories to inspire and inform for my own tiny company, Lonely Scribe, has reached the proof stage and should be published very soon. It's been a long time since we started the project - and in the meantime she's set up the Positive Birth Movement, had a third baby and become a columnist for Best - but it's wonderful to finally be approaching publication. Here is a sneak peek of the jacket - watch out for news of when the book is published.

Friday, 22 August 2014

Why are we working hard to get mothers to breastfeed, then encouraging them to stop?

This week I've been thinking about the messages mothers get from their health professionals, peers and the older generation about breastfeeding past six months, and how this plays out in our culture of infant feeding in the UK. (This train of thought was sparked off by several conversations I've heard
Breastfeeding my poorly 23-month-old
recently between mothers - mostly first-time mothers - and health visitors, Children's Centre workers and doctors. It's not my intention to be particularly critical, more to explore what we are actually saying to mothers, and the effect it has).

There's a lot of focus (at least in my area of Derbyshire, where we've been working towards, and recently obtained, full Baby Friendly accreditation in the community (DCHS) and the county council (DCC)) on improving rates of breastfeeding initiation and continuation (measured at 6-8 weeks). All the hard work, by DCHS, DCC and volunteer organisations such as BEARS, the peer supporters I am involved with, is really paying off and we were delighted to get the UNICEF endorsement - part of which involves interviews with mothers themselves - that shows how far we've come in recent years and how much better we are doing in supporting women who want to breastfeed, at least initially.

But what happens to mothers after six to eight weeks? Peer supporters at breastfeeding groups often have experience of breastfeeding for much longer than six to eight weeks - so they are well placed to offer ongoing support to mothers who continue breastfeeding. But not all mothers attend the breastfeeding groups, and as their babies grow they have more contact with health visitors, practice nurses and Children's Centre workers at baby weighing clinics, developmental reviews and vaccination appointments, and their friends, relatives and casual acquaintances will all have something to say on the subject of continued breastfeeding too. As the weeks and months go by mothers are exposed to an awful lot of misinformation - hardly surprising when as a nation our breastfeeding rates at six months and beyond are so low, with fewer than 1% of mothers exclusively breastfeeding for six months, and only 34% breastfeeding at all at the six-month mark. Our society's collective knowledge about breastfeeding past six months is thus sadly lacking, something it is well worth bearing in mind when weighing up how much importance to attach to people's comments.

When I took my youngest daughter for her vaccinations at a year old I mentioned to the nurse that she was still breastfeeding (as there was a box to tick in her red book for 'still breastfeeding at all at first birthday'). She said, dismissively, 'oh, we don't need to collect that information'. She then went on to tell me how, if she ever had children of her own, she would definitely bottle-feed them, based on her experience with puppies! I was taken aback, but it was only later that I wondered whether, if I'd been a first-time mum rather than an old hand, I might have been more affected, even unconsciously, by the way she casually diminished the importance of breastfeeding.

I've recently heard a mother of a ten-month-old baby, still happily breastfeeding, advised to cut his daytime feeds in order to give him 'healthy' snacks, and to reduce and stop his night-time feeds as he 'doesn't need it nutritionally'. This mum didn't ask for help to stop breastfeeding; she was worried about her baby's wakefulness at night (for which she was advised controlled crying, despite saying that she didn't want to go that route - a whole different post...). The mother of a seven-month-old baby, who is mixed feeding - breastfeeding with one bottle of formula at night - was again advised to offer snacks in the daytime and encouraged to hurry her baby on to more solids rather than breastmilk so that he will 'cut down on his feeds' - she was told that the baby should ideally be moving to three meals a day plus two healthy snacks, and, somewhat confusingly, that he should still be getting a pint of milk a day, which would equate to '2 or 3 breastfeeds at the most', and she was told that her baby needed vitamin drops as part of the same conversation. The implication was that these mothers were now meant to be transitioning away from breastfeeding, when the reality is that for infants under a year, breastfeeding is still a hugely important part of their overall nutrition, and can continue alongside other foods for as long as mother and baby want. We are doing mothers and their babies a disservice if we are, even with good intentions and an eye on the nutrition guidelines, shepherding them down a path that leads to reduced feeds and an early end to breastfeeding.

Another mother I know of, who had a rough start to breastfeeding and was worried she might have to stop despite having fed her first child for a year, was told not to worry as the 'target' was six to eight weeks! The problem here is not the sentiment - I'm sure this person was trying to say something reassuring to a mum who was struggling - but that actually, her comment misrepresented the situation entirely. The immediate target for increasing breastfeeding rates may be the six to eight week measure in terms of the breastfeeding strategy in the county, but for that individual mother the NHS and WHO guidelines, which recommend breastfeeding to two years and beyond, are much more important for her own health and that of her baby.

What's missing, in all of the above, is an understanding and appreciation of the flexibility of breastfeeding an older baby, toddler or child: the way it continues to provide valuable, tailored nutrition, how it can fit in around solid food, going back to work and changing night-time routines, and the way in which it can continue to be hugely important to mothers and their babies for years to come, both in terms of nutrition, and in terms of their relationship (I wish more people could experience breastfeeding an older child who is poorly and miserable and can't stomach anything else, for example). Children grow up so quickly - why hurry the weaning process if there's no need? Why can't we support and encourage women to breastfeed in the longer term, and then support and encourage them when, for whatever reason, they or their children want to stop?

It's been heartening to see Sharon Spink in the news in recent months talking about breastfeeding her five-year-old, after Michelle Atkin did so earlier in the year. And I loved this story about a mother breastfeeding her toddler on Australian TV. I hope that stories like these, and the debates they provoke, will help us as a society to improve our collective knowledge of longer-term breastfeeding so that we can offer better support to mothers, who in many cases have struggled to establish breastfeeding, only to have it suggested, after a few short months, that they should be 'moving on'.

There's a point to be made here, too, about how that 'moving on' message is one that's frequently heard and seen in advertising for follow-on formula and 'growing-up milk'; if we think babies and toddlers need milk, what better milk for them than that of their own species, delivered by their own mothers, rather than an unnecessary product developed to circumvent the regulations governing the advertising and composition of infant formula, which exists to line the pockets of the big baby food companies? Those companies work hard to target health professionals and mothers to get their messages across - so it is not just that our collective knowledge is lacking, it is also being undermined by those with vested interests. (For much more on this see the Baby Milk Action website; good information about formula milk is available from First Steps Nutrition.)

I'm sorry the blog has been so quiet in recent months; I've been busy working on all sorts of exciting projects, of which more news in future posts...

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 are 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.

Wednesday, 22 January 2014

Doctors and breastfeeding - room for improvement

Image from Fit to Bust by Alison Blenkinsop,
published by Lonely Scribe. It appears opposite
a page criticising Dr Jessen for overlooking the
importance of breastmilk for toddlers in 2010.
This post has been prompted, in part, by the Twitter-storm yesterday about Dr Christian Jessen's comments on breastfeeding, published in Closer magazine this week. He complained he'd been misquoted; Closer issued an online clarification - my feeling was that although he had been misquoted, there was still quite a lot wrong with what he'd actually said. Luckily I don't need to take his words to pieces - the fabulous Analytical Armadillo, IBCLC and Tracy at Evolutionary Parenting have already done a brilliant job, complete with plenty of references to actual research. Baby Milk Action have issued a comment, and Milli Hill has written a piece for Best about it.

Coincidentally, I was thinking about doctors and breastfeeding yesterday anyway. I came across this PDF about the management of thrush in breastfeeding women, written by an Infant Feeding Specialist in Derbyshire, which distils current thinking and best practice for doctors and prescribers, and circulated it to our group of peer supporters. We encounter a lot of mums who struggle to get the treatment they need from GPs and I thought it might be helpful if we could point them to this resource. We shouldn't really have to: I don't think it's unreasonable to expect GPs to have an up-to-date working knowledge of breastfeeding.

Dr Christian Jessen is a high-profile example (there are others: Dr Ranj Singh, Dr Carrie Ruxton, Dr Ellie Cannon) of a doctor who is regularly invited to comment on general health matters, including breastfeeding, despite having no specialist knowledge in the field. In this, he's not unlike GPs across the country who see breastfeeding mothers in their surgeries day in, day out. What comments like Dr Jessen's show, writ large across our national media, is how little our doctors often know about breastfeeding - not only in terms of actual lactation, but also in terms of how a breastfeeding relationship affects the lives of mothers and their babies. The implications of this are profound: the high-profile media doctors' inaccurate pronouncements undermine the efforts of those striving to improve breastfeeding rates, in pursuit of gains in public health and reduced cost to the NHS, and provoke online rows that often divide breast and bottle feeders and reinforce tired stereotypes. And
GPs in their surgeries nationwide, if they do not have training in breastfeeding or prescribing for breastfeeding mothers, are being equally unhelpful.

Every peer supporter I know has a story to tell about breastfeeding advice from GPs (sometimes unsolicited when attending for something unrelated!). Here are just a few examples we've come across recently in our own area:

- a mum told to stop breastfeeding for 48 hours while on high-dose antibiotics. It transpired she wasn't taking a high dose and that it was safe to continue breastfeeding.
- a mum told to stop breastfeeding for two weeks (!) in order to pump all feeds to 'see how much she was making'.
- a mum referred to GP to request a tongue-tie referral (HV sent mum to GP after peer supporter raised issue). In our area this simply requires GP to fax consultant. However, GP insisted that tongue-tie would split on its own, that it didn't affect feeding (it was) and that he would prescribe Gaviscon for the infant's reflux (which was probably due to the tongue-tie...)
- one mum mentioned the WHO guidelines to her GP, and was told they only applied in developing countries (they don't).
- a mum with persistent ductal thrush was told no further treatment was possible, despite having been told by another GP at the same practice to come back for stronger/longer meds if necessary. Dr eventually looked it up and realised this was true.
- a mum whose GP called her 'ridiculous' for still breastfeeding her 18-month-old.

Earlier this week I saw a status from Wendy Jones, on her Breastfeeding and Medication page, bemoaning the number of calls she's had recently from mothers of young babies, who've never experienced pain-free breastfeeding, who've been 'diagnosed' and treated for thrush which is not resolving. These women need help with position and attachment (and possibly tongue-tie!), not thrush treatment, and their GPs should realise this.

I;m not interested in bashing doctors here. We can't leave doctors out of breastfeeding. They have a crucial role to play, particularly where, as is the case in my area, there's no way of referring women on for BFC or IBCLC support for breastfeeding problems. If the peer supporters and health visitors can't help, mums must go via the GP for any onward referral. But our GPs need to be up to speed, and the examples above show that many are not.

I've done a bit (and only a bit) of digging into where the problems arise. GPs in practice now may have followed quite different training pathways from each other. It's entirely possible that a doctor qualified as a GP having never done an obstetrics/gynaecology/paediatrics rotation in training, which it seems is where exposure to breastfeeding problems would come in. However, even then trainee doctors may have been warned off by midwives from giving breastfeeding advice - disempowering them from the start and leaving them with the distinct impression that breastfeeding is something dealt with by 'others'. While this might be true in a teaching hospital situation with highly trained midwives and infant feeding specialists on staff, it doesn't help that doctor a few years later when faced with a waiting-room full of mothers and babies. Not all doctors find it easy to say to patients that they are unsure about something and need to look it up; not all doctors are aware of the importance of breastfeeding to the breastfeeding mothers themselves. Some doctors have personal experience of breastfeeding issues - and I don't discount the value of that - but in the absence of additional training, using one's own experience to advise patients can cause its own problems. Indeed, peer supporters, health visitors and midwives who are trained to support breastfeeding mothers are encouraged to debrief their own experiences and then leave them aside when dealing with other mothers, whose circumstances may be very different, to concentrate on giving good, evidence-based information.

There is some good news: doctors-in-training today should have at least a cursory knowledge of breastfeeding. At Keele University, for example: "...there is formal teaching about breastfeeding, to support problem-based learning in the context of a growing family, for students in their first year. Thereafter students will meet the issues [diagnosing and treating breastfeeding problems like thrush and mastitis, prescribing for lactating women] as part of their learning on placements – they have units on Child Health and Women’s Health in secondary care; and extensive patient contact in primary care placements (22 weeks across the curriculum, of which 15 are in final year). One difficulty is that much of the peri- and ante-natal care that GPs used to do is now done via midwives and students have much less contact with them for learning opportunities." (my italics)

What more can be done to improve GPs working knowledge of breastfeeding? In Derbyshire, where we're aiming for full Baby-Friendly Accreditation, we're encouraging local GPs to do the UNICEF Baby-Friendly GP E-learning module: it costs around £10, takes around 25 minutes to complete, and is endorsed by the Royal College of General Practitioners. The problem is that many doctors don't know that it even exists! Mothers everywhere: contact practice managers at your local surgeries and ask them if your GPs can do this training. It counts for their CPD (continuing professional development). If mothers are better informed, they can push for better service from their GPs. Ask your GP to check whether medication is suitable while breastfeeding, or ask them to look up the relevant Breastfeeding Network fact sheets on the condition they're treating. Ask them who else might be able to help with a breastfeeding problem. Ask your peer supporters which local GPs are most clued-up about breastfeeding.

I've focussed on GPs today but really, the same applies to any doctor who meets breastfeeding women and their infants regularly. I'm not suggesting all doctors should be breastfeeding specialists, and I understand the pressures that GPs and indeed all doctors operate under - but I would like to see fewer women on the receiving end of poor advice.

You can read my follow-up piece to this post here.

What do you think? Have you had poor breastfeeding advice from a GP? How do you think the situation can be improved? Leave your thoughts in the comments!