Choice

On Thursday, obstetrician Maggie Blott, from the Royal College of Obstetricains and Gynecologists (RCOG) spoke on BBC Radio 4's Woman's Hour in a feature on pregnancy and birth, she stated that some women do not have a choice in where (and one must assume, how) they give birth.

The feature was generally very good and well balanced, I have no complaint with the BBC over this. The host, Jenni Murray was her usual calm and collected self, giving equal floor time to all of her guests. Sheila Kitzinger, founder of NCT and Birth Crisis, author and all around birth activist was interviewed and was asked about choice, birth plans and even orgasmic birth. A woman who had had a home birth recently was interviewed with her midwife and they both talked about how wonderful the experience was. The midwife was enthusiastic about home birth and talked about how rewarding her job was, which was refreshing coming from an NHS midwife, who are so often beaten down and jaded by the hideous system within which they have to work.

The issue of maternity services commissioning came up, following the Royal College of Midwives (RCM) recent conference, at which general secretary Cathy Warwick criticised the government for their U-turn on this topic. In the White Paper released in the summer, it was announced that while much commissioning would go to GPs to be determined on a local level (quite rightly so), maternity services would be commissioned by a national body. The reasoning for this is that maternity services is not generally dealing with people who are unwell, so is therefore outside of a GP's field of expertise. It is also something best looked at on a national level, because where complications do exist in small numbers not every local authority is going to have the resources to fund expensive facilities for very rare cases. It needs to be looked at on a larger scale so that the best provisions for those who need more care can be made in a sensible fashion. For example, not every local hospital needs a maternity unit and Special Care Baby Unit (SCBU), but at least one major hospital per region does need this. If commissioning is local then how will these facilities be funded?

However, some GPs inexplicably came out against this decision and have lobbied the government with such spurious arguments as "this is stupid". Hmm, helpful and how professional.

Cathy Warwick appeared on Woman's Hour and presented the case against GP commissioning. Health Minister, Anne Milton was also interviewed and she stated that no decision has yet been reached and that all sides were being considered. The general feeling among those in the know is that the government is going to come down in favour of the GPs. Why are the GPs even interested in this? What is in it for them? What does it mean for women and their families if their GP practice decides to reduce funding? The whole ethos of choice and quality care is under threat. It will become a postcode lottery as to whether a woman and her family can enjoy the essential quality of care that she needs. Women may end up having to travel large distances to receive their antenatal care if community midwives are made redundant by GP practices and the choice of where to give birth flies swiftly out of the window.

Which brings me back to the opening of this post. In the UK we are lucky to be able to exercise our fundamental human rights without fear from the government. Mostly. We are much better off than some countries. The Universal Declaration of Human Rights (UDHR) stipulates in Article 3 that "Everyone has the right to life, liberty and security of person." Security of person relates to the body and the mind, so basically every person has the right to bodily autonomy; they decide what happens to their physical body, and has the right to protect their emotional and mental wellbeing and no one has any right to override that autonomy. It would be under this fundamental human right that choice in birth comes. Every woman has the right to choose how and where they give birth. It may be that she has certain risk factors that may incline her care givers to recommend one place over another, but ultimately it is the woman's choice to take or leave that recommendation. For instance, an intense phobia of hospitals may mean that a woman chooses an elective caesarian in order to be able to plan the date and time of her birth and to control the amount of the time spent in that environment. Or it may mean that she chooses to give birth at home, perhaps even on her own with no midwife present if her phobia extends to hospital staff. That is her right.

During my first pregnancy I had no "risk factors". I was totally free from any medical-based prejudice towards one location or another for my birth. I was lucky enough too, to live in an area that nominally supports and encourages home birth. Unfortunately, there are so few women in this area choosing to birth at home that the midwives are not as skilled and experienced in normal, un-medical birth as they ought to be and as such, I was given a medical birth at home, which was never going to end well. Now I do have "risk factors". Next time I am pregnant, the NHS will "advise" me to have my baby at hospital. Not because it is what is statistically safest for me and my baby, but because their protocols are set out by a team of lawyers with the paralysing fear of being sued forever at the forefront of their minds. They want to control and manage all risk, rather than simply dealing with problems on the rare occasions that they do occur, so that they can say "we knew this was a risk and we tried to avoid it".

However, what many women genuinely do not realise is that they still have their fundamental human rights, as protected by the UDHR. They can decide for themselves whether to take the advice they are given or not. Because I am well-informed and have taken a great deal of time and effort to research the risks for myself and to analyse the reasons for protocols and guidelines to be in place, I know for myself that not only can I still have my next baby at home if I want to, but that there is even an official guideline that tells maternity personnel that I can make that choice. There is a NICE Guideline that states that women with one previous c-section should be treated no differently from any nulliparious woman (someone expecting their first child).

So, when I hear an obstetrician from RCOG on national radio stating that women with a previous c-section, for this was one of several specific examples that she gave, "do not have a choice in where they give birth" I am furious. Not only is she stating that some women do not have their fundamental human rights for the sole reason that they are pregnant, she is also going against the guidelines she is otherwise so tied to!

Midwife Cathy Warwick was wonderful at this point in the interview and did intercede to state that women do still have a choice and should be supported in that choice even if she has risks that her obstetrician is unhappy with. However, my fear is that Maggie Blott has given a green light to her colleagues to lie to women in their care. I know that the practices of lying and coercion are already very common in maternity care, from my own experience and those of other women I know, but to hear it on national radio from a member of RCOG has had quite an impact on me.

I urge women and birth activists everywhere to not let this go by without comment. Tell your friends, relatives, strangers in the waiting room, that being pregnant does not strip a woman of her human rights! Write to RCOG and demand a formal public apology for Maggie Blott's comments. I will be doing just that.

And on the subject of maternity services commissioning, please write to your MP as a matter of urgency and demand that the government stand by its commitment in July. The final decision on this is due in just a few weeks so there is no time to lose. You can find contact details for your local representatives here: http://www.writetothem.com/

Guess the Weight

Guess how many sweets are in the jar, or better yet, guess how much the sweets inside the jar weigh. Not including the jar itself but including all the sweets you can't actually see in the photo....

I'll give you a little help, you see that green one near the top left? Well the distance from the highest tip of that sweet to the lowest tip of the red stripy one down the bottom is... let's say 25cm. NOW tell me how much the contents of the jar weigh.

What? You mean you can't work it out?

No, I couldn't either, neither can my mathematically gifted husband. Although he does argue that he is familiar with these kinds of sweet jars and would therefore be able to estimate that the sweets weigh 1kg. But he is missing my point a bit.

From looking at this picture alone, with one arbitrary measurement and without being able to see maybe 80% of the sweets in the jar, there is absolutely no way that with this information alone anyone would be able to estimate with any degree of accuracy how much the sweets weigh. My husband is right though, using his life experience, he can guess the weight fairly accurately. But we do know with some degree of certainty that these exact sweets were weighed before putting them in the jar prior to sale. The same cannot be said of a baby in the womb.

So why do so many people believe a sonographer when they say that their unborn baby weighs xlbs in utero? It's the same sort of equation. An ultrasound gives the sonographer a view of a small section of the uterus at any one time and gradually builds up a picture as the transducer is moved across the abdomen. Three measurements are taken during a growth scan, the biparietal diameter (distance between the 2 sides of the head), femur length and the abdominal circumference. These measurements are entered into a computer program which then calculates the estimated weight based on charts created by researchers. You would think it would be fairly accurate. All that science.

The problem is that for one, the scan is only as good as the sonographer. All humans are capable of error. What one sonographer measures one day may be totally different to what another sonographer measures the next (on the same woman and baby). I have even heard of one sonographer giving a woman and her obstetrician quite a fright by writing down measurements that implied that her baby had SHRUNK! That was human error, babies don't shrink, as the obstetrician quite rightly pointed out, and later apologised to her and admitted that a mistake had been made.

But also, who made these charts and from what research? My best guess is that researchers have measured aborted and miscarried fetuses in order to establish average lengths, diameters and circumferences at different gestational ages. I wonder how many samples they looked at before coming up with these charts? From how many different ethnicities? Did they account for growth abnormalities in unhealthy fetuses?

There is a wonderful bit of research that demonstrates the complete unreliability of growth scans in late pregnancy:

Pregnancy outcome following ultrasound diagnosis of macrosomia.
AUTHORS: Delpapa EH; Mueller-Heubach E
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Pittsburgh, Magee-Women's Hospital, Pennsylvania.
SOURCE: Obstet Gynecol 1991 Sep;78(3 Pt 1):340-3
Extract: "In 66 of 86 women (77%) delivering within 3 days of ultrasound examination, estimated fetal weight (EFW) exceeded birth weight. In only 41 of these 86 women (48%) were the EFWs within the corresponding 500-g category of birth weight."

So basically, this study (admittedly only a small one), found that 77% of growth scans predicted a higher birth weight three days BEFORE birth, so if these scans really are as accurate as we are led to believe then 77% of babies shrink in the last days of pregnancy. See above. More alarming is that 48% of scans, i.e. less than half, were accurate to within 500g, which is more than 1lb. What a large margin for error! The difference between a 9lb baby and a 10lb baby can be a HUGE difference to the mother and her care providers both psychologically and in terms of her care during late pregnancy and birth. To look at it the other way, more than half of scans were LESS accurate than that. 52% of women scanned were expecting either much bigger or much smaller babies than they got.

Why does it matter?

Because if a midwife sends a woman for a growth scan because of concerns late in pregnancy, and the obstetrician that the woman sees after her scan decides that, based on this one scan, her baby is too big or too small, then interventions may be advised that are simply not necessary. For example, if a baby is suspected to be too big, early induction or c-section will be advised. Except in the current NHS system the woman will come away thinking that it is not advice that she has been given, but an order to comply with.

Why does it matter?

Because interventions without clinical need are a waste of resources and may have long-lasting negative effects on the mother and baby. Caesarian sections are known to leave babies with more breathing problems, greater risk of diabetes and cause risk factors for the woman in future pregnancies, never mind the risk of post operative infection and post traumatic stress disorder.

Why put women through that? Why subject a woman at the end of her pregnancy to fears about the wellbeing of her baby? Even when the prediction of a too big or too small baby is accurate, how often does it actually mean ill health for the newborn? According to one study, "Our ability to predict macrosomia is poor. Our management policy of suspected macrosomic pregnancies raises induction of labor and cesarean delivery rates without improving maternal or fetal outcome." (My emphasis).

The Delpapa and Mueller-Heubach study above also concludes that "A trial of labor resulted in vaginal delivery in 76 of 106 women (72%). There were five cases of shoulder dystocia but no birth trauma. Estimated fetal weights and birth weights were not significantly different between the women who had a trial of labor and those who did not. Our results do not support cesarean delivery or early induction as a means of preventing infant morbidity when fetal macrosomia (weight of 4000 g or more or the 90th percentile for gestational age) is diagnosed by ultrasound."

So ultrasound is NOT an accurate estimate of fetal weight and even when a baby is genuinely large (4000g+), spontaneous labour and vaginal birth are still the safest option.

The C-Word

Cancer. What is it? Why are we so scared of it? And what can we do about it?

Cancer is basically the mutation of cells. Cells that divide beyond the normal growth rate for their type and that invade and kill neighbouring cells are loosely defined as cancerous, sometimes they also travel around the body via blood or lymph.

We hear alarming figures thrown around such as 1 in 3 women will contract a female cancer in their lifetime and that almost all of us can say that they have been in some way affected by cancer, either themselves directly or a loved one. It's no wonder that we are so scared of this disease. But is this accurate?

According to Cancer Research UK, there are now over 2 million cancer survivors in the UK, approximately 3.3% of the population and around 10% of those over 65 are cancer survivors. The number of diagnoses per year keeps increasing, but the so does the survival rate. The most common cancer is breast cancer, with about 550,000 current survivors in the UK today. In 2008 the mortality rate was 0.176% of the UK population. That doesn't sound so scary.

Why might cells mutate? 90-95% of cancers are caused by environmental or lifestyle factors, only 5-10% are genetic. Tobacco is the big one, we all know that, smoking is the cause of nearly 30% of all cancer deaths, 83-90% of lung cancer deaths and is also linked to cancers of the oesophagus, larynx, pharynx, oral cavity, pancreas, bladder, nasal cavity and sinuses, stomach, liver, kidney, cervix and myeloid leukaemia.

Other environmental factors that can increase the risk of cancer are UV exposure, weight, diet and infection.

But the one I really want to talk about is hormones, particularly female hormones and the "female" cancers; breast, cervical, uterine and ovarian.

Certain lifestyle choices are known to impact on our chances of contracting a female cancer. The combination oral contraceptive pill slightly increases the risk of breast and cervical cancer whilst taking the pill, but once no longer taking it the risk decreases again. However, there is a significant reduction in the risk of ovarian cancer for women who take the pill for five years, lasting for more than 20 years. And when I say significant, I really mean it: 50%. There is also a 40-60% reduction in instances of endometrial cancer (uterine cancer) for women who take the pill.

Having 7 or more children and having a first child before the age of 17 are known to double the risk of cervical cancer

The oestrogen only Hormone Replacement Therapy (HRT) has been shown to increase the risk of breast, uterine and ovarian cancers.

And last but by no means least, women are at 4% less risk of breast cancer for each year that they breastfeed and women who do not breastfeed at all are twice as likely to contract endometrial cancer and two thirds more likely to get ovarian cancer.

While all these figures are interesting, what I am most interested in is why. What no one seems to be saying is that cancer is thought to occur in cells that are over-stimulated, that's why the pill is so protective, it prevents ovulation and therefore gives the ovaries and uterus a rest from menstruation. Just like pregnancy and breastfeeding does. The pill basically replicates the consequences of reproduction, but in a more thorough and predictable way. It is my belief that the cells in any given part of the body are programmed to behave a certain way, according to their function and if they are not given the opportunity to perform their function as they expect then they are more likely to mutate and turn cancerous.

The ovaries expect to ovulate regularly until conception and then take a break of an average of 22 months (9 of pregnancy and 13 of breastfeeding, this is the average return of menstruation for women who breastfeed their children on demand). The breasts prepare themselves during pregnancy for lactation, regardless of the mother's intentions, the breast tissue fundamentally alters. What happens then if the mother does not breastfeed? Likewise, the cervix prepares itself for birthing a baby during late pregnancy and labour. So what are the implications for those who do not labour or who have a surgical delivery? I didn't find any statistics on that, but I'd love to know if caesarian sections carry an increased risk of cervical cancer. It certainly wasn't a risk listed on my consent form. Does some research need to be done on this?

Could we go back to a time before cancer became the single biggest health scare simply by living as our bodies expect us to?

Informed Consent

Every day for the last two years I have encountered either directly or recounted through someone else, at least one woman who genuinely believes that because she is pregnant she has sacrificed her most fundamental human rights. The vast majority of women become submissive to the will of their care providers and the NHS does nothing to correct this misconception, in fact, it perpetuates it. Women are regularly told by their midwives and doctors that they are "not allowed x", or they "must have y". I myself, while in labour, was told by a midwife that I had to have an internal examination every 4 hours. No consent was sought, it was presented to me as non-negotiable and this happens routinely, probably with the most regularity in relation to induction.

Women are told that their baby is due on a specific date, the Estimated Due Date (EDD), with the emphasis on "due" rather than "estimated". Women fall for this almost every time, if they go just one day past their EDD then their baby is "late". Midwives seem to not point out the fact that babies can and do arrive whenever they are ready and that the World Health Organisation (WHO) defines normal pregnancy as lasting anywhere from 37 to 42 weeks. Once a woman passes 40 weeks, which about 50% of women do, they are told that they are now on a clock and must go into labour quickly otherwise they will "have to be induced".

The exact date at which hospitals routinely induce women with no clinical need, varies from one area to another, but what doesn't seem to vary is the lack of informed consent. Women and their families are not given the facts that enable them to make a decision for themselves, they are routinely led to believe that they have no decision to make, they will be induced, this is non-negotiable. They are not told the risks of the induction process, they are however given exaggerated and out of date "advice" about the risks of remaining pregnant for longer than 41 weeks.

If a woman's waters break she is put on a clock and if labour does not start spontaneously within 24 hours she is told that she must be induced. I've known women be told this and given no reason, at best they are told that it is because of the risk of infection. What they are not told is that the risk of infection only increases significantly after 96 hours and that it is a significantly higher risk in hospital than at home. Premature rupture of membranes (PROM) occurs in about 6-19% of pregnancies, 86% of women will go into spontaneous labour within 24 hours and 94% within 95 hours. Statistically, a baby born in hospital is 4 times more likely to acquire an infection than a baby born at home and around 9% of women birthing in hospital will acquire an infection, the highest risks being those who have a catheter and especially those undergoing a caesarian section, both of which are higher risks for those undergoing an induction.

It saddens me to hear women talking about their births as though they have no choices, no input to how and where it happens and what makes it worse is when people like myself try to inform them we are accused of being bullies! It is my sincere hope that the tide begins to turn soon and that women are given full, accurate information and are empowered to make their own choices for their births. It is one of Airedale Mums' primary goals, though it is not clear yet how we go about achieving it.

Autumn

We are rapidly approaching my favourite time of year. I felt it today for the first time. All of my immediate family have summer birthdays, my mum is the last on 31st August (happy birthday Mum!) and once this date passes it's like autumn suddenly rushes up to meet me. The days are growing shorter, the evenings are still warm but there is a crispness to the air. It's about now that the memories of some of the best times of my life start to kick in and the anticipation of the forthcoming holidays and festivals starts to set my pulse racing. I always seem to reconnect with music at this time of year too. I listen to music all year around, but it seems to be a background thing most of the time these days, unlike pre-Jack when live music and clubbing were a big part of my life, but around this time of year I start really listening again and listening to different bands and artists, more rock and less of the pop and dance that I tend to go for in the summer months.

We're only 3 weeks from Mabon and I find myself feeling a little sad that we won't be at Avebury this year, which had become a little tradition when we lived in Bristol. I don't recall missing it last year, but we were busy with Jack hitting the six month mark and all of the challenges that came with that. Mabon is not my favourite Sabbat, but it is the one that I always get a little more excited about, perhaps because it marks entry into the festive season, where the next two Sabbats, Samhain and Yule, seem to come in such quick succession and everyone else gets excited about their secular or Christian counterparts.

I love the way we all get swept along with the season, like the golden leaves dusting the ground and the build up to its inevitable conclusion - winter. Don't get me wrong, the ridiculously long and drawn out build up to Christmas annoys the hell out of me. "Festive" goods and songs in shops from September is ludicrous, decorations and lights going up in October completely misses the point of the holiday to me. But what I do like are the simple things, the human aspect. I love the way people start grinning and wanting to talk about the holiday and I love the weather turning cool and crisp, the frost and even the first snow (when we get some before new year that is). But long before that, just the little buzz in the air, the sense that the seasons are changing, I love it and I felt it today.

Free stuff for Home Educators

One of my HE contacts has a fab blog here and is giving away free stuff in celebration of HE kids NOT going back to school! So just check out her blog and leave a comment about why you love HE and get yourself an entry into the prize draw :)

French Police Brutality

Captured on film in July, French police have shown themselves to be a disgrace to the law enforcement profession. African immigrants were forced to leave their council housing earlier in the month and had set up camp on the streets in the area. Women and children were the main occupants of the Parisian streets, with no where else to go, they stayed close to their friends and families. Many of the immigrants were there perfectly legally and had been living in France for more than a decade. Police arrived to move the campers along and the video, published on YouTube by French news site Mediapart, depicts the African families sitting peacefully on the pavement, arms linked together, being assaulted by the authorities.

Women were dragged away from their friends and families, babies ripped from their mothers' arms and wraps. One woman was pulled from the group by her legs, dragged over the ground on her back, where her baby was wrapped, she was pulled across her child, apparently squashing him into the ground. A pregnant woman is shown lying on the ground, her head perilously close to a concrete bollard. It is unclear whether she was injured or "playing dead" to make it more difficult to be moved, but the police were making a good go of shifting her.

I have never seen anything quite like this in my life. The brutality involved is shocking. To manhandle people in this fashion is bad enough but when you consider that it was women and children, who had done nothing more than attempt to sit it out when being forced to leave their homes, this is troubling indeed. I don't know if it is even worse to know that this did not take place in some obscure dictatorship, but right here in Europe, in Paris no less.

We live in troubling times indeed.

Here is the video, please be warned, this clip depicts police brutality upon women and children and viewers may find it distressing: