Wednesday, 25 November 2015

Don't Fear Sunday's Child - A Look At Today's Headlines On Weekend Births

If  I was pregnant at the moment I suspect I'd find today's headlines pretty scary. They report that giving birth at the weekend, something most women can not control or predict, puts babies lives at risk.

It would be great if we could dismiss this as yet another case of media hype, a rouge press release or even (as has been suggested) a conspiracy theory aiming to turn the public against junior doctors.  But having read the stories, the press release and the paper they are all based on, I think it's all a bit more complicated than that.

The first thing I want to say though, to any readers who are pregnant and scared  by this news is please, don't be.

The headline story that there is a binary difference between weekend and weekdays simply isn't true. Take a look at the data below, taken from the BMJ paper this is all based on. The death rate is highest for babies born on a Thursday. In fact the most notable trend isn't a peak at the weekend but a drop on Mondays and Tuesdays. This trough drags down the average across all weekdays, making the weekend average seem much higher  by comparison.  This data doesn't tell us that lives would be saved if weekends were more like weekdays. It shows we'd be better off if every day was more like Tuesday (this may be the only time in all of human history when that sentence has been true!)

Plot taken (axis adapted for clarity) from the BMJ paper 

So should we instead  be terrified of giving birth on a Thursday?  The paper doesn't really address this issue. It merely speculates  (unconvincingly in my opinion) that babies born on a Thursday may be more likely to die a few days later because of the care they receive over the weekend.

This study also doesn't prove that weekends are more dangerous because the consultants are all off playing golf or something. It found no difference in death rates between units that met the recommended consultant levels and those that didn't. In fact of all the outcomes looked at, including injuries, infections and hospital re-admissions, the only one where weekend consultant numbers were important was the number of perineal tears. Yet even this isn't necessarily an indicator of poorer care when consultants aren't around. It is quite widely believed that obstetricians are more risk averse than midwives and more likely to recommend emergency caesareans. The decreased number of tears when there are more consultants may be due to an increase in possibly avoidable C sections. I expect many mums will have an opinion on which is the lesser of those particular evils!

I am, by the way, just speculating on the fewer tears means more C-sections thing. But that brings me to the fundamental flaws in this paper and how it's being reported to the public. The news stories and (unusually) the paper itself all seem determined that there is indeed a "weekend effect". They gloss over or ignore the data showing that this effect starts on Wednesday, and, having shown that consultant cover isn't an issue, offer only speculation on potential causes. Much of these seems to have been thought up to make the data fit the hypothesis. For example, while it may be the case that outcomes for babies born on Thursday are influenced by their care the following weekend, there is no real evidence for that. The data doesn't tell us how long babies were in hospital after the birth. Similarly it doesn't tell us how long the mother was in labour (and in the hospital) prior to birth, a period where good care is crucial. A large proportion of the women giving birth on a Monday and even Tuesday will have been receiving weekend care during labour, yet these are actually the days with the lowest death rates. Why? We don't know, but perhaps the question of why babies born at the weekend fare worst should be re-framed so we're asking what we can learn from the Monday and Tuesday births.

This study is fascinating and will certainly be a valuable contribution to the academic literature on the subject, but it generates more questions than it answers.

For example, the birth rate is 21% lower at weekends. Even if elective c sections (which are very low risk and almost always done on weekdays) are removed, it is still 11% lower. Why? Could a reduction in the number of Inductions (IOL) at the weekend be involved? There is increasing evidence that IOL for overdue babies improves a number of outcomes, but this isn't covered int he paper so we don't know.

If consultant cover makes no difference what about the number of midwives, junior doctors, pediatricians etc.? What about their work patterns and moral?

What about dozens of other factors that we just haven't thought of? The simple answer is we don't know.

What we do know, if we actually look at the data not the headlines, is that there is no reason for women to be afraid of going into labour on the weekend. I've heard several health care professionals today express concern that women who start to get contractions, who's waters break or who feel a reduction in their baby's movements could delay going to hospital to avoid the weekend effect and in so doing risk something worse. The prospect of giving birth can be scary enough as it is, women need real evidence not hype. I find myself saying this over and over again, we are grown up adult human beings - why are we so rarely treated like it when there are column inches up for grabs (and perhaps in this case academic impact factors)?

Clearly more research is needed on the questions raised by this paper, it could be the starting point for something really useful, maybe lifesaving. But right now, it and the media response to it, only risk causing yet more fear and confusion.

If you are pregnant and reading this, just take this one thing away: The NHS is flawed and under funded, sometimes it makes mistakes, sometimes it just doesn't do things as well as it should, but if things get difficult in childbirth it has your back. The vast majority of women will take home wonderful, healthy babies, whatever day of the week they decide to turn up on. I, and my babies, wouldn't be here without it.


In case you missed the other links - the original paper including the full version of the diagram above can be found HERE

Friday, 6 November 2015

A Mum's Guide To Dodgy Science: Publication By Press Release

Sometimes, it sucks being a grown up. I've actually had enough time to write some blog posts recently but other events have left me with a lack of motivation for anything other than eating cake and reading Tudor crime novels under a blanket (it's a fairly niche slump). Anyway, in an attempt to drag myself out of it, before any more Lutheran priests meet a grisly end, I've decided to revisit some old blog posts as a way of sharing tips on how to spot dodgy science and health stories. The reproductive lives of the Tudor queens may have been subject to much debate and gossip, but hey, we modern Mums have to deal with medical advice from the Daily Mail!

First up in what will hopefully be a series of posts - Publication By Press Release:

Note on stock photos: anything featuring mobile phones gets very dated, very quickly.

What is supposed to happen when a scientist completes a study or set of experiments it that she/he writes it all up and sends it to a scientific journal who get other experts in the field to check it. They then usually ask for a few corrections and maybe some extra data and decide if the work is good enough to be published. It's a process known as peer review and there are any number of flaws in it but it is the best available system for scientific publishing and the one all scientists are supposed to endure  engage with.

Increasingly though I see cases where this isn't happening. A good example came almost exactly a year ago when a whole raft of news outlets got all excited over initial results from a study hoping to increase breast feeding rates by giving breast feeding Mums shopping vouchers. You can read my post from the time here but essentially this wasn't a story about a published paper, it was based on the author planing to give a presentation at a meeting. As I said at the time, you could in theory get up and say any old nonsense you wanted at a scientific meeting so simply planning to speak at one tells us nothing about the quality of what will be said. Of course if you do talk rot you'll face some pretty stiff questioning from the audience afterwards and I hope that happened in this case, I certainly had a lot of queries about the quality of the study! Interestingly, a year on, I still can't find any published results. To be fair the peer review process can be achingly slow but so far all that seems to have come out of this much touted study is two papers about how the study team sought opinions from a small number of women and health care professionals. Not very impressive, and really not worthy of repeat slots on breakfast news!

Breast feeding is totally absolutely always just like this *snort*

Instead of waiting until the study had been assessed and the results checked, someone, somewhere (I could probably take a guess at who), decided to get some media attention and put out a press release and because the media just luurve stories about health/ breast feeding/ women's bodies/ judging poor people that press release was gratefully picked up.

So who's to blame for this kind of non-story? It's tempting (presumably unless you are one) to just blame the journalists, looking for sensational stories and to hell with the truth. Sometimes that's fair, In an ideal world a journalist receiving a press release about some scientific research would check the published data and seek out alternative expert opinions. But we're not talking about getting this done in time for tonight's print run or the 10pm news bulletin anymore. If it's news, it needs to be up online and on social media in hours or perhaps minutes and it needs to compete in an almost infinite fight for attention. So perhaps it's not surprising that journalists often depend on a press release from a respectable institution being accurate. In the immortal words of Whitney Huston: It's not right, but it's ok.

Sing it Whitney

Actually no it's not ok, but I had that song in my head for some reason, anywaaay,

Sometimes the blame for this sort of thing needs to be shared out. If the journalists are relying on university press releases to be accurate, then university press officers need to make sure they are. But again there is a conflict. Not putting out a press release because something isn't published yet isn't going to get you any publicity, so there is an understandable temptation to take any opportunity to get your institution talked about. The scientists themselves should be checking that press releases are an accurate reflection of their work but this also doesn't always happen. Scientists are ordinary people they're busy, they may be under pressure to publish or at least get some publicity and some ordinary people just really like their own opinions and/or their 15 minutes or fame.

Which brings me on to another old blog post. In this case there was a published paper, but it bears little resemblance to the the press coverage it generated.  According to the Telegraph and (oh yes) The Daily Mail, we should all co-sleep/bedshare with our children until they are three. Not because they like it or it's just the only way for anyone to get some sleep sometimes, but because not doing so results in lasting damage to children's hearts and harms brain development causing behavioral problems later in life. Pretty damn scary news if, like me, your kid was actually pretty happy in her own cot most of the time. But the paper says absolutely nothing about these dreadful long term problems, it looked at the heart rate of a few newborns being held by their mother and compared that to their heart rate when they were in a crib. Presumably one of the authors got rather carried away and extrapolated wildly from that to the three years or brain damage headlines. The media were happy to go along with it because hey look! Another opportunity to tell Mum's we're doing it wrong!

Actually if Mum's are so dreadful at this baby sleep thing perhaps Dad's should be in charge of it, all of it *evil cackle*

All this bugs me. There is loads of good, interesting, important science going on out there. A small proportion of which offers real, useful advice to improve people's health and well being. But when small, unchecked, unproven studies start fighting for column inches or the stories that reach the public are wild fantasies based only vaguely on the evidence, then how can anyone know what to believe and act on? The valuable stuff gets crowded out or people simply feel drowned in information and give up on all of it.

Clearly most parents have one or two other things to do and don't have time to conduct their own personal scientific literature review for every single bit of health advice so here are a few things to look out for in a news story which may suggest you're looking at Publication By Press Release rather than a properly checked over bit of research.

The Spotters Guide To:

Publication By Press Release

If a health news story meets any of these criteria, it may be a bit dodgy:
  • There is no mention of or reference to a scientific paper
  • The story says the information will be presented at a meeting
  • The story says the information came from an interview or other media article
  • The only quotes and opinions come from people who worked on the research

Basically just don't ever put too much faith in one off bits of information and advice in the media and online.

Like for example information and advice on random blogs.


Next up - more exaggerations, From Petri Dishes To People.


Friday, 16 October 2015

The Loneliness Of the Smart Phone User?

I've seen links to images by American photographer Eric Pickersgill a few times now on social media. He took photos of people looking at their smartphones but removed the phones. It's supposed to highlight now strange and lonely smart phones can make us, how we can be in the presence of friends, family or lovers yet be isolated from them by mutual screen addiction. Take a look at the pictures and see what you think.

Then, imagine that instead of replacing the phones in these people's hands, we put books there instead. Would we consider a couple snuggling on the sofa together reading to be sad and distant from each other? Would we shudder at the sight of three young brothers all reading books? The book readers are no more likely to be interacting with each other than the smart phone users but few people would criticise them for their page hours. Books are old and good, phones are new and bad. But I'd bet people once said the printing press would drive families apart.

I find the idea that modern technology makes us less social very odd. Of course there needs to be limits, we try to eat meals as a family around the table and phones are banned. My husband is no doubt raising a sardonic eyebrow at this post as I often tell him off for staring at the phone when I'm trying to talk to him. But overall, smart phones, tablets etc. help me to communicate more, not less.

Here's a few examples from yesterday, a pretty typical day.

I had a few minutes for myself before the kids got up so I flicked through twitter, catching up with news and opinions from American. Not the global events that would be in the UK press too but the smaller things that were interesting people while I was asleep.

After breakfast the girls were dancing around the kitchen so I took a few pictures on my phone and made a quick collage of them on Instagram. They are mostly blurred, but they meant that my Mum, who lives five hours away, would get a peek at what her grandchildren were doing that very day. 

At work I was watching a very dull experiment when I got a lovely message on WhatsApp from a colleague who works different days to me. She sent a picture of a meal she'd cooked, thanking me for the recipe and arranging to pop round to my house at the weekend and return some baby things I'd lent her. 

At lunchtime I only had time for a quick break on my own, so I flicked through Facebook and saw pictures of a friend's children playing in her house, she lives in Australia now and I've not met them all. 

I ran home from work with my phone stuffed in my bag but was still able to take a call from my husband, thanks to my bluetooth headphones. Afterwards I used my smart watch to send him a link to my phone's GPS. It meant he knew exactly when I'd be home and that it would be worth keeping the kids up so I could read them a bedtime story.

At the end of the day I curled up on the sofa with my husband and we watched a film, streamed to our TV and controlled by an app on his phone.

None of this is big interesting stuff, it's just the mundane everyday business of life. If everyone you know and care about lives in the same village as you then smart phone communications probably don't matter. But like so many people my loved ones are spread around the world, keeping in touch with them was the main reason I started blogging. Without my smart phone and laptop I'd still probably hear about the big things, the marriages, deaths and babies but I wouldn't get to share the everyday details of life. The silly poster someone spotted or the friend who's had a bad day at work. I wouldn't get to read interesting articles from writers all over the world in publications I may never have heard of. My parents wouldn't be able to see their grandchild via skype, jumping about in her fancy dress costume. I wouldn't have met many wonderful, fascinating and diverse people through online groups and discussions.

Technology can come between people, but it can also bring us together, shrinking the barriers of geography and time zones. It can be lonely, being at home with only very young children for company, waiting for yet another delayed commuter train or living many miles from all your family. But with my smartphone in my hand I always have friends a few taps away. My village is global but I carry it in my pocket.

Tuesday, 13 October 2015

Acupuncture For All - On the NHS?

I was really disappointed to read this article today in the Guardian, The general gist is that some doctors think acupuncture works and should be available on the NHS with all doctors learning at least a little about it in training and midwives being trained to administer it to ease labour pain. According to the article the NHS is only denying us this treatment because of the "entrenched scepticism...of the medical establishment" and GPs "making a judgement on something they do not know anything about".

The first thing that really bugged me about this piece is how very one sided it is. Those promoting acupuncture are painted as brave and caring individuals fighting against a faceless dogma. But non of those sceptical establishment figures or judgy GPs actually get to articulate why they don't refer patients for acupuncture. The piece also throws in various claims to support the practice but they don't stand up to a great deal of scrutiny and the writer doesn't question any of them. Edzard Ernst has gone over a number of these on his blog so head over there to see what I mean.

But what really bugged me was the statement that a major London hospital was offering acupuncture to all women who wanted pain relief in labour. I actually find this idea a bit insulting.

At this point it might surprise you to know that I had acupuncture just before MissE was born. I was overdue, hot, uncomfortable and desperate to avoid an induction. The acupuncture session was lovely. I lay in a dim room for an hour, soothing music playing and a friendly woman listening to how I felt, offering to help with my concerns and asking if there was anything else she could do for me. I came out feeling calmer and less achy than I had done in weeks, but I didn't go into labour for another four days and I suspect a good massage would have had much the same effect.

Which is one of the things that concerns me about offering acupuncture in labour, The evidence for it is, at best, limited. But I have no doubt that a midwife taking time to listen to a women, understand her fears, acknowledge her pain and offer ways to ease it would make labour easier, less stressful and probably less painful. That's the placebo effect, it's very powerful and you don't need needles to achieve it, you need time. If a women accepts the offer of acupuncture and gets dedicated one to one care, even just for a little while, then that's great for her, but does it also draw care away from women who don't want needles put in them? Perhaps this hospital has plenty of midwives to go round so they can afford to give every woman great care, needles or no? If so I'd rather they were promoting whatever it is they've done to achieve that because it certainly wasn't the case for me at another major London hospital not far away!

I hope they also have lots of anesthetists available. I hadn't wanted an epidural when I had MissE, but 24 hours into labour with no end in sight I asked for one. I then had a miserably long wait as all the anesthetists were busy, then the drugs had run out. Frankly, if they'd offered me acupuncture instead at that point I'd have thought they were taking the piss! Difficulties in getting an epidural are a pretty common story, I've heard plenty of tales of women told they couldn't have an epidural because they weren't far enough along/ were too far along/ should just try to cope without. Perhaps those things never happen at this hospital? I certainly hope women aren't being encouraged or perhaps forced to rely on an unproven technique instead of effective drugs.

Which all in all leaves me wondering if women are being fobbed off here? Sending a midwife on a one day course is a lot cheaper than training and employing more anesthetists. Taking time to listen to and care for those women who want acupuncture is easier than applying the same standard of care to all. I also get that familiar, uneasy feeling that women who choose the serious, pharmacological pain relief options in labour are being judged for it. Acupuncture is ok because it sounds ancient and mystical and (if it does anything) it'll only help with the pain not remove it entirely. But drugs are modern and man made and perhaps women should still suffer to bring forth life?

In a fantasy world where NHS maternity services had infinite supplies of money and staff I'd be fine with it offering acupuncture for all, chuck in some massage therapy for those who don't like needles, doula's for anyone wanting non medical encouragement etc. etc. But that isn't the NHS we have or, probably, ever will. So I'm really uncomfortable with the idea that we should be spending more time and money promoting techniques that may be little more than placebo, especially if doing so could mean ignoring the need to improve access to proven forms of pain relief and better midwife care.

Time, care and choice - I wish those were available to all on the NHS


Wednesday, 16 September 2015

Why It's Not Science V Nature

Getting back to nature seems to be increasingly important to many people. Wander about health advice on the internet or in print and you'll soon find stories about how eating, living and parenting like our wilder ancestors will make us happier and healthier. That we can, if we learn from them, get back to a time when our lives were simpler and free from the fatigues and stresses of the world we now inhabit. Take a detour to the more judgey end of parenting advice and you'll be told that failing to be natural, to breast feed, baby wear, co-sleep etc, will lead to irreparable physical and psychological harm. These are powerful promises and they breed powerful desires. When faced with a medical system that often can't explain, never mind cure, our maladies, alternative remedies and restrictive diets offer the tantalising promise of control. Of actually being able to do something for ourselves.

Although there is little, if any, good scientific evidence for many of these claims they do feel desperately appealing and intuitively correct. The lack of cold, hard, modern science, if anything, seems like further proof that these alternatives are better, kinder and more holistic. I keep seeing articles and comments which assume that science (and often modern medicine too) is divorced from nature. That we scientists have set ourselves apart by obsessing over percentages, chemical formulas and our own powers and in so doing we've become blind to the simple truths offered by nature.

Science stands alone and aloof at one side of the room. Nature, art, beauty and creativity are at the other.

But that's not how I see it. It was a love of nature that drew me to science in the first place. As a child I devoured BBC natural history programs that brought biology into my home through innovative technologies and presented it like works of art. I was fascinated by dinosaurs, owls and strange, exotic animals. I learned how these creatures interacted, how ecosystems depended on impossibly intricate webs of connection, containing everything from tiny insects to giant predators. I dreamed of going on pilgrimage to the Amazon rain forest or Galapagos Islands so I could see these wonders first hand. As I got older I also found that sense of wonder in the human body. It seemed (it still does) that every time I learned something new it only revealed another layer of complexity, another set of questions that I had no idea existed. Once you understand the organs of the body - what about the cells that make them up? Then there are the different components of those cells - what do they do? How are they powered? What are the individual molecules involved? The atoms?

I am a scientist, not because I deplore nature, but because I am in awe of it. Learning something new about how our bodies work is, to me, like experiencing a great work of art. It can be emotional and beautiful, it can teach us truths about life and humanity, while also challenging us with new questions. Physicists may search for the Theory Of Everything but in biology it's the very fact that we are no where near understanding even a fraction of everything, that makes it so fascinating.

This doesn't, however, mean that I see or seek perfection in nature. Working in medical research it's easy to find examples of what can go wrong. The complex DNA blueprints in our cells are copied and repaired perfectly, billions of times in our life, but it takes just a handful of little errors, a few misspellings, to set off a fatal disease process. Sometimes those errors are the result of our modern way of life, tobacco smoke for one, is undoubtedly dangerous. But more often these little mistakes are utterly random. Nothing, not even nature could create something as complex as a human being and make it flawless. To get back to this blog's pet topic for a moment, that's why I hate it when people say we humans are "perfectly designed for childbirth". We aren't perfectly designed or even perfectly evolved for anything. We are a fantastical compromise, a phenomenally intelligent mammal which can run for hours on just two legs, yet still get our babies' enormous heads through the twists and turns of our altered pelvises. Evolution, nature, does not require that compromise to work for everyone, it doesn't produce perfect finished products. The benefits to our species of being clever and keeping our hands free for tools are so great that nature is happy to sacrifice the mothers and babies whose unusual pelvis/ big brain combination just doesn't work. Nature is ok with a bit of collateral damage.

Of course I don't speak for all scientists, or even all biologists. There are scientists who show little empathy for other people or the natural world, who cheat and fake results to get to the top, who act unethically or just aren't very nice human beings but that is true in any large enough group of people. It is, sadly, human nature. But speaking for myself, nature is not this scientist's enemy. It is flawed and complex and much of it is beyond my comprehension but this is why I am a scientist. Because I never want to stop asking why? how? and what went wrong?

Like most people I would love to get rid of the lingering fatigue of modern life. I am tired and sometimes things hurt. I wish I were slimmer, happier, more energetic, less stressed and a dozen other things. I wish I could achieve all that by tapping into ancient wisdom, by eating like our caveman ancestors or breastfeeding my toddler. But as a scientist I reluctantly concede that it just isn't that simple, nature isn't that simple. So I will continue on, dressed in my health and safety protection gear, surrounded, unnaturally, by millions of pounds worth of droning and buzzing high tech equipment and maybe I will contribute just a tiny bit to our understanding of nature. There are no simple cures, there was no golden era before science, when humans bursting with vitality lived joyfully at one with nature. But Science is not nature's opposite or opponent. Science glorifies nature and in so doing, in slow tentative steps, we might come to understand what ails us and perhaps how to fix it.

Most scientists are just ordinary people. We juggle work and family, try to follow our passions and leave the world a little better than we found it. Sometimes we wish life were simpler or we felt healthier and sometimes we just wish that we could get away. That we could stand alone on a beach, with the sun on our skin and stare out at the mysterious depths of an ocean. Or sit in a forest surrounded by the sounds of birds and trees. Just like our ancient, natural, ancestors did.

PS I did go to the Amazon and the Galapagos Islands. They were even more amazing than I'd imagined.

Wednesday, 9 September 2015

Have Your Say In The NHS Maternity Review

A big review of NHS maternity services is currently underway and those involved are actively seeking out the opinions and experiences of Mums and Dads. This week they launched an online consultation which you can access here:

If you or your partner/friend/family member has had a baby with the NHS please please take a few minutes to fill this in.
I am eternally grateful to the NHS, in another time or place MissE and I wouldn't have made it or if we did, the cost would have been crippling. But my first experience of bringing a child into the world was, to be honest, pretty hellish. I hope one day my little girls will become mothers and that when they do the NHS will be there to help them, but services need to improve, as a minimum women must feel safe and respected, currently that isn't always the case. Money is tight but improvements can be made, I had a pretty positive experience with my second pregnancy and much of that was thanks to actions and attitudes that cost nothing.

But you don't need to be passionately interested, or actively involved in maternity services to take part in this review. It doesn't matter if your own experience was great or terrible or just a bit meh. If this review is to do anything then it needs to understand the full spectrum of NHS maternity experiences and actually I suspect it's those who fall somewhere in the middle, who's care was ok or quite good but not amazing or terrible, who are least likely to speak out. Yet those experiences are valuable and important too.

 It's vital that the review hears as many different voices as possible. They are of course talking to doctors, midwives, charities and campaign groups as well, so there are a lot of strong voices joining this discussion. But as I wrote at the start of the review, it needs to hear the quiet voices too because the loud ones may not speak for everyone.

PS. I'll be filling it in twice as my two experiences were so different!

Tuesday, 18 August 2015

C Section Rates - The Economist Edition

So I was going to take a break from blogging this month. It's the school holidays and I've been trying to juggle childcare, work and my new sideline reviewing festivals (check out the fab Festival Kidz website btw). Frankly, I'm exhausted.

But, MrSB sent me an article in the Economist and now I'm sneaking back in here for a bit of a rant. Actually, it didn't make me all that cross, it was more a despairing sigh than anything. I'll fess up to not being a regular reader of The Economist. Frankly, if I had any interest in economics I wouldn't be working part time in a lab. So I had always assumed it was a pretty serious publication and would likely deal with numbers and data in an intelligent and non sensationalist way.

oops, my bad!

Essentially it is (yet another) story about how there are far too many C sections going on and it could have been cut and pasted from any of the many similar pieces. In fact, let's play a little game shall we?

HOUSE!!  This article has the lot.

There is nothing new or insightful here in fact I'm a bit puzzled as to how it is news at all as it seems to be based on a Lancet article and subsequent WHO statement that I (among others) wrote about back in April.

The only novel thing is an interactive infographic which plots C section rate against maternal mortality. From which the writer concludes that where the Cesarean rate is above 10-15% (so basically the entire developed world) the extra c-sections don't save any mother's lives so must have been unnecessary.

But, fancy and interactive though that graph is, it tells us nothing about the optimal C-section rate. Firstly it says nothing about infant mortality, which is y'know kind of important (the Lancet piece shows a similar effect to maternal mortality but that's barely mentioned here). But it also gives no information about other bad outcomes. Death isn't the only thing that is worse than a C section. Certainly cesareans have serious down sides, but I'm guessing that women who've suffered for years with obstetric fistulas, or who have dedicated their lives to caring for a brain injured child, would probably think that one off surgery was the lesser evil. So without the data on these outcomes we can't say that 10%, 15% or any other figure is optimal (blimey, how many times have I said that on here?!)

The piece also tries to prove the pointlessness of all these C-sections by comparing the rates in economically similar countries - if there weren't loads of unnecessary C-sections going on how come there are twice as many in Mexico as in Costa-Rica? Or in Italy compared to the Netherlands?

But for me, that just hints at the point that has been so widely missed in this piece and so many like it. Certainly there are women who are coerced into C sections they didn't want and probably didn't need but what if in addition- just maybe, some women are making rational, reasoned decisions about their own bodies? You know, like proper grown up human beings? What if the differences between Italy and the Netherlands aren't entirely due to women doing what they are told by doctors but because there are considerable cultural differences between these countries and that may apply to women's attitudes to birth as well?

I'm speculating here of course but is it so utterly inconceivable that women should think a bit sometimes that it doesn't occur to the Economist to mention the possibility? Well except to trot out the same old tales of wealthy women choosing C sections to fit conveniently in their schedules or just to avoid traffic jams (seriously they say this)!

Like so so many articles it starts with the assumption that "as nature intended" is the best thing for all women's bodies. But in a world where we can eliminate diseases that once killed millions, where a woman might just be the next president of the most powerful country on earth and where a magazine can add an interactive infographic to the greatest and most accessible pool of human knowledge ever imagined, why is it so inconceivable that nature might not always know best on this one little thing and that choosing to do the unnatural might actually be ok for some of us?

Rant over, I need sleep, I'm taking MissE to Hamley's tomorrow (yay!!)