Tuesday, 26 July 2016

A Missed Miscarriage

I had hoped that today I would be sharing some happy news on this blog. First thing this morning I was supposed to be going to the hospital for a twelve week scan, a first look at our third baby. But sadly that appointment had to be cancelled.


I’ve been wondering whether to write about this on the blog or not. A miscarriage early on is a complex thing to grieve for. As a biologist I know that technically there never was a baby, just an embryo. So can I say my baby died, when it never fully lived? Yet of course I do grieve for it, or the idea of it at least.  I also don’t deal well with being on the receiving end of sympathy, like compliments it flusters me. Does a blog post risk seeking that out?


But then I share or perhaps over share so much on here that it feels odd not to talk about it and for me, writing things down, doing my best to form them into some kind of narrative, is often therapeutic. Miscarriage still seems to be something people don’t really talk about. Perhaps that in itself is a reason to write about it? It is such a common, ordinary thing, something I know many people reading this have also been through. Would it make the whole sad, lonely process a little easier if we could all be open about it?


I don’t really have any answers right now. But I’m going to share something I wrote on July 16th, the day after my “Surgical Management of Miscarriage” operation. I’m also sending out love to all those who have had similar experiences, whether I know you or not, whether you told me or not. The telling of the story isn’t the important part, this is just my own reaction to events, everyone else’s will be different.


****************


There never really was a baby. So I can’t say I lost it, or that it died. There was a bunch of cells, perhaps some tentative, primitive form. But it’s heart probably never made a first beat, it’s brain never sparked a first thought. It hovered for a few, hope filled weeks on the blurry brink of life and then simply faded. Until all that was left was some indistinct grey pixels in a black void on an ultrasound screen.


Yesterday the surgeon, nurses and anaesthetist brought to an end that which nature had long since given up on but couldn’t or wouldn’t let go.


I’ve had three pregnancies and they have all ended in an operating theatre. The first surgery was a terrifying emergency, the second calm and joyful, but with both of those I went home with a healthy baby girl in my arms. Yesterday I was processed, slowly but kindly, from a waiting area, through forms and tick boxes into theatre and then woke up, not long after, in my designated recovery bay. But this time I was alone. These was no baby in my heavy arms and nothing was left in my womb where it had tried to grow. It was quick, efficient and, after two weeks of waiting and worrying, it was over. I was glad of that but I wished these arms of mine weren’t so heavy. I couldn’t lift them to wipe away the tears that finally came.


It is one of those great dreads of early pregnancy, the blank ultrasound, a “missed miscarriage” an “early embryonic demise”. This pregnancy had taken far longer to begin than the others and so I had paid for an early scan at eight weeks. I had a day off work anyway and I thought it would help set my pestering worries aside, that I could treat myself to a first look at our new baby. But in the smart third floor office of a Georgian town house the big flatscreen TV on the wall showed only a black hole. A small, almost empty gestational sac, no obvious baby, no flickering heartbeat.


The next morning I sat on the floor in a hospital corridor with all the other women who were tired and worried and waiting for the early pregnancy unit to open. When my turn came the scan showed just the same. But biology always evades direct questions. Perhaps, just perhaps, it wasn’t eight weeks afterall. A few days here, another few there, a test showing a little pink line a bit earlier than it should have. Perhaps, at a pinch, it was just too soon to see that flicker of a heart? The doctor said it might all be fine, I should come back in two weeks.


But I did the maths over and over again. The dates on the app that tracked my periods, the date of the tests and how early that little pink line should be possible. I tried to find hope but I also pressed a sanitary towel into my underwear when I went to work and closed my eyes for a second whenever I went to the loo, please, no blood.


At the next scan, after those two long weeks,  they didn’t show me the screen. The doctor, who seemed to be new to the department or perhaps just quite junior, didn’t want to make the call either way. There was something in the sac, strange and amorphous, but there. Yet still no heartbeat. She called for her senior consultant and I lay there, torn between hope that perhaps my maths was just rubbish and the tiny creature inside me was growing after all and the dread of more uncertainty, of another long wait.


But the consultant knew that the blob would never be anything more. It must be horrible to break that news to women over and over again. Or perhaps it stops bothering you after a while but either way she did it with kindness and certainty.


So, ten weeks into the pregnancy, I knew there would be no baby. She/he was a fantasy based on a bundle of doomed cells and the hormones still thundering through my body. The hormones that had forced me to spend the evening of my birthday layed flat on my bed as they world span sickeningly every time I tried to stand up. The hormones that made me ache to the bones with tiredness and gave me bouts of nausea only controlled by the eating that had piled pounds on my belly already. All the things I had happily accepted, believing they were good signs of a healthy pregnancy.


But signs can be misleading. I would not now have a little rounded belly when I took Miss E to her new school in September, I wouldn’t be stopping work at Christmas. I would instead have to choose from three unwanted options. Let nature eventually take it’s course, who knows when and how, take drugs to hopefully speed that up or end another pregnancy in surgery. I chose the surgery. It was at least the quickest and most certain option. But it meant a general anaesthetic, something that terrifies me. I signed the forms and went home to make arrangements.


Perhaps being a biologist helps in all this. I know miscarriages are common. That a random mismanagement of chromosomes is probably to blame and that, as far as nature is concerned, I am well past my reproductive prime anyway. I know that technically what grew in my belly never even achieved the status of “fetus”, nevermind baby and that wiser people than I have argued forever over whether something that tentative is actually alive.


I also know that, for me, it would have been worse to see that empty sack  at the 12 week scan. To have suddenly, unexpectedly started bleeding and cramping or to have lost an older, more tangible baby.
But for now, I will sit on my bed while the house is quiet. With my surgical stockings and my painkillers and write this all down. That baby will never grow in my belly or come home in my arms. It’s almost life will matter not one jot to the world and I will carry on, just hugging my girls a little tighter.

But I will grieve for the baby that could have been. Even scientists know that biology isn’t everything. That a dream can be more than the genes and cells and almost life it is based on. So perhaps it doesn’t matter that there never really was a baby. There was love and hope and they are real enough. I will cling to them and send them drifting out to the stars. To them we are all just brief moments, just flickering bundles of cells and barely tangible life.

SBx


Saturday, 16 April 2016

Choosing A Caesarean, And Having that Choice Refused.

I seem to write endlessly about caesareans on here, it was never my intention with this blog, but hey that's the joy of having one's own little online vanity project. Often I'm writing in response to news articles on the subject and almost always those talk about the terrible rise in C sections, how unecessary they are etc. etc. It's seems very odd then to have been seeing stories yesterday about the dangers of women being denied caesareans. Except that those headlines chime more with my own experience.

Options?

Almost two years after MissE was born I attended a birth "debrief" at the hospital. I'd been trying, all that time, to just forget about it. I had a healthy baby after all and that's supposed to be all that matters. Dwelling on how horrible the birth had been for me seemed self centered and unforgivably ungrateful, two attributes no good Mother is supposed to display. But we were thinking about baby number two and I wanted to at least understand what had happened and why and perhaps be a little better prepared next time.

To that end, I asked what my options would be. I had imagined the hospital would be supportive of a VBAC (Vaginal birth after caesarean), they had been keen to tell me, almost as soon as MissE was born, that I could have one with the next baby. But I hadn't expected to be told so firmly that I had no choice, I would have to attempt a VBAC, it was hospital policy.

At the time I was undecided, if anything I swayed towards wanting the VBAC, it was a chance for a do over, to show I could do the whole birth thing after all, lay some personal demons to rest and perhaps avoid another long and terrifying postnatal stay. But even so, I was shaken by the assertion that I had absolutely no voice in a decision about my own body.

I was also told that there could be no short cut to a C section if the labour went badly again. I would have to work my way through the same list of medical interventions all over again, each one spaced out by the specified hours of waiting and contracting. I did have the right to refuse the interventions, but not to demand one I wanted, so those hours would always remain.

The only other option, were I to persist in my unreasonable request, would be to try to convince the team's psychiatrist that a caesarean was vital to my mental health.

In effect, there were two way to "choose" a caesarean, serve your time for the required number of hours in  a difficult labour or convince someone that your decision wasn't considered, informed or pragmatic but the symptom of a psychological condition.*

Hospital Policy

I can't say for sure why this was the hospital policy, I very much doubt it was based on safety or clinical consideration as, although there are certainly risks to caesareans, over all it is questionable if they are greater than for a VBAC and every case is different. As far as I could tell a VBAC would have been very slightly safer for me but equally slightly riskier for the baby and of course that all assumes that the VBAC works out, an emergency C section is much riskier than a planned one.

Which leaves me to to speculate on two possibilities. Either the hospital wanted to stop women having C sections so they could reduce that much talked about % caesarean rate or they were trying to cut costs.

Which is where this weeks news stories come in. They stem from the tragic case of a baby who died from oxygen starvation after extended attempts at an instrumental vaginal delivery. His mother had asked throughout the pregnancy and birth for a Caesarean, having been warned she would need one after a previous difficult birth but she wasn't listened too. Instead she got ventouse, forceps and an episiotomy, the instruments used with such force that she was repeatedly pulled off the bed. Eventually an emergency C section was done, in the rush the mother had to have a general anesthetic and the father was sent out to wait alone with no idea what was going on. But it was too late and baby died a few days later. The coroner investigating concluded that the hospital, and others were denying women C sections in an effort to save money.

Money

The money thing though is tricky. I've seen various figures chucked into this story saying a c section is twice or four times the cost of a normal birth. I have no idea which, if any, are accurate so I'm not going to list them here. To me those figures are a bit meaningless anyway. Firstly, no woman gets to choose between a C section and a normal birth because no woman gets to choose a normal birth. You can hope for one, as I did with Miss E, but if it doesn't work out that way and you end up with all those hours and interventions and the emergency Caesarean then that "normal" birth is suddenly way more expensive than a quick elective C section (In the states, elective C sections are often considered cheaper because they are so much quicker).

Also, I am not convinced that cost is the major driving force behind refusing women C sections. Which ever figures you use, the difference in cost isn't actually huge, we're talking a grand or two not tens of thousands here. Surgical birth may be more expensive, but frivolous maternal request caesareans are not to blame for the troubles in our beloved NHS.

To me a more likely culprit is those percentage targets and the wider, deeper, paternalistic treatment of pregnant women. For every story of a women denied a caesarean there is another who felt forced into one.

The charity Birthrights held a conference this week called; Policing Pregnancy. It looked not just at birth but at some of the other ways in which pregnant women are treated not as rational , individual human beings, but as merely potentially hazardous vessels for the future generation. This Storify of tweets from the event is well worth a look.

When I did get pregnant again, my uncertainty over how I wanted the baby to be born disappeared almost immediately. My desire to prove myself by finally having a vaginal birth just went. I knew I wanted the safest possible option for my baby and that I would rather know in advance that I would have to endure a c section than leave it up to chance again and risk another emergency one.  But this decision meant that I spent the first few months of that pregnancy absolutely dreading my first appointment with the obstetricians. It hung over me as a constant dark cloud. I had moved to a new area and a new hospital but that first consultant's assertion that I would have to have a VBAC or else fight my case with the psychiatrist, stuck with me and I didn't feel like I had much fight left.

He Listened

I was called into that first appointment, unusually for the NHS, a little early, before my husband arrived. I sat alone in the chair next to the doctor and tried to summon the courage to stand up for myself. I couldn't entirely keep back the tears when he asked me to tell him what had happened last time but the odd thing was, he listened. He said he was sorry I had been through that and then he asked me what I wanted this time. He didn't tell me what I should do, what his opinion was or what hospital policy dictated. He did apologetically say that he had to tell me a VBAC would be safe but otherwise he said very little, other than to answer my questions.  After a while the consultant came in, one of those "old white men" who are supposed to want to tell women what to do, but he listened too and wrote in my notes, so that no one could over rule it, that this time it would be my choice. I was a capable human being, I could weigh up options and reach a decision that wasn't the product purely of ignorance, fear or mental illness. The person who would decide what would happen to my body, was me.

SB

*This took place shortly prior to the introduction of NICE guidelines which recommended women wanting a C section without medical reason should be given counselling to look into their fears but ultimately given the surgery if that remains their choice. Done well, this sounds like a good idea although it seems in practice it doesn't always happen and there is a fine line between exploring a woman's fears and trying to persuade her to change her mind. Arguably with one emergency C section already under my belt my request wasn't entirely without medical reason anyway.





Thursday, 24 March 2016

Would Women Be 50% Better Off Not Getting Their Health Facts From Jamie Oliver?


Celebrity chef turned healthy eating campaigner, Jamie Oliver, has been telling us all about the wonders of breastfeeding - Queue backlash and counter backlash but has he got a point and do his stats stack up?



I wasn't going to, I really wasn't, but then, yeah, stuff it, it's my blog and I'll weigh in if I want to...

Last week Jamie Oliver was probably riding pretty high, his crusade against sugar had seen the surprise announcement of a new tax on sugary drinks included in the UK budget. He's already brought about changes in school meals so the natural question was - what's next? 

Next apparently (although he's since back peddled a bit) is Breastfeeding:


Miles of online column inches and many a social media rant have been written in response to this so I'm not going to write any more about why breastfeeding isn't easy for an awful lot of women (it's really not). I'm also not going to explain why a man shouldn't be talking about something he has never done himself. People can have an informed opinion on plenty of things they've never personally experienced, so I don't think men should be barred from all discussions on breastfeeding. But what I do take issue with is when anyone, man or woman starts making personal opinion sound like fact. Especially if they are talking from a position of perceived authority.

The thing that really grabbed me in Oliver's comments was the bit about a 50% reduction in breast cancer if you breastfeed for at least six months. I was certainly aware that breastfeeding reduces the chances of a mother getting breast cancer, but I had thought that you had to breastfeed for at least two years and that the reduction in breast cancer was, even then, more modest.

So I decided to take a look at this figure, after all Oliver has far more access to knowledgeable advisers than me, so I could just be out of date. Or have we never heard about the 50% figure because it's rubbish?

 Having asked around it seems that the 50% may have come from this study from 2001. It looked at 404 women breastfeeding in China and did indeed show a 50% reduction in the incidence of breast cancer for some of them. But only if they fed each of their children for at least two years. The study also looked at how long the women involved breast fed in total. That data showed that the protection from breast cancer only kicked in after at least 73 months of breastfeeding. That's a full six years of your life breastfeeding to see the 50% cut.
That though is just one study and it's always risky to rely too much on the information from a single group of scientists working with a small group of people in a specific location. It's far more reliable to look at the overall trends seen in lots of different studies. Well, you can bet there are plenty of studies on this subject but finding and analysing them all requires both a lot of time and some pretty top end stats skills. I, like most Mums, posses neither of these things but thankfully there are other people who do. 

The Lancet published a series of articles and papers about Breastfeeding recently. One of the things it looked at was a meta analysis of breastfeeding / breast cancer studies. From this it concluded that yes, there does seem to be a strong link between breastfeeding and reductions in breast cancer. But, the stats are very different from Jamie's. The Lancet reported a reduction in invasive breast cancer of 4.3% for every 12 months a women breastfed. Clearly a far lower figure,  but they still estimated that if almost every baby in the world was breastfed, there would be 20,000 fewer women dying of cancer each year (not all of these are breast cancer btw, breastfeeding also seems to reduce ovarian cancer).

But even with the Lancet's more reliable data, we're talking about global averages. For individual mums it's not simply a matter of x months breast feeding = y% reduction in breast cancer. There are cultural and ethnic factors and some women's genetics will over rule everything else. Then there is smoking, alcohol and obesity. Whether or not breast feeding totally stops a woman's menstrual cycle may also be significant and breast cancer isn't a single disease. There are a variety of types with different responses to different hormones. Breast feeding may not be protective against them all. 

So breastfeeding for a bit longer probably will help some women avoid breast cancer but it offers no guarantees. It can be a consideration in the decision to breastfeed or formula feed, but so should a whole lot of other things and, just in case I actually need to say this - that decision should always be made by the person with the breasts, not their partner, friends, midwife, doctor or favourite TV chef.



To be fair to Oliver, I think he was caught unprepared. He quite rightly talks about the need to support women to breastfeed and that is a huge issue. As so many of us know, you get bombarded with pressure to breastfeed as soon as you enter the world of pregnancy and birth, but once the baby is out that rarely turns into good help. Let's support women who want to breastfeed, let's stop making them hide in the toilets to feed their babies and let's make sure they don't have to battle through poor, inconsistent or non existent advice. But let's also make sure we have accurate information.

Jamie Oliver has established a reputation as a healthy eating campaigner, as someone who knows the facts and can call on experts to help him out. To mangle an over used quote, with great respectability comes great responsibility. It would have been far better if he had stopped at saying breast feeding seemed to reduce breast cancer and he was still searching for more facts on the issue. Instead he seemed to grasp at a half remembered statistic which a lot of people will understandably believe, based on their opinion of him, to be true.

Sometimes taking the lead in informing people means not just sharing what we do know, but also being honest and explaining what we don't. Now when do you ever hear that? - Never?

SBx
PS. As ever I am by no means an expert on this subject and I've not done a comprehensive literature review, so if anyone has better or more up to date information please please comment below.
PPS. Also, as ever, never get your health advice from random blogs on the internet, even mine!

Monday, 29 February 2016

The National Maternity Review - What Does Choice Mean?


The NHS National Maternity Review has called for women to have more choice and greater continuity in their maternity care - yet it was very quiet on some of the choices many women want or need. So what does choice really mean for pregnant women and will the options recommended in the review ever be available to all?





Last week the UK National Maternity Review published it's findings. The reactions I've seen in the media and online have ranged from tearful delight that more women will supported to have home births to accusations that the authors will have blood on their hands. The Report makes a number of recommendations and at this point that is all they are, recommendations. The devil may be not so much in the detail as the delivery (if you'll forgive the potential pun there). But the bit that made the headlines and has sparked the most debate and confusion is the proposal that women should be given a £3,000 budget to buy their maternity services.

This is being touted as a great step towards giving women more choice in their maternity care, allowing Mums to select their antenatal, birth and postnatal support from a range of local providers who will work with, but not necessarily for, hospitals. This could include private (independent) midwives and new NHS midwifery practices operating out of community maternity care hubs. The report also champions choice in place of birth, calling for all women to have access to Midwife led birthing centres and home births (This is already recommenced by NICE but a large number of women still don't have all these options in their area).

Giving women choices about our bodies and about how we go through what can be the most agonising and most wonderful events in our lives is a noble cause, but having read much of the report and the many and varied responses I'm left wondering:

What do we actually mean by choice?

The choices talked about in the report all seem to lean towards one end of the childbirth spectrum - home birth, independent midwives, Midwife led units, some of the media reports extended this to suggest hypnobirthing and the cost of at home birthing pools could be covered by the £3,000. I have nothing against any of those choices and once upon a time may have made any or all of them for myself, but these are not the only choices that a woman can make. Sometimes they are actually the choices she can't.

The report makes no mention of Caesarean sections, other than to highlight the work of a network which keeps tabs on hospital trusts based on, among other things, their C section rate (something the WHO warned specifically against). It also makes only a few passing comments about pain relief. Saying vaguely that women should be informed about it's availability when choosing their place of birth (epidurals are not an option for home births or most midwife units). But these things, and many others are also choices, or at least i think they should be. Certainly there are risks and drawbacks to them, I've had two C sections and I wouldn't recommend it, but sadly none of our choices when it comes to childbirth are risk free, if women are capable of weighing up the pro's and cons of a homebirth, why not a surgical birth? If they can opt for water to ease the pain, why not drugs?

Can we really call it choice if only certain choices are ok?

This of course goes beyond just where and how we give birth. Women's broader reproductive choices are still legally or subtly limited around the world. Ireland, a western European country, still won't allow abortion, even when it is known a baby will not survive. Women are forced to carry to full term a child they know they will never take home. In America employers can refuse to fund contraception on religious grounds and women might even face prison if they miscarry but are suspected of having bought abortion pills online.

Either women's bodies are our own or they are not. Truly supporting choice should mean supporting all informed decisions not just those that someone other than the mother has deemed to be correct. 

Correct choices for women seem, almost always, to be those perceived as natural. Often they are also those that appear to involve pain and hard work. The idea that men would never cope with childbirth, and would have invented a better option by now if they had to do it, is a long running joke. But there may be some truth in it. Our society has no big problem with men becoming fathers in an entirely pain, and often effort, free way. But with women there is still this lingering feeling that we should be martyrs for our children.  Of course most of us would lay down our lives to save them without thinking twice, thankfully we rarely need to. Yet our image of a good mother is still someone who gladly endures pain and exhaustion and gives up all her own desires and ambitions for her child. We can talk about "me time" and "self care" but often only as a guilty luxury.

This is the backdrop to choice and the stigma attached to it. A friend who had an epidural in labour explained to me why she had to, she hadn't planned to, she'd tried so hard without... She couldn't just say, it bloody hurt and she wanted to the pain to stop. That didn't seem like an ok choice to her. We have never had so many options for childbirth. They all carry risks and benefits but overall, bringing our babies into the world has never been safer. Yet, as a society we seem squeamish about embracing choices for women which invoke not God or nature but human technology and science. To truly embrace choice we need to put aside our age old prejudices and fears and take a cold hard look at the world we find ourselves in today. Maternal request elective C sections and all.




Will everyone have a choice?

We also need to ensure, not just that all choices are acceptable, but also that they are actually available. One of the most popular proposals in the review was that women should have greater continuity of care. Being looked after before during and after birth by an individual midwife who worked as part of a small team. I've been lucky enough to experience this model of care (and it was infinitely better than the ad hoc, whoever is about at the time service I got with my first pregnancy). But as a high risk mum I was very very very fortunate to be able to access it at all. Ordinarily in my area these "case load" midwives are reserved for those living in very specific areas, who were low risk, want a home birth and sufficiently in the know to get on the list the minute they get a positive pregnancy test. In effect it's an NHS service used predominantly by the healthy and fairly wealthy.

The £3k budget to buy maternity services could get over this inequality problem but the review states that it shouldn't end up costing the NHS more. So where are all these caseload teams going to come from? If a type of care widely demanded and held up as a gold standard can be achieved for free why the **** has it not happened already? Even if it was cost neutral to set up more caseload teams would there be enough midwives willing to do it? Labour doesn't happen to a rota and it doesn't fit into fixed length shifts. Caseload midwives need to be on call at all hours of the day and night - they also need to be able to look after their own families and you know get some sleep. It might not be be an appealing or practical working pattern for all.

Perhaps more cynically I also wonder how many midwives would be willing to work this way for high risk women who were going to give birth in hospital. I once considered hiring an Independent midwife but almost every single one I looked into talked about specialising in home birth, or championing normal, physiological birth. I needed someone who would champion my decision to have an elective repeat C section and a boat load of drugs so I gave up. But I can see the appeal of working with home birth mothers, the midwife can build a relationship where she is the primary care giver, where it is her personal skill and knowledge which will guide a mother through. Working with high risk mums and hospital births means relinquishing autonomy and sharing that relationship with obstetricians and other specialists.



With all these potential barriers I wonder if caseload care will ever really be available to all women. The review itself is a little vague on this and leaves it up to CCGs to decide whether all women should get the £3k budget or if it should be "restricted to women receiving standard care".

I was able to ask Baroness Cumberledge, the chair of the report, about this in a Mumsnet chat last week and she confirmed that different CCGs may prioritise different groups of women. So caseload care may still only be a choice if you are low risk and planning an out of hospital birth. Not much help if you know you'll need a C section or that your sick baby will need specialist care from the moment it's born.

Which brings me to my final concern. I am all for choice and all for continuity of care but if there is to be no extra money and these enhanced services are only to be offered to some low risk women - what will be leftover for everybody else? Will this draw money and midwives away from the already struggling hospital units that many women need?

I hope that the recommendations from the Maternity Review will be implemented, but I hope they extend to the full scope of maternity care and the needs of all women. Improving access to home birth and midwife led units is great, but choice is meaningless if you can't have the options to want or need. For me the report was worryingly quiet on the options that matter to many women, improving hospitals not just abandoning them, ensuring access to pain relief or C sections, making sure high risk mums aren't bounced from one health care professional to another at every appointment, etc. etc.

If we're going to call it choice, let's make it real choice and for everyone.

SBx

PS there are a raft of other issues I could bring up about the maternity review and a lot of aspects of it I agree with. I've focused on the issue of choice for for those not planning home/ midwife unit births only because it seems to be an area that hasn't got as much coverage as some other concerns.

Wednesday, 3 February 2016

The Microbiome: Seeding Some Questions


The current next big thing in health news seems to be the Microbiome. According to a growing number of reports it could be involved in everything from Schizophrenia to Obesity. So there has been speculation about where it comes from and if how a baby is born, either vaginally or by C section, could determine the make up of their Microbiome and even their future health. In this post I'm going to take a look at those claims and at some newly published research which attempted to "seed" the Microbiome of babies born by caesarean.


I've been re watching some classic episodes of the X files recently. One (Ice) starts with a panicked man repeating the phrase " We are not who we are". It turns out he's being controlled by a tiny alien parasite, which is all pretty fantastical (also mid 90's CGI - lol). But there is growing evidence that our physical, and even mental, health could be influenced by the huge number of microbes living in and on us. It is a fascinating, huge and complex new field of research so I've been wondering just how excited should we be getting about it right now and do we know enough to start making changes to our lives, or our children's lives, based on it?

A study published this week starts to bring together three threads of the Microbiome story; 

1- Many previous studies have reported links between the Microbiome and a huge range of medical conditions. 

2-Others report that babies born by C section are more likely to develop certain diseases. 

3- A final set have found differences between the Microbiomes of babies born vaginally and those born by C section. 

So it's tempting to suggest (as many media reports have) that:  C section = bad Microbiome = poor health. 

Or even that the worldwide increase in obesity and other diseases should be blamed on the increasing C section rate. But that seems like a bit of a leap at the moment, and there are quite a few blanks that need to filled in in that equation before we can be sure. 

The idea behind the new study is that babies born vaginally rub against and swallow their first dose of Microbiome organisms as they make their way through their Mother's vagina. Babies born surgically clearly don't do this, so the researchers attempted to "seed" the microbiomes of the caesarean born babies by placing a swab in their Mother's vagina for an hour prior to birth. Then wiping it over the new born's mouth and skin. 

Some people reading this may think it's about as weird as something Mulder and Scully would investigate, but a few Mums are already requesting the procedure and others are advocating it strongly as a way to restore some of the natural processes of birth. So this first published data will no doubt be of interest.

But I have a few questions,



Actually I have loads of um, first up....


Is the Microbiome Cause or Coincidence?

Just because a study shows a link between certain Microbiome characteristics and a disease, that doesn't prove the former is causing the latter. The same can be said for links between C sections and medical conditions. 

I wrote in 2014  about a study which found an increase in obesity in people born by C section. Both factors are becoming more common in many countries but does that mean c sections are causing obesity? Could the two increases just be a coincidence or could there be a third factor that's driving up both? It's really not clear yet and that's before we start thinking about how/if the Microbiome is involved. Unfortunately throwing in speculation about healthy and unhealthy Microbiomes seems to be a good way to grab a bit of media attention though (see this post from November for an example of this). 

What is a healthy Microbiome anyway?

While quite a few studies have shown that the Microbiome of C section born babies is different to that of their vaginally born peers, it's worth remembering that different doesn't necessarily mean worse. It's easy to assume that the Microbiome of vaginally born babies is better because it was acquired through a natural process. Maybe it is, but nature doesn't go about producing perfect finished products and as I said above, we don't yet have much evidence for Microbiome changes actually causing or preventing specific diseases.

One big thing that isn't made clear in a lot of Microbiome news stories - we don't really know what's there. Current tests can miss some species all together and only notice others at the genus level. Lactobacillus were looked at in the seeding study, but there are at least 180 different species included in the Lactobacillus genus, they may all do subtly different things.

Another problem is that most Microbiome research looks at what's in the gut using, well, poo samples. Not all the bacteria will come out in poop. So we have even less chance of identifying those hanging on in there in the gut.

So instead of charting the entire Microbiome, most studies look at the presence or proportions of particular bacteria. But our Microbiome is likely to be a complex ecosystem and the way different species work together may be even more important than the percentage of a particular individual.



Where Does Seeding Some in?


The seeding study found that babies who were born by C section and then had the seeding procedure carried out, developed Microbiomes that were more like those of vaginally born babies than of C section babies without the seeding. So if more evidence comes in that my c section = bad stuff equation is actually true, it could be a way of preventing that bad stuff.

Some more buts though...

This is (as the authors make clear) a very preliminary study and the numbers involved are tiny I mean seriously tiny. The test group was made up of just four babies and there is also no information on how they were chosen. So it is possible that the reason for the C section or even the mother's reason for agreeing to take part, could also influence her Microbiome and that of the baby. For example, Mums agreeing to seeding might have been strongly motivated to make their births as natural as possible, these values could also alter their diet, how they care for their baby or their home environment.

 Another important issue is that the study only checked on the babies until they were one month old. So we can't know if the differences continued once they hit crucial milestones like weaning, and crawling around sucking on shoes (that's not just my kids right?). It certainly doesn't tell us anything about the health of these babies in the long term.

Again the authors are quite clear on this - more work is needed, way more, for longer periods and with more babies. If seeding does turn out to be useful this might not even be the best way to do it. In the future we may be able to identify the key beneficial organisms, and produce a simple treatment containing them. The Microbiome of the gut seems to be very important but wiping a gauze over a baby might not be enough to get that going.



But if there are possible benefits should we just give it a go?

The study authors also state that they aren't provided a guide for DIY seeding.

Everyone's Microbiome is unique. It's not just a couple of species, it's a whole, complex ecosystem and ecosystems are rarely made up entirely of the cute and harmless. Some bugs, which live unnoticed on a full grown adult, can be very dangerous for new borns. We probably all have some nasties lurking around, perhaps kept in check by the other species surrounding them. The process of seeding won't transfer as many bacteria to a baby as they would get in a vaginal birth but worse, it's possible that it could transfer the wrong mix, with more of the harmful bacteria making it across. There needs to be a huge amount of work done to optimise the procedure before we can be sure it works or even that it's safe.

A couple of things struck me as potentially problematic with the protocol in the study. Firstly not everyone has an hours notice of their C section so many Mums won't have time to do the gauze technique and planned C sections can get delayed (mine was by hours) leaving the gauze in place too long may encourage nasty bacteria. The researchers also wiped the baby with the swab within two minutes of birth, before handing the baby to doctors for "standard detailed checks". This means the baby wasn't spending it's first few minutes next to it's mother's skin. Something which is often now considered the ideal and which may itself aid Microbiome seeding.


The Ranty Bit

Along with epigentics, the Microbiome seems to be the current fashionable scientific field for health news and, as ever, some of that news is a bit misleading. In researching this I've come across stories based on tiny or poorly designed studies and on unpublished data, press releases and interviews. If this post seems overly negative it is only because so much of what I've read veers wildly in the other direction, So a great deal of caution is needed when trying to draw out useful facts from the noisy excitement. But with all that said, I still think the Microbiome is fascinating and may live up to all the hype around it. In the future we may well be thinking about food and supplements not just for their taste or nutritional value but for how they will benefit our internal ecosystems. I just don't think we are quite there yet.

In terms of seeding, lots of babies have been born by C section and most of them live normal healthy lives. Surgical birth clearly doesn't determine a child's entire destiny, and I am wary that the idea of seeding may be pursued by some because of a belief that C sections are unnatural and therefore, somehow, always inherently wrong. I was disappointed to see that both the seeding paper and a comment article about it claimed that only 10 - 15 % of c sections were medically necessary and referenced the long since outdated and abandoned WHO claims on this.We certainly need to understand the risks of surgical birth, but we need facts for that, not just belief in the wonders of nature.


 If I was going to opt for any kind of medical intervention with a precious new born, be that seeding or vitamin K injection* or anything else, I'd want to weigh up the risks and benefits. With the microbiome we don't even know what the risks and benefits are yet, never mind how they stack up against each other. The new natural worlds we're discovering in our own bodies are fascinating and wonderful but to try to recreate them based on our current understanding would be like trying grow a new Amazon when we've only identified parrots, ants and few Brazil nuts and our gardening experience amounts to growing cress in an egg shell. This study is just a first attempt at preparing the ground.

I'm sure we'll be hearing a lot more about this in the coming years as more work is done on the subject, and as all X Files fan's know:




SB

* The benefits of vitamin K injections are well understood, as are the risks, the benefits definatly win by the way.

PS. Thanks to Clare and Selina on the Caesarean In Focus group for sharing links and to Lisa my lovely microbiologist friend who knows way more about bacteria than I do!

Thursday, 7 January 2016

2015 A Year in Pictures



I've done this for a few years now, it's a bit out of character for this blog but I hope those who just come for the ranting will forgive a little self indulgence just for one post!

Overall 2015 was a pretty good year. Looking back through my pictures has reminded me of all the fun things we've done as a family. There was no single stand out event but I guess I'll remember it as a year of getting outdoors and sleeping under canvas as I had the opportunity to become a festival reviewer and we spent much of the summer in sunny fields watching bands or, more often, kicking back while the kids had fun. By the time we finally packed our tent away for the year MissM was decidedly unimpressed with the idea of sleeping in a house again!

It was also a year dotted with sadness. Of course you don't get to 36 without having lost some people who were important to you but this year we unexpectedly had to say goodbye to friends our own age who we had known since university. I'm not sure I'll ever feel old enough for that.

These are the things that make up life though I suppose, love, loss, crowded commutes and drinking cider in the sun. Watching your children grow through days that can seem unending while years are gone in a blink.

So goodbye 2015, here's your edited highlights from the SouthwarkBelle family:

January

We visited the Otters in Battersea Park and MissM braved the cold on Peckham Rye


February

There has been a lot of dressing up this year, in Ferbruary it was "Flamingo dancer" for MissM and Tinkerbell MissE for World book day - I made that tutu! Me! I did craft!



March

MissM moved into a big girl bed, so we did our first ever Ikea hack to make bunks with a den.




And we returned to Coombe Mill in Cornwall for another lovely Easter holiday. MissE and I went a bit Poldark when she had her first go at horse riding up on Bodmin Moor and MissM made some new furry friends.







April

We came home via Devon and some more ponies, the girls also got a visit from The Easter Mummy





May

We kicked off a summer of outdoor fun with festivals number one and two (of five). First we returned to Feast In The Woods, with the whole family this year (last year MissM had chicken pox so MissE and I went alone). We finished up the half term with my first assignment for Festival Kidz, reviewing Wychwood Festival in Cheltenham.




Its a tough job being a festival reviewer!



June

More camping, this time just the four of us in the woods, the kids had their tea while Daddy inflated our new, enormous, inflatable tent (I honestly think it's bigger than the first studio flat me and MrSB rented in London).





July

Time to start the main festival season, three weekends in a row starting with a very VERY wet one at Jimmies Farm. MissE had a great time though, taking to the stage with the wonderful Flying Seagulls Project...



 and it would have taken more than a wind and rain to put the girls off enjoying Justin Fletcher and Mr Bloom

August

For festival no.2 the sun came out and we had a blast at Standon Calling


MissE storms to a win in the Kids v Hen party dance off

Kids science workshops! Yay!
We finished off our festival year at the gorgeous and really rather posh, Wilderness festival

Wilderness - where the kids craft activities are run by The V&A

Me and MissM went for a walk and found a Mardis Gras parade
Chilling out with a view of the main stage

Oh and someone turned 6!





September

We'd bought a family membership for Historic Royal Palaces in the Summer so made use of it with trips to Kensington Palace and Hampton court


October

We spent half term with my parents in Devon and found ourselves with some keen babysitters and for once good weather up on Dartmoor so MrSB and I headed off for a good long walk and found this gorgeous ancient oak wood.






November

In November MissM turned 3 (how did that happen???!!) and we celebrated at Sandy Balls holiday park (don't laugh) (ok, laugh)





December

Lots of fun, lots of dressing up, a bit of Star Wars and of course, sprouts






So then, lets see what 2016 brings!

SBx




Saturday, 12 December 2015

Saturday Morning

And now for something completely different...



Saturday morning before kids:




10.30am

SB: *yawn* I'm tired, can we skip that party tonight and watch a DVD?

MrSB: ok

SB: Cool, let's have a lie in, then get Dim Sum and play Mario Karts all day.

MrSB: ok




Saturday morning after kids:




6.30am

SB: *Yawn* I'm tired, but shall we try to have a "date night" and stream a film tonight?

MrSB: ok

SB: Cool, but I'll be too knackered to concentrate after 10.30 so we'd better get the kids to bed on time.

Which means they'll have to have dinner at 5, so I'll have to start cooking at 4 and we'd better take them to the park before that to wear them out which means MissM needs to go down for her nap by 1 or there won't be time.

So we'd better have lunch at 12 and we'd better be home by 11.30 to make it so we'll have to come straight home after swimming lessons which means going to the shops before the lessons and getting all the swimming stuff ready before that.

Oh and we really need to do the laundry.

So basically we can watch a film tonight if we get up half an hour ago.

Still, it's nice to be at home for a relaxed weekend sometimes.

MrSB: ok


I may be over thinking things. Tell me I'm not the only one?

SBx