Friday, 22 August 2014

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

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

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

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

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

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

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

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

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

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

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

Wednesday, 12 March 2014

Making the case for independent midwifery: The Baby's Coming by Virginia Howes

Virginia Howes's book The Baby's Coming - A story of dedication by an independent midwife was published this week, just as the Department of Health announced that the government would not support independent midwives' proposed insurance solution, which means that when new EU legislation is implemented later this year independent midwives will become illegal. To anyone who has had any involvement, however remote, with independent midwifery - even if they've done no more than watch Virginia on TV in ITVs Home Delivery - this must seem like total madness: independent
midwives are highly skilled and offer choice and high-quality care to women with a wide variety of needs, relieve the pressure on an over-stretched NHS and save £13 million per year in costs to maternity services. You can read more about the situation facing independent midwives in this article in the Express, this blog by Angela Horler on the Huffington Post, or on the Independent Midwives UK website.

Reading The Baby's Coming this week, then, means that I have read it with an eye on the wider picture too. And, having read it, it couldn't be clearer to me that if independent midwifery is outlawed then we will have lost something of immense value, and outcomes for the women who would choose independent midwifery if they could will be less favourable as they are forced to birth in circumstances they wouldn't have chosen - either within the NHS or alone and unsupported.

Although the book is in many ways an entertaining read, packed with wonderful birth stories, moments of humour and everything that birth junkies like me love to read about - it's also profoundly political, stuffed full of clear demonstrations of where there is room for improvement in our maternity services. In a climate where choices in childbirth are becoming limited within the NHS, due to the suspension of home birth services, the closure of stand-alone midwife-led birth centres and fear of litigation - and all this despite a European law that enshrines a woman's right to choose the circumstances of her birth - it seems to me that we need independent midwifery more than ever.

I'm involved with the Positive Birth Movement, and at meetings we share positive experiences of birth and discuss how women can make their own choices and work with their caregivers to ensure their needs are met; in the process we often hear how difficult this can be and debrief previous experiences. Virginia's book, it seems to me, could be seen as almost a manual for mothers and their caregivers for how respectful, woman-centred maternity care should be delivered, whether in home or in hospital, within the NHS or outside it. There are 'scripts' in its pages that mothers (and midwives) could use to great effect and that's a real strength of these stories - they are an antidote to the 'am I allowed'/'will they let me' position that so many women find themselves in and they show how, even in difficult circumstances, you always have a choice about your care and your informed consent should always be sought.

I had all three of my children at home - with NHS midwives - and I love how the book, again through real-life birth stories, gives a truly realistic picture of what home birth can be, both when all goes well and when there are complications. (I absolutely loved the story of the parents who planned a home birth, went into hospital for monitoring, found all to be fine, then dashed back home again to have the baby in the pool as planned!) Parents considering home birth can read the book and get a sense of the 'back up' that's in place, whether the care is independent or NHS, and feel reassured. On the whole the book is immensely reassuring; it's a long way from the 'drama' of birth on television shows like One Born Every Minute. Even through the (admittedly very unusual!) story of a breech birth that took place in a moving ambulance in a snowstorm there is never a sense of panic, more a sense of wonder that birth can often unfold spontaneously even in the strangest of circumstances. I also relished the moments where traditional (yet evidence-based!) birth wisdom - so easily overlooked in more medicalised births - was in evidence: Virginia describes how something as simple as getting out of the pool could slow down labour enough to give her time to arrive to be with a nervous father worried about having to catch the baby, and how labours that are progressing well can be stalled by people coming in and out and talking to the mother, or turning on the lights. She often talks about the subtle signals women give about what is happening in their labours, without the need for vaginal examinations or calculations of 'rates of progress'. There's valuable knowledge here that we would all do well to take note of.

It's probably clear by now that I loved this book (I've ordered a few copies for my mobile book stall so I'll be spreading the word...) And I'm with Virginia in hoping that it doesn't become a historical document in the near future: if you can join in the campaign to save independent midwifery, please consider doing so. You can go to the IMUK website and take it from there - lobby your MP, donate to the fighting fund, sign the petition.

Finally, I wouldn't be an editor worth my salt if I didn't flag up the fact that there a few proofreading errors in the book, and that some of the dialogue sounds a bit clunky (that's down to the fact that someone decided not to use any contractions - strange, given the subject matter! - so instead of 'I'll' 'I'm' or 'We're' these are spelled out in full). These are minor niggles, didn't spoil my enjoyment of the book and can no doubt be corrected in future editions (of which I hope there are several, revised and updated to include many future birth stories!)

I received a review copy of the book from Headline; my opinion of it is, of course, my own!

Thursday, 27 February 2014

New breastfeeding research: approach with caution!

You may have seen this article in the Daily Mail, with the provocative headline:
"Breast milk is 'no better for a baby than bottled milk' - and it INCREASES the risk of asthma, expert claims". Having done some digging, including reading the abstract, extended abstract, press release and the full text of the scientific paper (Colen, C.G., Ramey, D.M., Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons, Social Science & Medicine (2014), doi:10.1016/j.socscimed.2014.01.027. - available via ATHENS, or to purchase online) that this article is based on, and other reports, it's clear that the findings of this study should not be dismissed out of hand simply because they appear to contradict what we think we know about the long-term impact of breastfeeding on child health.

I recently heard scientific research described as 'like a jigsaw puzzle, except that there are no straight edges, and no picture to follow on the box' and thought that this was a useful way of thinking about it. Each new piece of research fits in somehow, but the how and where of it can take a long time to unravel. What's interesting, and what moves our understanding forward, is continuing to delve deeper, and, instead of dismissing results that we instinctively feel are 'wrong', asking 'How did the researchers obtain these results? Are their methods sound? Why did they get the outcomes they did? Are there clues in their work about other things we need to know before we can draw a sensible conclusion? Should we be acting to alter our recommendations or behaviour based on this research, or not?'

Of course, the above has nothing to do with the poor reporting of the research in the media (for interest, compare the Daily Mail article with this one for an illustration of how different two reports based on the same press release can be). My hackles rose at the line 'The NHS recommends that mothers breastfeed for around six months' - it doesn't, it recommends exclusive breastfeeding for around six months and continued breastfeeding alongside other foods after that, with no maximum duration specified. That the most basic of fact-checking hasn't been carried out makes me suspicious of reading too much into the Mail's slant on the story (that, and past experience of the Mail's anti- breastfeeding/anti-breastfeeding supporter agenda). Looking closer at the piece it follows the press release fairly closely, except that in certain telling ways it exaggerates the impact of this study, despite the authors taking care in their discussions to take a fairly moderate view. Something as simple as the Mail choosing to include a bullet point beneath the headline that reads "Dr Cynthia Colen says the benefits of breastfeeding are exaggerated", when in fact the press release says "A new study comparing siblings who were fed differently during infancy suggests that breast-feeding might be no more beneficial than bottle-feeding for 10 of 11 long-term health and well-being outcomes in children age 4 to 14." (my italics) serves to overstate the importance of this one study in the context of all the research into breastfeeding, artificial feeding and maternal and child health that is currently being carried out. Characterising Dr Colen as a generic 'expert' is another case in point; she's a sociologist, and an assistant professor - but what does this tag of 'expert', as applied by the Mail, mean? That she's more expert than other breastfeeding researchers? That she's the 'best expert' on breastfeeding that there is? There are plenty of other intelligent, committed, qualified researchers into breastfeeding currently working on research that may or may not support the findings of this paper - but the way the Mail uses the term 'expert' here suggests to the reader that this particular paper is somehow more important than others. I've talked before about the danger of believing that each new research paper moves everything 'forward' and it's helpful to remember it here - there are countless blind alleys and twists and turns in the quest for knowledge, and avoiding hyperbole when reporting new research would be a good start in making this more generally understood.

I've read the full paper and, I've got to confess, I am no statistician, so I am not best-placed to comment on whether the methodology is robust. At first glance, as an interested lay-person, it seems like a useful study, carefully designed to address some of the difficulties of previous studies, with some interesting results. The questions that immediately sprang to mind as I read it, which I would love others to examine in more detail, were the fact that the sample size of the differently-fed siblings was small - could it be that the numbers aren't sufficiently powerful to show statistical significance? I also wondered about breastfeeding duration - the researchers asked whether breastfeeding was initiated, and how long (in weeks) it went on for, but I couldn't find any numbers for this in the paper - what was the mean duration of breastfeeding in these families where one child was bottle-fed and one child was breastfed? If we are talking about the difference between two months or less of breastfeeding and bottle-feeding from birth, I would expect the results to show less of a difference than if we were comparing six months, or a year of breastfeeding against bottle-feeding from birth (based on the research I've read that shows a dose-response effect of breastfeeding on infant health). I found myself wondering about the scenarios in which one child in a family is breastfed and the other bottle-fed and how those might appear in these statistics - a common scenario in our culture of infant feeding in the UK, which I come across regularly as a breastfeeding peer supporter, is that a mother tries breastfeeding with her first baby, stops early due to a lack of support, then doesn't 'put herself through all that again' with subsequent children. I also wondered about whether the results of this study could be extrapolated to the UK or other Western cultures - the Mail certainly seems to think they can, as it was very unclear in their article that this was actually a US study (despite it being clear in the title of the paper itself). Differences in the racial and socioeconomic profiles of our respective societies might be important (indeed, the researchers note that one of the features of the differently-fed group is that the racial profile is different from that of the other two comparison groups, with the highest proportion of black/Hispanic families - although they urge caution in attaching too much significance to this).

Something else that was interesting to me is how the authors of the paper position themselves in terms of the research and debate surrounding infant feeding. In the introduction the authors write:
"Scientifically, disparities in infant feeding practices raise the critical question of the degree to which unobserved heterogeneity between children who were breastfed and those who were not may be driving the frequently noted positive association between breastfeeding and a wide variety of childhood outcomes. If this is the case, a well-intentioned, narrow emphasis on breastfeeding promotion would, at best, fail to realize positive benefits and, at worst, be a source of oppression for women who do not nor cannot breastfeed." (my italics)
This all sounded familiar to me and there's a reason for that, which becomes clear at the end of the paper:
"A truly comprehensive approach to increasing breastfeeding in the U.S., with a particular focus on reducing racial and SES disparities, will need to work toward increasing and improving parental leave policies, flexible work schedules and health benefits even for low-wage workers, and access to high quality child care that can ease the transition back to work for both mother and child. Hopefully, this multifaceted approach will allow women who want to breastfeed to do so for as long as possible without promoting a cult of “total motherhood” in which women’s identities are solely constructed in terms of providing the best possible opportunities for their children and the risks associated with a failure to breastfeed are drastically overstated (Wolf, 2011)." (my italics).
I think this at least sets the paper in context (for more, see my previous post about Joan Wolf). I should have guessed from the clue in the title of the research paper, 'Is Breast Truly Best?', which itself echoes the title of Wolf's book.

Let me be clear - I'm not dismissing the results of this paper. But just as its authors urge caution about overstating the benefits of breastfeeding in order not to oppress women, I urge caution about the importance we attach to the findings reported here, and suggest that we view them instead as one small piece of a very large jigsaw, and as a point of departure for asking further important questions.