If this is cost-cutting, just be honest, please

Now here’s an odd bit of news. Britain’s Royal College of Gynecologists (RCOG)—in one of those partnerships that make you go “Huh?”—has teamed up with the National Childbirth Trust (NCT) and the Royal College of Midwives (RCM) to issue "Making sense of commissioning Maternity Services in England – some issues for Clinical Commissioning Groups to consider," a set of guidelines on maternity services to British general practitioners.

British GPs (who are rather like family doctors) are often the first point of contact for pregnant British women and have considerable impact on their choices, so this is important stuff. The guidelines give GPs pointers on how to assist pregnant women, on which sort of birth units they should advise patients to go to, and what sort of questions they should ask of their local hospitals/birth units to make sure they are fit to be recommended.

Much of the guidelines covers matters such as ensuring pregnant women receive medical care early on, looking out for socially vulnerable women etc.—all great stuff and very welcome. But then things get surprising. Credit goes to Pauline Hull of Cesarean Debate who spotted the oddities in the guidelines and posted her own very thorough riposte which can be read in full here. Although the guidelines spend a lot of time talking about “choices,” they do nevertheless seem to be awfully keen that women make the choices that the NCT and RCM consider correct. They encourage GPs to push women towards midwife-led birth units, saying (for example) “There is now a good argument to be made for multiparous women being advised to choose a non-obstetric birth unit” (my emphasis). Most curiously of all, the guidelines also advise GPs that “a 20% rate [of cesarean section] is achievable and sustainable. Every provider unit should have a clear action plan for increasing its normal birth rate…”

I don't want to just repeat everything Hull has already said, so I'd like to focus on the bit about "increasing [the] normal birth rate." On the face of it, that doesn’t sound too scary—after all, nobody would want a woman to have an abnormal birth, surely… who could possibly object to increasing normal birth rates? Well, quite a lot of people, actually. The guidelines define “normal birth” as “without induction, without the use of instruments, not be caesarean section and without general spinal or epidural anesthetic before or during delivery.” The guidelines also advocate raising the vaginal delivery rate, which includes forceps and vacuum. Put this another way—“Every provider unit should have a clear action plan for decreasing its epidural rate, and—if necessary—resorting to more forceps and vacuum deliveries in order to get the cesarean rate down” —and suddenly it all sounds a bit less cozy.

The problem with targets (or, what if you like being abnormal?)
The problem with these kinds of targets is that in practice, they always end up reducing choice and harrying at least some women into birth experiences that they don’t want, simply because of the way target-driven healthcare tends to work—as pointed out by numerous posters on the popular online discussion forum, Mumsnet, where there has been for the most part a pretty angry reaction to these guidelines. In hospitals where VBAC/“normal” birth rates are below target and cesarean sections make up more than 20% of births (i.e. more-or-less all hospitals) medical practitioners are sure to start feeling the hot breath of their organizational managers down the backs of their collars, urging them to “see if they can’t get those rates down a bit,” which in turn will inevitably lead to women who prefer cesarean section being pressured, nagged or tricked into birth styles they don’t want—unwanted VBACs and forceps/vacuum deliveries especially. I’m a strong supporter of the continued availability of VBACs and forceps on delivery wards, as I discussed here—but I wouldn’t want either myself, and I don’t think women should be pressured into them or not given full and unbiased information on their risks, as well as on those of cesarean section. I’m particularly concerned about epidural coverage, because there is convincing evidence that British women are already being subjected to the Great Epidural Bait-And-Switch.

The problem is—and the guidelines themselves sort of admit this, funnily enough, if you read them through—British women are waiting until later and later in life to have their first child; they are heavier than ever at conception; they are gaining more weight during pregnancy and having bigger babies. My concern is that if this reality collides with political pressure to "get those cesarean rates down," we will inevitably see more and more “bad vaginal births”—more long and traumatically painful labors, deep instrumental deliveries, injuries to babies and serious pelvic floor trauma. No wonder Maureen Treadwell of the Birth Trauma Association has expressed her concern about these guidelines.

Strange bedfellows
As Hull says, the Royal College of Gynecologists teaming up with the NCT and RCM is…well… surprising. The NCT is a rather crunchy mothers’ association; and while the RCM is generally respected for its role turning out the National Health Service (NHS)’s own highly-trained midwives it is still heavily biased towards natural—sorry, “normal”— birth. In addition to its Campaign for Normal Birth—see, that word again—the RCM back in 2006 also (as Hull mentions) floated the idea of charging women 500 pounds for “unnecessary epidurals,” but backed down when faced with popular outrage.

But if I thought the RCM and NCT were strange bedfellows for the RCOG, my jaw dropped when I saw page 2 of the 2006 Making Normal Birth A Reality produced the Maternity Care Working Party and included on the RCOG website; “Members supporting the consensus statement” alongside the RCOG include the Independent Midwives Association and the Association of Radical Midwives (do check out the latter’s Facebook page; it makes interesting reading, especially the approving links to Birth Without Fear posts like the one on a "Home Birth of Twins Born Past 41 Weeks, One Footling Breech"?). You do have to ask, what the hell is the RCOG playing at?

Cost-cutting with added crunch
Now, there’s little doubt why the NCT and RCM like the idea of pushing women away from epidurals and c-sections—but it would appear that they’ve thought carefully about how to sell this idea to the NHS:

“Between 2001 and 2010 the national birth rate has increased by 22%... The cost… is set to rise… Commissioners… will need to work in close collaboration with their local maternity providers to ensure that services are both clinically and cost effective.”

The guidelines helpfully remind us that “Every potential cesarean section that is enabled to be a normal birth saves 1,200 pounds in tariff price alone.” Okay, now we're getting down to brass tacks.

In recent years we have seen a lot of initiatives springing up all over the world which dovetail  with earthy-birthy views of how we “should” mother, and which—by a delightful coincidence!—just happen to be marvelous little money-savers as well. There’s the Kick women out of hospital as soon as possible early discharge system which has become popular in places like Australia, and which is great for freeing up beds ensuring mothers and babies can enjoy special bonding time away from the dehumanizing atmosphere of the hospital  (see here and here... ah, and I see the phrase "normalise childbirth" yet again in that last link...). There’s the Baby Friendly Hospital Initiative (BFHI), which has resulted in the compulsory rooming-in policies now found in most Irish hospitals, for example—nice for the hospitals who no longer have to pay for well-baby nurseries or the staff needed for them… let mum do all the work, day and night (if you want to know how the Irish mothers themselves feel about the system, see here).

When I first heard about the BFHI, I remember thinking “So… where’s this going to end? Is the next thing going to be targets for reducing epidural take-up too?” Turns out that wasn’t such a far-fetched idea.

Just be honest, please
If you want to cut costs without howls of protest, there is no better way to do it than to do it in the name of “baby-friendliness,” “normal birth” and so on. It’s clever, really. Anxiety about being a “good” mother and a “real” woman is the 21st century woman’s Achilles’ heel. A woman can’t criticize initiatives which purport to be based on “baby-friendliness” and “normal birth” without leaving herself vulnerable to accusations that she is an abnormal mother who believes in being unfriendly to babies and probably punches kittens and puppies as a hobby in her spare time.

In an age of austerity and rising healthcare costs, governments of nationalized healthcare systems everywhere are looking for ways to limit or ration healthcare services. And you know what? That’s okay. No, honestly, it really is. No healthcare system—especially one funded by taxpayers—can pay for everything for everybody all the time, and sometimes tough choices have to be made. It’s fine to have discussions about whether free formula or cesarean delivery by maternal request (CDMR) or homebirth or whatever is something which taxpayers can’t afford to fund any more when there are other pressing demands on NHS money.

But if we are going to debate cost-cutting, can we please make the debate about cost-cutting, dammit, and not cloak it in sweetly-honeyed words like “natural,” “baby-friendly” and (for the love of God) “normal.” If someone thinks the NHS can’t pay for well-baby nurseries or epidurals, fine—they’re entitled to their opinion; but please just say so frankly. Because then we can all sit down and have an honest debate about where cuts should be made. When a plan to reduce epidural availability or kick women out of hospital early is put in terms of “Oh, but we’re doing this for the babies’ good!” this effectively silences women and shuts down open debate. And that’s just not good for babies, for mothers or for the NHS.

Cow's milk and the Law of the Lowest Common Denominator

Happy first birthday Baby Seal! First birthday, first ever chocolate cake (with homemade ganache). I appreciated your cake-eating enthusiasm.

As we all know, birthdays are magic and the first birthday is the most magic of all, because at the moment the clock strikes midnight on the day baby turns 12 calendar months old, something strange happens. In the upside-down carnival of the first birthday, all sorts of things which were previously "bad" become "good" and vice versa. Things that were fine to do before suddenly become A Problem. And everything baby does must be interpreted in a different light. Twelve months is officially the age at which solid food stops being "for fun," and becomes an essential nutrition source. Up until that fated birthday, baby's needs were the same as baby's wants; now baby has lost her innocence and becomes capable of manipulation. Pacifiers, which were fine yesterday, are now a Bad Thing. Bottles too (time to drink from a cup). If you are like a lot of westerners, one year old is the age at which breastmilk suddenly loses all nutritional benefit (exactly how is never explained) and the act of breastfeeding becomes something unseemly and not far from Child As Sex Toy. If you are a certain type of lactivist, 12 months is the point at which you will grudgingly tolerate another woman weaning without actually making snarky remarks (possibly).

And then there's cow's milk. There is a lot of confusion on parenting boards about cow's milk, formula and breastmilk...the when and the how and the why (and that's even before you bring in bottles vs. cups and other factors). The American Association of Pediatrics states that "Whole cow's milk is considered an inappropriate option for infants, which FDA defines as babies not more than 12 months old. According to the AAP, cow's milk contains very little iron and the small amount present is poorly absorbed into the body. Starting an infant on cow's milk too early can result in iron-deficiency anemia, particularly if the baby is not given an iron supplement or foods with iron." Formula or breastmilk should be the only milk given to the baby. Meanwhile, this National Health Service (NHS) resource advises us that "Babies shouldn’t drink cow’s milk before 12 months," but adds that "you can add cow’s milk to food before 12 months" and also recommends "full fat, low sugar dairy products like cheese, yoghurt, fromage frais, or custard."

Given this, us ordinary mothers on the discussion boards could be forgiven for being a bit confused. "My health visitor said it was fine to give DS cottage cheese or yogurt. I'm confused; they say no cow's milk before 12 months... why are yogurt and cheese so different?" Someone else will then chime in to speculate that it might be because yogurt and cheese are "cultured" foods which alters the proteins and sugars contained therein. To which someone else will point out that they have been mixing small amounts of cow's milk with their baby's cereal for the last month--with the health visitor's blessing. Surely if cow's milk has these evil iron-destroying powers, they are not going to magically disappear just because you've added a bit of Ready Brek, no?

I think the key to resolving this is to understand that this is an example of a common phenomenon in the world of official childrearing advice: The Law of the Lowest Common Denominator. Basically, what are the AAP and NHS worried about? Well, not about the perfectly healthy children of mothers who are conscientious enough to be on a childrearing-related discussion board in the first place. They worry about the children of parents who are young, poor and a bit clueless. Who might be tempted one day, when looking into the refrigerator, to think "Hey, we've got milk here. In a carton, all ready to drink. I know, why don't we just fill Suzy's bottles up with this stuff instead of fiddling about with that expensive formula bollocks?" Bad idea. Cow's milk and goat's milk, unlike formula/breastmilk, are not a complete diet, and babies fed in this way are at real risk of dehydration, kidney damage and anemia. Even older babies risk iron deficiency if cow's milk starts making up a substantial proportion of their diet. On the other hand.... a bit of cow's milk, for an older baby? No problem. It's essentially no different to any other complementary food. Can you give an older baby apple as a complementary food? Sure. Should you start giving them cupfuls of pureed apple all day long instead of formula/breastmilk? Of course not.

Trouble is, official organizations know perfectly well that if they start wheezing out long-winded explanations about core foods versus complementary foods and iron and how it's okay to give this much milk but not more than this... unless you are giving other dairy products as well, in which case you should probably give less milk... and it depends on how quickly they take to solids, and.... well, people's eyes are going to start glazing over (especially the kind of parents who are most likely to ignore sensible pediatric advice in the first place). On the other hand, if you make a crude blanket rule of "No cow's milk as a drink before 12 months. A bit with cereal is fine, and a bit of yogurt and cheese is fine," then people are more likely to remember the advice and adhere to it.

The same rule governs a lot of other childrearing advice. I remember (pre-baby) pursing my lips disapprovingly when I heard my sister had acquired a baby walker--didn't she know all the official guidelines said they were Bad For Babies? But (as my father pointed out to me) the reason baby walkers have a bad press is because some idiots leave babies in them for hours or use them as a excuse for not supervising, resulting in serious accidents. Used for short periods under supervision like other toys, there is nothing terrible about them. I think a lot of arguing on message boards and within mothers' groups could probably be avoided if the Law of the Lowest Common Denominator was more widely understood.

Anyway, I have been breaking the official recommendations by leaving Baby Seal with a cup of cow's milk plus water and solids whenever I go out in the evening (about once a week) since the age of 10 months. I hate pumping and have the smallest freezer known to man; while I have nothing against formula, there was a recall on Japanese formula at the end of last year due to the radiation scare, and frankly it's put me off a bit. With her only eight weeks to go until her first birthday, it hardly seemed worth dragging British formula all the way home on the plane. Also, I have heard too many stories of babies who were kept away from cow's milk completely during the first year, and then refused it vehemently when their parents tried to introduce it later on. So cow's milk it is. Now all I need to do is to get her drinking it from an open cup without throwing it everywhere. We can but hope.

Going with the flow...

It's now March, and this month Baby Seal will turn one.

Before Baby Seal was born, I said to anyone who asked that I would "give breastfeeding a try, but if it didn't work out, I would feed formula with pride and joy." After she was born, and I astonished myself with being about to actually, like, produce milk from my own body with next to no problems, I decided to breastfeed for "at least six months... maybe nine." Nine months came and went, and I realized with a jolt that I only had three months or so left. Then I realized with another jolt that I didn't actually "have" to wean her at 12 months. I could keep right on going, just as long as I wanted to.

It was a strange moment. It wasn't that I had ever thought of nursing past 12 months as being improper or icky (I've been in too many parts of the world where women will flip an entire tit out to feed a toddler to be under such delusions). It's just that I never, ever thought of "extended nursing" (even now, it seems so odd to see those words applied to myself!) as something that people like me did. Extended nursing was for mothers who gave birth in paddling pools and kept their babies in slings on a permanent basis (except, of course, when in the Family Bed). Or for women in poor countries who had to nurse for years on end. Not for normal developed-world mothers like me, who do paid employment for The Man and who told their obstetricians that during labor they wanted to be as high as a ****ing kite throughout.

For this change in attitude, I have my beloved knitting website, Ravelry (aka "Facebook for knitters") to thank in part. It's crunchy-ish, but not insanely crunchy, and above all does seem to have a lot of "mothers who think"(well, we are knitters/crocheters, after all). And there are lots of women who nurse past 12 months over there. Call it "peer orientation" or whatever you will, but just being around mothers who nurse for longer really does make it seem less of a freakish thing to do.

The flip side of websites and forums that supported extended nursing is that in general, they can't limit themselves to supporting extended nursing; rather, they tend to foster an atmosphere that pushes it on every woman. Ravelry, thank God, is largely free from overt pressure in this respect... unlike, say, Kellymom or Mothering, where a mother asking for tips on how to get her 12-month-old to accept cow's milk so that she can wean her will get responses ranging from outright criticism to "Could you explain why you are weaning her right now?" In that polite tone of voice that tells you so much more than the words themselves.

There was recently a post on one of the Ravelry groups where the posters were discussing the scientific case for nursing past 12 months. All the usual sources were cited in favor--Kellymom, the World Health Organization, that bloody Gulick study. I kept quiet, as I suspected that my own opinion might not be too popular--my opinion being that in developed countries, the benefits of extended nursing are likely to be extremely small for the child (ironically, there is probably better scientific evidence for extended breastfeeding's benefits for the mother, in the form of a slightly lowered risk of certain cancers).

As for the fact that the WHO recommends breastfeeding to two years or more, I am afraid I really could not care less. The WHO is the World Health Organization, and as such it (reasonably enough) tailors its advice primarily to those most in need of it: poor parts of the world with high infant and child mortality rates. If you are living in a community with no clean water, no pasteurized animal milks, not a lot of nutritious food for toddlers and no birth control for mum, then breastfeeding for years genuinely does raise children's survival rates. If you are living in the developed world, breastfeeding for years is more on the level of taking your child to Mommy and Me classes; it's harmless and a pleasant thing to do if that's your thing. It's not remotely necessary for producing a surviving, thriving child.

However, I am going to shut up now, since Good Enough Mum has discussed all this far more eloquently than I could ever do.

While I'm glad whenever I see the You Must Wean At 12 Months, Because Nursing After Then Suddenly Becomes Icky attitude being questioned, I'm not sure how much of an improvement it is if this just gets replaced with You Must Breastfeed Until Two Otherwise Your Child Is Being Deprived (especially when the claims as to why are so scientifically dodgy). Just a modest proposal, but how about a different idea; the idea of just stopping when you damn well want to... for whatever reason? No plans, no dates or deadlines (in either direction), no pressure. Just you and your child and whatever feels "right" for both of you. The more I think about this idea, the more I like it. Just stepping into the water and letting the current take you, and seeing where you end up. Going with the flow.

So why am I going to keep going for a while? Well, mostly because we both enjoy it and I see no reason to stop. Plus--can I be honest?--it's a convenient lifestyle tool for me, because nursing time is increasingly my internet time! The to-wean-or-not-to-wean question has come up recently in my due date club, and all I can say is that there seems to be a very strong correlation between babies' distractability and mothers' weaning intentions: those of us who were planning to keep going were all saying things like "It's our relaxation time, he blisses out at the breast while I catch up on Facebook," while those who were stopping or planning to stop shared stories about how their babies were so distractible that nursing has become a fight and a bore, and they were taking this is a signal that He's Just Not That Into You any more. An example of "seeing where the current takes you," and a very good one.

By the way, this is another reason why I'm so wary of the increasing pressure found in some quarters to breastfeed until two as a maternal duty. Extended nursers may enthuse loudly about how nursing an older baby or toddler makes parenting a toddler more convenient, but it would be truer perhaps to say "No, nursing your particular child makes life more convenient for you." Increasing pressure on all mothers to breastfeed for two years no matter what will inevitably mean that many women will feel obliged to keep struggling away with nursing even when their particular circumstances or child means that this is not convenient or a tool that makes parenting easier; for example, even if their child is so distractible that the only way to nurse is to shut yourself and baby away in a darkened room, or even if they get pregnant again and are in pain and resenting their child. As if that's not bad enough, there seems to be more and more cases of advice along the lines of "If you [give bottles regularly/spoonfeed solids/nightwean/don't allow access to the breast at all times] your baby is likely to self-wean early" (which then means you are breaking those all-important finger-wagging WHO guidelines). "Nurse to two years no matter what" thus easily becomes a tool for frightening or guilting mothers into practicing certain mothering styles which they may or may not be comfortable with. Not good.

That said, since I am fortunate enough to have a baby who is prepared to ignore my flickering PC screen during milky time, and since we both still enjoy the closeness of nursing, I am going to "go with the flow" and take full advantage of this, and nurse until I feel like stopping.

I even had nursing to thank for getting me through a hellish day last week when my childcare provider cancelled on me on a day when I had several deadlines to meet--somehow the day's work got done, though a mixture of making the most of naptimes and letting Baby Seal hang out at the milk bar as much as possible while I typed with one hand. Oh, and Peppa Pig on DVD, if I'm honest. And letting her pull things out of cupboards and strew them all over the room and destroy the baby gate, as demonstrated above. Such is the life of a freelance worker with a small child. Bring on Year 12-24 Months--I'm ready!