Friday, 15 May 2015

The Measles Vaccine - With Extra Life Saving Bonus

Or - why science is amazing and wonderful and cool.

Two things happened this week which reminded me just how fascinating science, and especially biology, (sorry Prof. Brian Cox) can be.

Firstly I gave a tour of our lab to some non scientists. I had 45 minutes to fill and it was a little daunting. Our lab is very specialised and technical, I didn't want to either bore them with incomprehensible science-speak or come across as some patronizing smart-arse. I think I pulled it off, and most of them seemed genuinely interested and amazed by our equipment and what we can do with it. I sometimes take it for granted that I'm involved in complex, novel research every day. So every now and then it's nice to be reminded that this isn't ordinary stuff to most people. Chatting to a colleague about it afterwards we both realised that - yeah, this is a pretty cool job, we can do stuff and find out things that would have been impossible just a few years ago and we're very privileged indeed to do that every working day.

The other thing I got chance to do was catch up on some reading. I worte some posts about Measles and measles vaccination a while ago but I'm by no means an expert on this subject and since then I've learned some new stuff. This is sort of a good news / bad news thing:

The Bad News:

I hadn't realised that getting through a case of the measles, as I did when I was five, didn't mean you were in the clear. There is a (thankfully rare) condition called subacute sclerosing panencephalitis (SSP) which can occur years after the initial disease seems to have gone away and which is sadly usually fatal. As I said, it's rare,  perhaps around 1 in 10,000 measles cases will go on to become SSP although the exact number is unclear and there is no specific diagnostic test for SSP, so it's quite possible that, since it could be 15 years since an SSP patient had the measles, the link might not be made. The good news here is that SSP is now very very rare indeed because vaccination means there are so few cases of measles in the first place (There is even an early episode of medical drama House where SSP turns out to be the mystery disease). But that isn't actually the main good news....

The Good News:

A new study suggests that the measles virus, as well as being potentially deadly and making you feel pretty damn miserable, also does a sort of factory reset on your immune system. By the time it's done you have good immunity to the measles but all your immunity to everything else is gone. All those immune cells that remember other, previous battles, against other diseases are wiped out. This means a fairly robust school child suddenly goes back to having the immunity of a vulnerable new born and in some cases it can take up to five years for them to get back to their pre-measles state. The study authors suggest that pre- vaccination, half of all deaths from childhood diseases were caused, indirectly, by measles.

Errr - how is this good news?

It is honestly  - hang on in there...
The reason we know this, is because it hardly ever happens anymore. Whenever measles vaccinations were introduced to a country the number of deaths from measles plummeted, but so did deaths from every other infectious disease too. Vaccinate against measles and you don't get measles which also means you don't get that factory reset of the rest of your immune system.

My immediate question was - how do we know it was the vaccine preventing the other deaths? Could it just be a coincidence? perhaps the vaccine was introduced at the same time as better food or sanitation? The correlation v causation question is always worth asking but in this case it really does seem to be the vaccine doing the job. The same dramatic fall in deaths is seen repeatedly in different decades and countries. Measles vaccination wasn't introduced to Denmark until 1987 but the same thing happened there, a rich, developed country. In fact the reduction in non-measles deaths is even more prominent in wealthy countries where most kids will survive measles and so go on to that susceptible period afterwards. Sadly in poorer countries many children never make it past the initial disease. Measles still kills 140,000 people a year.

This study also provides yet more evidence against some common anti-vaccination claims. Firstly there is the idea that catching a disease gives better immunity than vaccination. There is no evidence for this anyway but now we also know that catching the measles, rather than being vaccinated, actually wrecks immunity against everything else too.

I've also heard people claim that breast fed babies don't really need immunizations because they get all the immunity they need from their Mum. Breast milk does provide some immune protection although it seems to be fairly short term. But even if nature were as magical as some claim - one dose of natural measles virus and all that would be wiped out.

Biology is fascinated, there is always something new and unexpected, even when you have been studying and working with it for decades. Measles vaccination can now be considered one of the best and most cost effective health interventions on the planet. It's saved countless young lives and prevented a huge amount of suffering. But humans are pretty amazing too - we might not have realised how good it would be at the time but we made that vaccine and every scientist who worked on it, every health worker who delivers it and every parent who brings their child along has played a part in saving countless young lives.

I spend a lot of time on this blog saying "the press have hyped it up" or "the results don't really mean much" but we should celebrate our triumphs too. There is a lot of good news in science, a lot of genuine progress is being made. I wish more people could share in the complexity, beauty and wonder of it.


Saturday, 9 May 2015


Imagine you are taking part in some sort of extreme sport endurance event, say a really long, non stop hike. You're not at peak fitness but, at the start, it's going ok. However, 20 or 30 hours in it's got a lot harder, you're climbing up ever steeper hills, tired and in a lot of pain. It's as much a psychological battle as a physical one, you want to give up but you force yourself on, up the next hill and the next, you can't even see the finish line yet. Then suddenly something happens. Maybe an accident or an injury. The event you expected to be tough but safe has suddenly become life threatening. There are people everywhere and you're rushed to an operating theater for major surgery. You are exhausted and terrified but thankfully you pull through.

Now what you might think you'd need after all that is rest and sleep so you can start to recover. But weirdly you find yourself in some strange world where, not only is it assumed that you'll stay awake, possibly for several more days, but you're also expected to think it's all been the most wonderful experience of your life. Oh yeah and did I mention you'll also be handed the biggest responsibility of your life at the same time too?

(Have I stretched the metaphor too far yet??)

Seems ridiculous right? Of Course people would realise you need to sleep after all that. But swap the endurance hike for a long labour and make the surgery an emergency c section and it's a pretty ordinary experience of an NHS postnatal ward.

The absurdity of that struck me somewhere into my second sleepless night on one such ward. The doctors and midwives were telling me I needed to be in hospital to recover but all I really needed was someone to keep an eye on me, regular pain medication and some rest. I was getting none of those things on that ward (you can read more about my postnatal care here, it's not a happy story) The complete lack of sleep was unbearable. I finally left the hospital on a Thursday afternoon, the last time I'd gone to sleep was the previous Saturday.

Of course we expect new mums to be sleep deprived, it's kind of a grim joke and oh how everyone loves to tell you all about it when you're pregnant. But does that mean that mums don't really need rest to physically recover from a c section or a difficult birth or even a pretty straight forward one? Does one source of sleep deprivation mean you should just accept all others? Noise? Pain? Fear? Suck it up ladies you're a mother now. Major physical trauma is no reason to sleep on the job!

It's also possible that sleep has a roll in psychological recovery. Many women who have had difficult births walk away with just some bad memories or a good horror story, others suffer lasting psychological trauma. There is likely to be a large number of factors involved in determining who develops trauma symptoms but I wonder if sleep, or the lack of it may contribute. Heads up I really am speculating here which isn't very scientific I know, but there simply isn't much research on this at all. We do know that sleep problems are a symptom of trauma and PTSD and there is some (very limited) evidence that sleep disturbance prior to a traumatic event increases the likelihood of PTSD but I wonder what effect extreme sleep deprivation after giving birth might have?

I started thinking about this a few years ago following a conversation with a clinical psychologist. After my daughter was born I found myself telling the story of her birth over and over again in my head. I didn't want to, but it was always there, nagging at me. The Psychologist explained that sometimes difficult memories get stuck, the brain fails to file them away as it should and they remain rumbling around where they aren't wanted. We do know that sleep is important for consolidating learning and memory, could it be that sleep deprivation after a traumatic event interupts that filing process and increases the risk of problems later on? As I said that is pure speculation I couldn't find any studies on it other than one in mice which actually suggested the opposite. I'd love to see more research in this area.

So, if we accept that new Mums need to be able to sleep, for physical healing, maybe pschological healing and just because oh god how we need sleep - what can be done to make it possible? It's tricky, but I don't think you should criticise something without offering alternatives so here are a few ideas:

The dream scenario: (no pun intended)

Single rooms, space for partners, noise limiting design, lots of time with kind and reassuring staff. This would all be great, but of course it costs money!

The easier stuff:

Respect - staff, mums and visitors should be encouraged to keep noise to a minimum at night. That's surely just common courtesy but it often doesn't happen.

Babies of course can't be expected not to make noise and if there are four or more in a room that could be a lot of noise. So perhaps if there isn't space for single rooms a few quiet spaces could be set up where mums could go to get away from the noise of others for a while, even if only to rest rather than actually sleep. It would be a whole lot better than the night I spent on a plastic chair in a milk pumping room! Or maybe there could be a nursery, not the strictly enforced separation of mum and baby that used to happen, but an option to have your baby cared for by someone else just for a short period of time.

Out of Hospital Care.

Maybe we should also be looking at caring for women away from hospitals all together? Like The Duchess of Cambridge, many women who have straightforward births now go home within hours, but could more complicated cases also be cared for at home? If there was better and more consistent out of hospital post natal care then many more women could probably go home sooner. Even after my emergency C section all I really needed was pain relief, occasional basic checks and some help with breast feeding. All that could have been done at home, in my own bed, with my own food and no noisy strangers. I was only minutes from the hospital if there was a problem. This level of home care is already available to a lucky few who have NHS caseload midwives. It would be great if it could be extended to everyone who wants it.

Ultimately being a new Mum is bound to be exhausting but the noisy and chaotic environment of post natal wards and the resultant lack of sleep is something many women struggle with. I've heard several Mums say that their experience on the ward was far worse than the birth itself. Surely it's worth taking a few simple measures to promote rest and recovery? Is it really indulgent or ridiculous?

This post goes along with the end of the #MatExp ABC on twitter. There has been a lot of talk about creating  safe, comforting and calm environments for women to give birth in. The Maternity experience is, for most, just the start of a lifetime of joy, and hard, hard work, I think we should extend that nurturing and care for just a little longer, so that mothers can head out into their new life ready for all the trials, and all the wonder, to come.

Home, asleep


Monday, 27 April 2015

Normal Not Normal

A #MatExp post

N is for Normal

Today we reached N in the #MatExp ABC and that brings me to "Normal" birth. Regular readers of this blog will have noted that I tend to put normal in " " and may also have guessed that that is because I'm not very keen on the the phrase.

One of the things often discussed using the #MatExp hashtag on twitter is the power of the language used when talking about birth. For example, I know that a lot of Mums and some medical professionals dislike the term "failure to progress". It's a technical term and intends no judgement on the mother's efforts, but the word failure is of course very emotive. That one didn't personally bother me, perhaps because I work in medical research and am used to there being lots of words and phrases that mean one thing to those in the field and something different to everyone else. But I appreciate that language is important and one phrase that I find really problematic is "normal birth".

For those who aren't familiar with the term, a "normal" birth as defined in the Birth Place study is a birth without induction, forceps, ventouse, caesarean, episiotomy or epidural, spinal or general anaesthetic  I have a number of issues with that:

1- Conforming to a standard; usualtypical, or expected:
1.1 - (Of a person) free from physical or mental disorders:

If This Is Normal - What Is Abnormal?

The main problem is, if you declare that a birth is only normal if it meets a strict and specific set of criteria then, by default, any birth that falls outside those criteria is not normal, it is therefore abnormal. Clearly forceps and epidurals etc are not natural parts of birth but are they really abnormal?  I find this hardest to reconcile where pain relief is concerned. As I've said many times on this blog, I see nothing inherently wrong with making an informed decision to want pharmacological pain relief in labour. For many women, giving birth is extremely painful and I struggle to understand how wanting pain relief for something very painful is an abnormal action.

Nudging Normal

Normal also implies that this is how the majority of births happen, i.e. how the majority of women give birth. Telling people that "that's what everyone else does" is a powerful way to influence their decisions and one that is utalised by advertisers and government agencies. For example, it may be more effective to tell people that most others in their area have already done their tax returns, than to just threaten individuals with fines if they don't. Suggesting to women that most other mothers, normal mothers, have unmedicated vaginal births applies subtle pressure on them to conform to this ideal.

Is "Normal" actually Normal?

I'm not even sure if most women are having "normal" births.  If anyone has better stats on this please let me know but going on the Birth Place Study data it seems like "normal" births aren't the clear majority. It found that for every 1000 low risk births in hospital, only 460 will be classed as normal. The majority of those planning homebirths do achieve the "normal" classification but that is still relatively few women so may not do much to alter the national average and, significantly, this data excludes all high risk births, which are presumably more likely to involve drugs or interventions. Essentially as far as I can tell, "normal" birth, isn't actually the norm.

***Update - many thanks to BirthChoiceUK who have confirmed that for England only around 40% of births meet the Birth Place Study definition of normal.***

What Is Normal Anyway?

Finally, I wonder about the criteria for normal. I can appreciate that syntocinon drips, instrumental deliveries and emergency caesareans should only happen in the event of medical need, ie. when something unexpected / not normal has happened. But then I come back to the pain relief issue. Why is it abnormal to have have a well researched and highly effective form of pain relief with known, minimal side effects (an epidural) but it's entirely "normal" to strap a small electronic device to your back and get it to give you regular electric shocks, even though there is little evidence that it's actually effective (a TENS machine)? Similarly if a "normal" birth is one that avoids any modern interventions why is it "normal" to labour and/or give birth in a recently invented, specialised pool of warm water? I'm not saying there is anything wrong with waterbirth by the way, I spent hours in the pool during my first labour and found it very helpful and calming, but clearly for most of human history women didn't have access to large quantities of clean warm water. Finally (actually I'm sure there are more but I think you get my drift) why is it abnormal for a birth to involve surgical incisions in the abdomen but a vaginal birth that results in the mother needing stitches, or even surgery under general anesthetic is still "normal"?

Of course sitting here and criticising from the comfort of my own blog is easy enough, I have no better word than "normal" for the type of birth described. I slightly prefer "natural" as normal birth is essentialy that - a birth which needs no help from modern medicine, and personally I would rather be unnatural than abnormal. But I appreciate that natural comes with it's own problematic connotations.

But do we even need a word to classify this? Doing so, and placing the emphasis on getting more women to have this particular kind of birth worries me. What about those who can't meet this standard due to medical reasons? What about those who can't or don't want to endure the pain? It seems to me worryingly patriarchal to hold up one kind of birth as the ideal for all women at a time in our history when there have never been so many good, safe, options available. I am all for supporting women who want this kind of birth but I worry about just where support and encouragement turn into persuasion and coercion.

For me, "normal" is a mother who wants to ensure the well being of her baby and who will make huge personal sacrifices to achieve that. Whether that means enduring the pain of a natural birth, the risks and indignities of interventions or the arduous recovery from a C section. There are so many different kinds of birth, none is inherently better or more valuable than the others, and none can claim the title "normal" by shear weight of numbers. The only thing that is genuinely Normal about birth is the everyday, ordinary heroism of mothers everywhere, bringing their babies into the world the best way they can.

Tuesday, 21 April 2015

H is for Hospital, Home and Genuine Choice

This is another #MatExp ABC post. Today we have reached H and when I went on twitter this morning the first suggestion I saw was H is for Homebirth. That got me thinking and, as usual, 140 characters wasn't really enough. So my H is for Hospital birth, Home birth and genuine choice.

To be clear I am not at all against home birth. I support the idea of making it available to more women and of giving them accurate information about how safe and beneficial it can be. But, especially online and in social media, I hear a great many voices, mothers, midwives, doula's etc. all championing that cause. I stand with them, but I also have some concerns.

I'll be honest, when I read stories of high risk mothers having home births it does worry me, ultimately I support the ideal that it's her body her choice, but as a mum who saw her straightforward natural birth become anything but, I can't help but worry about what might happen. That however isn't what troubles me most about the current advocacy for homebirth. I have two main concerns:

1-Avoiding the problems

The birthplace study led to many calls for all low risk women to be encouraged to give birth at home. It found that those who did were less likely to end up with interventions such as c sections and and epidurals. But what few commentators seemed to ask was - why are there so many more interventions in hospital and if they are unnecessary - how can we stop them? The consensus seemed to be that it was better just to convince women to have home births so they could avoid the problem. But where does that leave those who want to be in hospital? A lot of mums actively choose to have an epidural and you can't get that at home. What about the mums who would have loved a straightforward home birth but who's pregnancies have become too complex for them to feel safe at home? What about those whose home environment isn't safe and comforting?

1- Equality of care

My NCT teacher was a staunch advocate of homebirth. At our first class she advised us all to have one or to at least pretend we wanted one (then fake chickening out at the last minute). It might seem a bit bizarre to pretend to want a homebirth if you don't, but (on this at least), she had a point. In our area, planning a homebirth means you have a named midwife working with a small caseload team. That small team will all get to know you and care for you before, during and after the birth. Each midwife has a carefully limited number of women to ensure she has enough time for all of them. In a cash strapped NHS it's an amazing service. But it's only available to those choosing a homebirth.

I worry that these two aspects could combine to create a two tier maternity service within the NHS. Excellent, consistent care, a nice environment, time to discuss options and fears, no unnecessary interventions - but only if you are willing and able to have a homebirth.

Clearly the losers here are those many women who need to be in hospital. Who, in many cases will be those most in need of kind and consistent care. It effectively says you can either have modern medicine or compassion, but not both. Fall from that narrow pedestal of "low risk" and you may have to accept that the demon doctors will be waiting for you.

That said, I don't think this dichotomy is good for anyone. I am all for women making informed choices about where and how they give birth, but that choice should be between giving birth at home, in their own, familiar environment or giving birth in a modern hospital with every possible form of medical assistance and pain relief close at hand. If we simply wash our hands of the problems in hospitals and instead tell people to go home to avoid them, then that is not the choice that's being made. Instead we are asking women who think they will want an epidural to chose between between good care or pain relief. It means women who develop complications in pregnancy will have to decide between compassion or safety. That's not making the best choice for yourself, it's going with the least worst option.

Women should be able to chose hospital birth because it's what they want, not because they have over inflated fears of homebirth. But they should also be able to chose homebirth because it's what they want, not because the alternative is terrifying and those whose choices are limited by their medical or social situation should never be forced to accept sub standard care because no one was shouting loudly enough for them.


Friday, 17 April 2015

D Is For Demons

A #MatExp ABC post

For those who don't know what the #MatExp ABC is:

Each day over on twitter, midwives, mothers, obstetricians and anyone else who wants to join in are sharing a word which is important to them and which relates to maternity care. I've been joining in and also trying to link my words to old blog posts, to give a more detailed explanation of my thoughts for anyone interested (some people seem to be so that's nice!). Today though I've struggled to find a post that puts it succinctly enough so I'm writing something new.


D is for Demonising

My NCT teacher had some pretty strong opinions about childbirth. She was a retired midwife and, understandably had a great deal of love and respect for her profession. Those feelings did not extend to her former colleagues with medical degrees.

We were taught that "normal", natural, ideally home birth was a wonderful thing and that it was achievable by almost anyone so long as we kept mobile, banished our fears and were helped only by midwives and doulas. But stray from her principles and horrors awaited us. There were doctors just desperate to turn our births into cold, medical procedures, soley to speed it up for their own benefit. Or because they were terrified of the minute chance that something would go wrong and they would be sued. If we allowed fear to creep in and agreed to pain relief or that first intervention, then we would surely be stepping off a cliff into an inevitable cascade of worsening tortures.

At most times I am quite pragmatic and rational, but I challenge anyone to maintain that after 24 hours of labour. With hindsight it made perfect sense to transfer from the birthing pool in the midwife led unit to the obstetric unit so I could let modern medicine help things along and get some pain relief and rest. But at the time it felt like an utter defeat, like I was surrendering my body and my will to whatever my sinister new masters dictated. I hadn't been afraid when I went into labour, as I moved along that corridor, towards the doctors and their machines, I was utterly terrified.

Being unafraid didn't prevent problems in my case, perhaps it does help others. However, those who seem in a position of authority, who present themselves as knowledgeable on the subject, should never try to remove the fear from one kind of birth by piling it onto all others. Most low risk pregnant women won't have to deal with doctors unless and until something goes wrong. So they have only other people's opinions of them to go on. If those opinions lump all doctors and all interventions together to be demonised - what does that do to the woman waiting for her first encounter with the obstetrician?

Wanting a "normal" birth, even if you have everything seemingly in your favour, can never entirely guarantee one. How much worse, then, is the fear of all those women who unexpectedly find they will need those demon doctors and tortuous medical acts?


D is for Demons

For a long time after MissE was born I carried my own demons. The ones who kept telling me I'd failed by having an emergency Casearean. Who suggested perhaps I just didn't try hard enough, that perhaps it wasn't really as necessary as I wanted to believe. For a long time I thought the only way to be free from them was to prove that I could do better next time. That I could give birth naturally and have one of those wonderful, empowering, birth experiences they were telling me I had thrown away. But those demons are gone now, and when it came to it, that wasn't what drove them out at all.

I didn't placate them by passing their test. My Demons were vanquished when I lay, calm and determined, on an operating table. My body was cut open by a man I had only just met, but I was not afraid or submissive. I had looked at all the evidence and all the options and I had chosen this. I had been taught that a woman's power in childbirth came from nature. But nature can be random and cruel, last time she would have casually watched me and my baby die. This time I decided not to leave it to her whims, I found power in the human creations of science and modern medicine and in myself choosing the safest way to protect my baby girl on her short trip into this world. As she arrived, the bright winter sun poured in through the window and I sent my demons flying out into it.


Saturday, 11 April 2015

The WHO Recommended Caesarean Section Rate (2015 Edition)

Yesterday the World Health Organisation (WHO) issued a statement about Caesarean sections- the title was:

Caesarean sections should only be performed when medically necessary

This was, of course, picked up by the press, with The Guardian pretty much copy-pasting the headline. So, does the WHO have some striking new evidence that there are far too many unnecessary C sections going on and it's endangering women and babies?

Well, no.

The statement comes with the publication of an article in the medical journal The Lancet. This looked at two studies into Caesarean section rates in 21 countries around the world. It found that overall the C- section rate was increasing everywhere (other than Japan for some reason). One of the main observations was that in countries where the Caesarean rate had been very low, maternal and infant mortality dropped as that rate rose towards 10%.  Here's a quote from the press release:

“These conclusions highlight the value of caesarean section in saving the lives of mothers and newborns,” says Dr Marleen Temmerman, Director of WHO’s Department of Reproductive Health and Research. “They also illustrate how important it is to ensure a caesarean section is provided to the women in need - and to not just focus on achieving any specific rate.”

But isn't there a WHO recommended C section rate? 

I've lost count of how many times on this blog I've used the phrase:

There is no WHO recommended caesarean section rate!!!

It is a much loved "fact" dragged up by every journalist writing anything about Cesareans (and in the press release and Guardian article) that the WHO recommends all countries should aim for a C section rate no higher than 10- 15%. Much less than in many developed countries including the UK and USA. It's true that the WHO used to recommend this, but they quietly dropped that in 2010 after they admitted the figure was based on no real evidence. It pretty much just seemed like a good enough number to someone so he went with it.

This hasn't stopped journalists continuing to drag it out at every opportunity though. Want to say women are choosing C sections because they are too posh to push, because they think it's an easy option, or because they are worried about their sex lives? Drag out that 15% figure to show how unnecessary all those caesareans are. Want to say that all these surgical deliveries are making babies stupid or fat  or costing the NHS a fortune? Be sure to mention that the WHO thinks a lot of C section mums are just being selfish!

So what does this new study really tell us?

Rather than setting a maximum C section rate, all this study can actually do is set a minimum. It shows that when a country's caesarean rate is below 10% then women and children will die needlessly. It also found that that once the C section rate got above 10% there was no further decrease in maternal or infant mortality. However, that doesn't necessarily mean that 10% is the optimum number (as suggested by the Guardian). The Lancet team only had information on mortality but death isn't the only possible serious outcome of a difficult birth. My family knows first hand the life long effects of a baby being deprived of oxygen during a difficult birth and, while it's almost unheard of in countries with good access to modern medicine, there are many women around the world living with horrendous obstetric fistulas. Is a 10% C section rate enough to prevent these? We simply do not have the data and without it, setting an arbitrary target figure is potentially very harmful. Which is why the press release, the Lancet article and this interview with one of the authors all make the point that the focus should be on ensuring every women who needs a caesarean has access to one and not on achieving some specific national figure.

But all this must of course be balanced against the risks of potentially unnecessary major surgery. The paper doesn't tell us anything new about these but the press release makes some general comments about risks and also highlights the lack of data on the social and psychological effects of a mother having a caesarean as well as the cost implications. The latter being particularly important for weak health systems where increasing the number of C sections draws resources away from other vital services.

The WHO has a very difficult job here. It is, after all, the WORLD Health Organisation and, as with so many health issues, there is enormous variation in the caesarean rate around the world. This is evident in the data from the 21 countries in this report. Among the poorest, C section rates are generally low, in Niger the rate rose from 5.3 - 9.8% over the period covered. In some of the wealthier parts of central and south America the C section rate is very high. In Mexico, by the end of the study period, it had reached 47.5%. Clearly not all of those Mexican C sections will have saved a life or prevented long term harm and I've heard from women in other countries with very high C section rates who felt they were coerced or forced into the surgery without a good reason. I have no doubt that this is wrong and should be acted on. But at the other end of the scale the WHO is also dealing with countries where women and babies die because of too few C sections. We simply don't have the evidence to set an optimum caesarean section rate that applies to every country in the world.

The Lancet review seems reasonably useful. It looked at a variety of factors and how they influenced C section rates in 21 quite varied countries (although I notice that no European countries were in the list). But I find the WHO statement and the Guardian regurgitation of it troubling; if Caesareans should only be done when medically necessary, then how to we define "medically necessary"? When the risk of someone dying is 50%? 10%? 0.001%?  Is a C section "medically necessary" if it won't save a life but will prevent a long term disability? What about a minor short term problem? What if the medical need isn't physical? Vaginal birth with all the attendant examinations and indignities can have serious mental health implications for women who've experienced sexual abuse. Then there are the women who've already had traumatic births or who are just plain scared.

That's a lot of questions and the Lancet publication can not possibly answer them. It doesn't even try to. So I find it worrying and bizarre that an organisation as important and influential as the WHO should extrapolate so wildly from a specific and limited data set. It looks like an attempt to shoe horn in something controversial in order to gain column inches. If so it's been successful.

But that still leaves me with another question - even if we could define and predict which Caesareans are medically necessary - should they be the only kind?

Don't get me wrong there are some pretty major downsides to surgical birth. It may avoid the pain of labour but the recovery can be long and agonising and it's major surgery. Things can go wrong. But according to NICE (the UK National Institute for Health and Care Excellence) the overall risks of caesarean section aren't much greater than for vaginal birth. It recommends that if a woman with no medical indication wants a C section she should receive counselling to explore her reasons but if she still wants a Caesarean birth she should get one.

In the UK where most of us have the luxury of taking it for granted that we and our babies will survive childbirth this seems like a reasonable position. I've had two caesareans, the second was my choice but I wouldn't recommend it to anyone with a good chance of a straightforward vaginal birth. However,  It's not for me or anyone else to make that decision about another woman's body. I don't think it's a great idea to have a C section without a pretty good reason. I really don't think it's sensible to have a home birth after multiple caesareans but women do make these choices and so long as she has made it herself, based on accurate information, then ultimately it's her body her choice. 

It's also worth remembering that all these percentages are describing national averages. They can say nothing about any of the scenarios an individual woman may face. Just because your country has a worryingly high C section rate, it doesn't mean your placenta previa didn't really require surgery. Just because your country's rate is so low it's costing lives it doesn't mean you won't have a straightforward natural birth.

There is no WHO recommended caesarean section rate and there shouldn't be. The Lancet article demonstrates this but the media have once again twisted the limited conclusions of a piece of research into an opportunity to attack women's bodily autonomy. Bizarrely in this case, aided by a WHO press release.

Statistics are useful and interesting for those in the relevant field. Numerical targets may or may not be helpful at the national level. But individual mothers and babies are far more important than any numbers generated from them.

Monday, 9 March 2015

10 (+1) Things Not To Say To A C Section Mum

Whatever the Telegraph may think, most Caesarean sections don't happen because "posh" women want to schedule them around their manicures or business meetings. They are usually undesirable, often unexpected and occasionally downright terrifying. I was lucky enough to come out of my emergency c section with a healthy baby, without the surgery the outcome would have been very different.

Yet still, I got some pretty unhelpful comments. Some were well meant, but in the fog of the situation they seemed to hint at something else, something I was already deeply troubled by - that perhaps a caesarean birth, maybe anything other than an all natural drug free birth, was seen as a failure. Others just came right out with that opinion.

Whatever your own beliefs about childbirth, there is absolutely nothing to be gained by making a woman feel bad about how her baby arrived in the world, especially not if it's only just happened. So here are my top ten things NOT to say to a C section mum and how they might actually sound to her:

1- What they say:
All That Matters Is A Healthy Baby.

What it sounds like:
It doesn't matter if you had a hideous time, shut up about it and stop being so ungrateful.

I was acutely aware of how lucky I was to have a healthy baby. But that isn't the only thing that matters. The future wellbeing of that healthy baby is symbiotically linked to the health of the mother. If she is physically or emotionally damaged by a traumatic birth, that matters to the baby. Oh and another thing - a mother is still a human being, if she is hurting that matters too.

2- What they say:
Oh what a shame

What it sounds like:
What a shame you didn't do it properly. What a shame you missed out on one of those wonderful "birth experiences". What a shame modern medicine saved your lives. (?)

3-What they say:
It's not really birth

What it sounds like:
You didn't give birth to your baby, he/she was just surgically extracted.

There was a baby in my belly, it came out of a hole in body. Therefore I gave birth.  It may have been a sun roof delivery and assisted by a surgeon rather than a midwife but it was still a birth and no less special for the angle of exit.

4-What they say:
You should have tried yoga, hypnobirthing, a doula, a waterbirth etc. etc.

What it sounds like:
You didn't do it right, so it's kind of your own fault.

Actually I did try all those things (well apart from the doula). They can be great and many women who've had straightforward births swear by them. But no individual can ever know for sure if it was the yoga/hypnosis etc. that made the difference, it could have just been good luck. None of these things offers a 100% guarantee. If dumb luck deals you a really bad hand then no amount of affirmations or pregnancy sun salutations will change that and plenty of women have perfectly straightforward births without any of them.

5-What they say:
I never thought that would happen to you!

What is sounds like:
I always thought women only have C sections because they don't try hard enough, are too posh to push or freak out at the first twinge of pain. I didn't think you were like that... but now I'm wondering if you are.

6-What they say:
It was probably an unnecaesarearn!

What it sounds like:
I don't believe that your C section really saved anyone's life. You were tricked into it by the doctors and too weak or stupid to stand up for yourself.

If a women tells you she had a life saving c section then to her, it was necessary. Perhaps is was possible that a vaginal birth would have been fine too, but if she decided to endure major surgery rather than take any risk with her own life or her baby's, then it was necessary to her. End of.

7-What they say
Let me tell you about my amazing home waterbirth...

What it sounds like:
Hey look at what you could have won if you were just like wonderful me!!

It's great that many women have had wonderful experiences of birth, but those of us who haven't really don't need them ramming down our throats uninvited. Many women feel a sense of loss at not having had the kind of birth they hoped for. Maybe in time hearing positive stories will be helpful, but it has to be about what the listener wants to hear, not what about the speaker wants to say. If a woman asks you to share your story, do. If not, shut the heck up for now and go find a facebook group to share it with.

8-What they say:
That's nothing, listen to my horror story...

What it sounds like:
Stop whining! What happened to me was way worse, you have no right to be upset.

There are no medals for childbirth martyrdom, there is no ranking system for who had it worst. A two hour labour may sound like a dream if you were in labour for days but for the woman concerned it could have been brutal and shocking. A C section may sound like an easy option if you endured a difficult forceps delivery and vice versa. If someone believes their experience was traumatic, then to them, it was.

9-What they say:
You'll always have to have C sections now you know.

What it sounds like:
You have no options now.

This might have been the case in the past but it certainly isn't now. The way the surgery is now normally done means the scar is quite strong and many women go on to have straightforward vaginal births. About 70% of VBACs (vaginal birth after caesarean) are successful. In some cases another Caesarean may be advised but most C section mums should have a choice over future births.

10- What they say:
Well at least you didn't have to have stitches!

What I say
Ok I know what you mean and yes, most c section mums won't have had to endure a tear or cut "down there", I know they can be pretty awful, but er, what exactly do you think is holding my entire abdomen together right now? 

oh and one last one, this may just be me though-

11- Well, I know it was a big baby but you're so tall it should have been fine!

Yes, I'm tall, but my baby was a whopping 33% bigger than the average baby girl. I'd have to be 7' 7" (232 cms) for the two to compare. But even ignoring that - here's the thing, er, the length of the mothers limbs isn't exactly the vital statistic here is it??

PS. Of course every woman's experience is different - do you have any more "things not to say" to add to the list? Do you disagree with any of mine? Comments are always very welcome!