Tag: antenatal

An Exploration of the Aetiology of UK Women’s Perinatal Mental Health Problems.

(Originally written as an assignment for Masters in Public Health/Global Women’s Public Health)

Nature of Problem:

The perinatal[i] mental health (PMH) of women[ii] in the UK is an area of significant concern, needing investment and prioritisation to protect both women and their families’ lives. Poor mental health affects not just mothers: it can affect the child’s physical and emotional health[1], as well as other members of the familial unit[2]. Poor PMH can impact a foetuses’ heart rate[3], cause pre-term birth[4], and cause epigenetic DNA changes[5]. Prevention, detection, and treatment therefore are all crucial to support wider health.

PMH problems[iii] (PMHP) affect up to 20% of perinatal women[6]. This large sample, mixed-method study of perinatal women had responses from women already likely to be thinking about perinatal mental health, however the NHS[7] [8] support these statistics, making over-representation an unlikely influencer. Suicide is the biggest cause of maternal death in the first year post-birth and the second biggest in the first forty-two days post-birth[9]. These statistics have been collated by MBRRACE-UK from NHS reporting, cross-referenced with government resources, and analysed by multiple Expert Reviewers; the methodological rigour underpins the robustness of findings. PMHP cost the UK £8.1 billion per year[10]; economic modelling which includes a robust systematic review and meta-analysis following NICE standards, increasing internal and external validity. Three-quarters of this cost is associated with childhood morbidity[11].

There are regional variances in PMH in the UK. The North East has a referral rate to support services of 35% compared to the East’s 15%[12]: there is a similar regional response rate of respondents comfortable talking about their mental health with a healthcare professional and the report concludes the difference is likely due to (lack of) care received rather than need. The UK is not alone in its concerns over PMH. High Income Countries have a prevalence of PMHP in 7-15%[13] of perinatal women, Low-Middle Income Countries have a higher frequency of 16-25%[14]. These figures are not as recent as the standalone UK percentage so although the UK seems to have a higher rate it is possible that all countries have crept up over recent years. It is also possible that countries without the infrastructure to support large data collection under-report their prevalence.

Impact of Risk Factors:

Gender is a key determinant of good mental health: in England one in five women and one in eight men suffer a mental health disorder, with this number increasing in women over recent years but remaining stable in men[15]. PMH is clearly a factor in this gender disparity; it is possible that if a gender burden were removed in all other aspects of mental health determinants a disparity in prevalence between genders would still exist due to the perinatal period.

Birth trauma is a key trigger of PMHP, affecting around 30%[16] of women who have given birth. Factors influencing development of PMHP following birth trauma include those who have experienced any type of previous life trauma, an intervention-heavy birth, perceived poor care from their healthcare team, and those whose babies are born prematurely or are admitted to neonatal units[17]. Race, ethnicity, age, low socio-economic standing, and lack of empowerment in the birth-room are themselves a risk factor of developing these outcomes[18] [19] [20].  There is a paucity in research regarding prevention of birth trauma – reducing the root cause of an outcome rather than attempting to change the outcome itself may be the necessary action needed. There is also a disparity between both the topics that have been researched and the findings of the research carried out, and the experiences that women and midwives relay. To understand why such a disparity exists, and why preventing birth trauma has not been studied in any great detail needs the context of the UK’s maternity services. Obstetricians are, by their very specialty, more likely to only experience complicated births and have therefore normalised medical births in a way many midwives have not. Obstetricians are also more likely to conduct research, and their medical, male-orientated research is more likely to be funded than research into promoting the physiological norm due to the patriarchal nature of healthcare[21]. The biases of the researcher, therefore, result in research that misses some fundamental areas of lived experience. This is a situation that is changing, however it has become quite a deep-seated divide and the recent media coverage[22] of the newly released Ockenden Report[23] using the phrase “cult of natural birth” shows just how prevalent and entrenched medicalised birth has become. It is also possible that birth trauma figures are even higher as individuals may not count ‘feeling traumatised’ as a specific mental health problem if a diagnosis of PTSD has not been made, and a diagnosis might not be sought when the narrative around birth expects it to be a traumatic event[24].

Ethnicity is another key consideration of PMPH. Minority ethnic groups have a higher prevalence of PMHP while simultaneously being less likely to have them detected or treated[25]. Suffering a higher burden of poor mental health already from other determinants such as poverty, inequity in education and healthcare access, English as a second language, and community and cultural environments factor in these figures, however much current research ignores racism – both institutional and direct – in being a trigger for poor PMH. Since the 2018 MBRRACE report [26] a light has been cast on racial inequities in maternal mortality (including mental health) and grass-roots campaigns like FiveXMore[27] are championing change. Challenging deep-seated inequalities is an ongoing and lengthy process; the uncomfortable dissonance felt by maternity service workers has not fully receded to a point where research can be conducted into this with bias eliminated. It is, perhaps, not the ethnicity of a woman that is the determinant of poor mental health per se, but rather the intersection of a lifetime of socioeconomic factors that are underpinned by structural racial discrimination mixed with a healthy dose of individual ethnically-motivated prejudices. Consideration also need to be given to cultural stigma around mental health, which may exacerbate illnesses[28] [29] and ethnicities such as Travellers who commonly underutilise healthcare[30] meaning true data may be under-represented.

Strong links exist between socioeconomic status and mental health illness[31], a link continuing in the perinatal period[32]:  This study by Ban et al shows women in the most deprived quintile are up to 2.63 times more likely to develop PMHP compared to those in the least deprived quintile. It is, perhaps, unsurprising that women who have existing financial pressures would find them exacerbated by having a new addition to the household and that this increased pressure could trigger a PMHP. Linking in not meeting breastfeeding goals (discussed below) adds an additional financial pressure of circa £10 per week for a can of formula powder – doubly critical that when a woman wants or needs to breastfeed she is supported to do so. The large-scale cross-sectional analysis by Ban et al also correlates age and socioeconomic status: the older a woman is and the more deprivation she is in, the higher her chance of developing PMHP. The large sample size of 116,457 increases validity; although it is possible that those younger, those in higher deprivation or those in some minority ethnic groups are under-represented as they may be less likely to seek intervention.

Society has a role in supporting PMH. New mothers face pressure about how they and their baby should be feeling and behaving from multitudes of sources with many losing self-efficacy, triggering episodes of poor mental health due to a lack of empowerment. The decentralisation of extended families can result in a higher reliance on parenting books whose profit-driven priority is to sell a problem to be fixed by their method; reliance and ‘solutions’ that can trigger poor PMH[33].  How a mother feeds her baby is also a risk factor in triggering a PMHP. While breastfeeding is a protective factor against postnatal depression[34], poor mental health can be triggered if a mother does not meet her breastfeeding goals[35] [36].

The current Covid19 pandemic is limiting access to mental health services. A rapid response study has found that depression has increased by 26% and anxiety by 43% in perinatal women during the pandemic compared to perinatal women before the pandemic. Families feel they do not know where to access information and support[37] and service changes have contributed to suicide deaths[38]. With pandemic stressors on top of the ‘normal’ risk factors for poor PMH there is a big risk of a huge mental health crisis, swamping already underfunded and under-resourced services. Where usually women would have face-to-face appointments that would provide the opportunity to detect issues, these are not always happening (occurring virtually, where women have indicated that they are not comfortable talking about mental health issues over the phone[39]) or at all (where the healthcare team have been redeployed). 

Preventative Strategies:

Current detection of PMH relies on three access-points: pro-active requests for support; positively answering a wellbeing request from their healthcare professional; an existing complex mental health need resulting in a referral to a specialist pathway[40], however these are not without their potential pitfalls, the biggest being the woman being capable of vocalising her need – something which may be hard during a PMHP.  The NHS has prioritised mental health in their Five Year Forward View for Mental Health[41], transforming their Perinatal Mental Health Care Pathway[42] guidance, investing to meet greater need, and greater significance on mental health being placed on all contact points of perinatal women, including the newly contracted six-week postnatal maternal check via GP services[iv][43], although as this started at the peak of the pandemic the service has been oft-overlooked[44] this year.

Detection of PMHP could be improved by services strengthening their links; the NHS is not an homogenous entity and siloed working[45] between services creates gaps that women can slip through[46], especially in an under-resourced, over-worked environment where wellbeing checks become tick box exercises through time constraints, relationships between healthcare professional and service user do not have the opportunity to develop, and referred services have lengthy waiting times if a woman does manage to get that far. Healthcare professionals who interact with perinatal women need to have specific PMH training to help identify issues and be able to confidently manage a PMHP caseload in line with evidence-based pathways.

Prevention is better than cure: optimising preventative strategies is needed to reduce the burden of PMHP. The intersection and correlation of risk factors means that reducing prevalence of PMHP is no small task, starting with reducing long-term health inequalities in at-risk groups: gender, socioeconomic status, race, ethnicity, and LGBT+ status. If a woman is less likely to develop a mental health problem in a wider context it will only help in a perinatal context. However, much is to be done specifically in the perinatal period too. Reducing birth trauma – changing the narrative around how childbirth is ‘horrendous’ so people expect better[47], reducing unnecessary intervention[48], establishing strong relationships through continuity of carer[49], increasing doula use[50], good quality feeding support[51], and supporting new mothers instead of adding pressure to them[52] will all reduce a woman’s chance of developing a PMHP. Indeed, continuity of carer during pregnancy, the intrapartum and postnatal periods is of great benefit not just in preventing birth trauma and detecting mental health problems themselves, but also in detecting other psychosocial factors that can increase a woman’s chance of developing PMHP. Intimate partner violence increasing during pregnancy[53], poor social support, financial pressures and life stresses are all risk factors for developing PMPH[54] [55] and can all be reduced by a woman being cared for by a trusted midwife over the entire period.

The cost of funding sufficient PMH services is £0.28 billion per year compared to an annual cost to the UK of £8.1 billion[56]  – a compelling argument for public health strategic intervention. Key to all prevention strategies is the co-creation of services with experts-through-experience, paying particular attention to the most at-risk cohorts of women giving birth. World-beating PMH services are useless if mothers cannot attend[v]; women’s lived experiences and needs must be listened to. Although the NHS commits to co-production of services in all the guidance documented in this essay, the reality is that services are so fragmented and under resourced that co-production is often lip service at best.

It is inevitable that some PMHP will exist no matter how stringent the prevention and detection measures put in place are. Treatments need to be timely and accessible, and they need to take into consideration the family constraints a new mother has on her, including high-needs inpatient services. If drug treatment is deemed necessary it is important that prescribers consider a woman’s desire to continue breastfeeding and ensure that the prescribed medication is suitable for breastfeeding mothers, otherwise not meeting her breastfeeding goal could trigger poor mental health.

Peer support as well as medical care is a useful intervention in the treatment of PMHP[57]. It can help reduce feelings of isolation, validate feelings, and provide signposting to specialist services. Peer support services tend to be charity or third-sector led, a wary consideration that may lead to reduced public spending on essential services as the gaps are plugged by volunteers. Peer support is also a useful tool in encouraging under-represented groups to seek additional support, helping to validate feelings in demographics where taboos exist about talking about mental health[58].

There is a wealth of data showing facts and figures around PMH: qualitative research is needed – and the importance of findings acknowledged – to prevent and detect PMHP and create services fit for purpose at treating. Only a multi-factorial position that puts women at the heart of the framework will reduce prevalence of PMHP.

Conclusion

PMHP are a changing burden on women in the UK. Women bear the brunt of the burden for obvious gender reasons, and the burden is increasing over time. Birth trauma is increasing, driven by increasing medicalisation of birth, advancing maternal age, and pandemic restrictions[59] [60]. Non-white-British population is increasing[61], and although work is being done to combat health inequities in ethnic minority populations it is yet to be seen whether this will offset an increase in racially motivated prejudice[62]. Women continue to bear the burden of socioeconomic deprivation, a trend not declining[63]. The intersection of all these risk factors seems set to continue to adversely impact the burden of PMH. Existing strategies for prevention need to be strengthened and optimised to reduce prevalence – including society changing to meet its obligation in reducing the burden on women.

REFERENCES

[i] Using the widely used definition being from conception to one year post childbirth unless explicitly stated.

[ii] This report recognises that not all people who give birth are women, however for stylistic purposes ‘women’ has been used throughout.

[iii] ‘Problems’ has been used rather than ‘disorders’ as disorders implies a medical diagnosis which may not be true for all women.

[iv] A check that has been done for years but has not been contracted – therefore GP’s paid for and obliged to complete – until April 2020.

[v] A conversation with a new mother in 2019: a need specialist PMH support was detected, a local service available and had capacity – the mother unable to attend as babies not allowed to attend appointments. Her partner worked and could not take time off without financial impact. Financial strain would have added to the poor mental health situation. No family available to assist and baby was exclusively breastfed anyway.

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[26] Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2018

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[29] Rethink Mental Illness. Black, Asian and Minority Ethnic Mental Health Factsheet. 2020. [https://www.rethink.org/advice-and-information/living-with-mental-illness/wellbeing-physical-health/black-asian-and-minority-ethnic-mental-health/]

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[31] Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic Inequalities in Depression: A Meta-Analysis. American Journal of Epidemiology. 2003;157(2):98–112, doi-org.manchester.idm.oclc.org/10.1093/aje/kwf182

[32] Ban L, Gibson J E, West J,  Fiaschi L, Oates M R, ata L J. British Journal of General Practice. 2012;62(603):e671-e678. doi.org/10.3399/bjgp12X656801

[33] Harries V, Brown A. The association between use of infant parenting books that promote strict routines, and maternal depression, self-efficacy, and parenting confidence, Early Child Development and Care. 2019;189:8, 1339-1350. 10.1080/03004430.2017.1378650

[34] Butler M S, Young S L, Tuthill E L. Perinatal depressive symptoms and breastfeeding behaviors: A systematic literature review and biosocial research agenda. Journal of Affective Disorders. 2020. doi.org/10.1016/j.jad.2020.11.080

[35] Dennis C. L., McQueen, K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics. 2009;123(4), e736-e751.

[36] Brown A, Rance J, Bennett P. Journal of advanced nursing. 2016;1;72(2):273-82.

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[53] Finnbogadóttir H, Dykes A K. Increasing prevalence and incidence of domestic violence during the pregnancy and one and a half year postpartum, as well as risk factors: -a longitudinal cohort study in Southern Sweden. BMC Pregnancy Childbirth. 2016;16,327. doi.org/10.1186/s12884-016-1122-6

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[63] Reis S. DWP data reveals: women and children continue to be worst affected by poverty. Women’s Budget Group. 2019. Available at https://wbg.org.uk/blog/dwp-data-reveals-women-continue-to-be-worst-affected-by-poverty/. Accessed 5 January 2020.

 

 

Discussing the Impact on Pregnant Families in the UK Following Restrictions in Maternity Services Due to Covid-19.

[Initially written and submitted for a postgrad course which goes someway to explaining the dryness, and the full way of explaining the lack of swearing]

The Covid-19 pandemic has impacted most lives. While every sector has suffered detriment and every negative consequence is of course harmful, maternity services[1] is potentially the locus of the most far-reaching consequences, causing stress not just to the affected persons but also harm to the new generation of ‘lockdown babies’ including through transgenerational trauma[i]. This essay will examine the restrictions in place within maternity care, discuss their impact on pregnant families and question why new parents have been so badly let down. As the situation is ongoing and rapidly changing, if insufficient evidence exists from the UK, research from other high-income countries has been used. The essay also highlights the disparity in trust given to different types of evidence; we have countless real-world experiences[ii] [iii] [iv] which run the risk of being dismissed by the scientific community, policy makers and governments for not conforming to the hierarchy of quantitative evidence.

Maternity service restrictions were implemented early in the pandemic, affecting most NHS Trusts with obstetric units.

Area of Service Provision AffectedPercentage of Trusts Implementing Restrictions
Reduction of antenatal appointments70%
Partner restrictions at non-routine antenatal appointments95%
Gestational diabetes screening pathway70%
Partner restrictions at 12-week scan90%
Partner restrictions at 20-week scan88%
Partner restrictions in labour (inc. all labour, early labour, induction of labour)86%
Home birth or midwifery-led unit provision59%
Reduction of postnatal appointments56%
Partner restrictions at postnatal appointments50%
Remote consultation methods89%

                        Table One: Restrictions on access to maternity services March/April 2020[v] [vi]

These figures show the conditions of those who responded (42% and 63% respectively); it’s possible that the on the ground reality was different – for better or worse, although it seems likely that those who did not respond would be those enforcing stricter restrictions, especially taken together with the lived experiences already referred to and elsewhere in this essay. The impact on the amount of and type of care provided during the first wave of the pandemic is evident, and these constraints are continuing (43%) or would be reinstated if cases rise again (24%)[vii]. It is notable that 32% of Trusts did not work with service users to co-produce the implementation of their policies even though there is an obligation on the NHS to involve patients in service production[viii]. That 89% of Trusts use remote consultation methods, and 32% of Trusts do not co-create services runs the risk of ‘losing’ families who do not have access to these mean of communication, either through ownership (those in poverty) or safely (those in coercive relationships).

Data shows most perinatal families in the UK have had restricted service provision, but more important is how they have been affected by them. 38% of pregnant women are concerned about getting reliable, accurate information about their pregnancies without having face-to-face contact with their care providers, 34% believe care at birth was not how they had planned because of the restrictions, and 38% believe that the restrictions impact their ability to cope[ix]. Worryingly, 86% of Trusts experienced a reduction in emergency antenatal care being sought [x]. Data from April to June 2020 shows the stillbirth rate rose from 24 to 40 from the same period in 2019[xi] and although causation is not yet linked to the decrease in care being sought, clinicians do seem to be treating it as such[xii].

Partner exclusion is having a big emotional and physical impact on both parents. Women have better birth outcomes through reducing induction of labour, reducing labour length, decreasing intervention rates, reducing maternal pain, reducing fear, reducing postnatal depression rates and improving birth satisfaction[xiii] when properly supported by their partners; without their presence there is more chance of adverse outcomes occurring. Partner participation in maternity care is so important to health outcomes that the World Health Organisation have reiterated their call for their continuous involvement[xiv]. It is plausible that excluding co-parents from pregnancy and birth will impact their ability to bond with their child and increase paternal postnatal depression[xv] [xvi]. Their being ‘locked out’ of maternity care is not merely a question of a nice-to-have not happening but a health crisis in and of itself.

How babies are fed has also been impacted by the pandemic:

Area of ConcernPercentage of mothers affected
Lockdown helped protect breastfeeding relationship41%
Felt support was lacking27%
No longer exclusively breastfeeding41%
Of the above, felt ready to stop breastfeeding14%
Introduced unwanted formula69%

Table two: impact of maternity restrictions on breastfeeding[xvii]

The lack of infant feeding support is not merely a perception of parents: infant feeding teams have closed their services entirely with staff redeployed from the service; reduced service capacity; changed service provision away from face-to-face; and/or restricted access to those in most need[xviii]. Not breastfeeding has a health impact on the child and on the mother, both physically and mentally[xix] [xx], this reduction in service could have costly long-term health impacts on mother and baby, costing the NHS financially in the long-term[xxi] as well as costing the family to use formula milk: effectively disadvantaging lower-income families to a greater extent and increasing socio-economic disparity.

Unsurprisingly an increase in perinatal anxiety has been observed: women reporting higher levels of depression and anxiety, disassociation, post-traumatic stress and health anxiety for themselves and their unborn child[xxii] [xxiii] [xxiv]. 68% lack confidence that they could find appropriate support for their mental health[xxv] with 14% being reluctant to talk about their mental health over the phone[xxvi]. This is a huge mental health crisis on top of an existing one: suicide is already the biggest cause of maternal death in the first year post- birth, the second biggest in the first forty-two days post- birth and the fifth biggest during pregnancy[xxvii] –the removal and changes to services on top of increased stressors could create a massive mental health crisis in mothers. Indeed, we have already sadly seen the consequences with four women dying by suicide between March and May 2020 whose deaths were wholly attributable to changes in service provision[xxviii]. Maternal stress hormones can affect children as well as mothers, causing low birth weight, earlier gestational age, altered neurobehavioural development, psychopathology, poorer cognitive and socioemotional development and increased neonatal stress hormones in the child[xxix] [xxx].

The pandemic also appears to be widening the gap in care that already vulnerable groups receive, putting babies in those groups at greater long-term disadvantage[xxxi]. Women from Black and Asian backgrounds, and those living in areas or households with poverty are more likely to be infected with and have more serious cases of Covid-19[xxxii]. Clinicians should be considering women in these categories with a lower threshold of risk[xxxiii] and implementing a four-point action plan[xxxiv] to offer additional support to women of these ethnic backgrounds, however in many Trusts this is not happening[xxxv]. Fewer Black and Asian women feel they have the information they need during pregnancy and postnatally than White women, and Black women are less likely to have accessed information and support[xxxvi]. These factors will almost certainly have an adverse impact on families.

It is important communities work together to support maternity services to protect health[xxxvii] yet we saw earlier that 32% of Trusts are not working with their users to create or implement new policies, causing concern that the service is very quickly losing its co-production culture[xxxviii], potentially leading to a long-lasting quietening of women’s voices – ground that has been hard gained[xxxix]. Not listening to or involving those with lived experience of the issues causes unnecessary harm: Liverpool Women’s NHS Foundation Trust wrote and shared information with no involvement from their community. The backlash received ran into thousands of social media comments and an appearance in the press – not helpful to the information they were trying to release[xl] or the anxiety of the women in their care. Is one of the barriers to the consideration given to maternity services, its users, and the importance of the messages they give across one of the gender imbalances within NHS senior teams[xli]?

Keeping people safe from the disease is rightly a priority for the NHS, but what happens when the cure is greater than the disease[xlii]? Separating the familial unit when receiving bad news, through labour and after a child is born is cruel and has a demonstrable impact on the health of all. Despite affecting so many across the UK, the impact of these restrictions barely reached the nation’s consciousness until grassroots campaign #butnotmaternity launched in September, igniting attention from the Daily Mail[xliii]. There has been no government-fronted campaign to ease harm, as there has been with the hospitality industry’s Eat Out to Help Out campaign. It is easy to conclude that ‘women’s issues’ are lower in the food chain than ‘men’s issues’ of drinking in a pub from the coverage given to both in the media[xliv] and at policy-making level – especially when there is no immediate visible economic benefit.

The situation is so new and fast-changing that research must rely on rapid-return forms of evidence; there just has not been time for longer-term research to take place. However, bountiful qualitative evidence exists; to ignore it would be a huge disservice to those lived experiences.

There has been a big impact from the restrictions on pregnant families in the UK, and there continues to be so for many while the pandemic continues. The immediate impact is clear to see, however the longer effects may take years to be realised. Does the lack of women’s voices at a senior level impact the value given to righting this wrong? And we must give thought to low- and middle-income countries where the impact must surely be felt more deeply[xlv]. The consequences could be reduced by finding a way to lift restrictions without compromising safety. With so many already affected, it seems necessary to ensure there will be sufficient healthcare provisions, especially in mental health, to deal with the consequences of these restrictions.

[1] From the initial booking in appointment through antenatal, intrapartum, and postnatal care to 10 days, alongside specialist infant feeding and perinatal mental health support.

[i] Chan JC, Nugent BM, Bale TL. Parental Advisory: Maternal and Paternal Stress Can Impact Offspring Neurodevelopment. Biol Psychiatry. 2018 May 15;83(10):886-894. doi: 10.1016/j.biopsych.2017.10.005. Epub 2017. PMID: 29198470; PMCID: PMC5899063

[ii] Johnson, S. ‘There are more births in the car park’: a midwife’s experience of the Covid-19 crisis. [Online]. Available from: https://www.theguardian.com/society/2020/jun/04/more-births-car-park-midwifes-experience-covid-19-crisis [Accessed 2 November 2020]

[iii] Shuttleworth, P. Covid-19: ‘How lockdown stopped me from breastfeeding’. [Online]. Available from: https://www.bbc.co.uk/news/uk-wales-54369912 [Accessed 2 November 2020]

[iv] https://www.facebook.com/informedchoicematters

[v] Jardine, J, Relph, S, Magee, L A, von Dadelszen, P, Morris, E, Ross‐Davie, M, Draycott, T, & Khalil, A. Maternity services in the UK during the COVID‐19 pandemic: a national survey of modifications to standard care. BJOG: An International Journal of Obstetrics & Gynaecology, 1471-0528.16547. https://doi.org/10.1111/1471-0528.16547. 2020

[vi] Iacobucci, G. Partners’ access to scans and birth is a postcode lottery, data show. BMJ (Clinical Research Ed.), 371, m3876. Available from: https://doi.org/10.1136/bmj.m3876. 2020

[vii] Iacobucci, G. Partners’ access to scans and birth is a postcode lottery, data show. BMJ (Clinical Research Ed.), 371, m3876. Available from: https://doi.org/10.1136/bmj.m3876. 2020

[viii] NHS England. Personalised Care. [Online]. Available from: https://www.england.nhs.uk/personalisedcare/ [Accessed 5 November 2020]

[ix] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[x] Jardine, J, Relph, S, Magee, L A, von Dadelszen, P, Morris, E, Ross‐Davie, M, Draycott, T, & Khalil, A. Maternity services in the UK during the COVID‐19 pandemic: a national survey of modifications to standard care. BJOG: An International Journal of Obstetrics & Gynaecology, 1471-0528.16547. https://doi.org/10.1111/1471-0528.16547. 2020

[xi] BBC. Stillbirths rise during pandemic leads to safety review. [Online]. Available from: https://www.bbc.co.uk/news/health-54779857 [Accessed 2 November 2020]

[xii] NHS England. www.twitter.com. [Online]. Available from: https://twitter.com/NHSEngland/status/1323218707741614080?s=20 [Accessed 5 November 2020]

[xiii] Walsh, S. Re: Care during covid-19 must be humane and person centred – Partner attendance at maternity services. [Online]. Available from: https://www-bmj-com.manchester.idm.oclc.org/content/370/bmj.m3483/rr-1 [Accessed 3 November 2020]

[xiv] World Health Organization. Companion of choice during labour and childbirth for improved quality of care: evidence-to-action brief. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/companion-during-labour-childbirth/en. 2020

[xv] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xvi] Singley, D B, & Edwards, L M. Men’s perinatal mental health in the transition to fatherhood. Professional Psychology: Research and Practice. Available from: https://doi.org/10.1037/pro0000032. 2015

[xvii] Brown, A, Shenker, N. (2020). Experiences of breastfeeding during COVID‐19: Lessons for future practical and emotional support. Maternal & Child Nutrition. Available from: https://doi.org/10.1111/mcn.13088

[xviii] [redacted]

[xix] Victora, C G, Bahl, R, Barros, A J D, França, G V A, Horton, S, Krasevec, J, Murch, S, Sankar, M J, Walker, N, Rollins, N C, Allen, K, Dharmage, S, Lodge, C, Peres, K G, Bhandari, N, Chowdhury, R, Sinha, B, Taneja, S, Giugliani, E, Richter, L. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475–490. https://doi.org/10.1016/S0140-6736(15)01024-7. 2016

[xx] Brown, A. What do women lose if they are prevented from meeting their breastfeeding goals? Clinical Lactation, 9(4), 200–207. https://doi-org.manchester.idm.oclc.org/10.1891/2158-0782.9.4.200. 2018

[xxi] NHS. [Online]. Available from: https://www.nhs.uk/news/pregnancy-and-child/more-breastfeeding-would-save-nhs-millions/#:~:text=Overall%2C%20if%20the%20proportion%20of,the%20three%20reduced%20infant%20infections. [Accessed 6 November 2020]

[xxii] Berthelot N, Lemieux, R, Garon-Bissonnette, J, Drouin-Maziade, C, Martel, É, Maziade, M. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstetricia et Gynecologica Scandinavica, 99(7), 848–855. https://doi.org/10.1111/aogs.13925. 2020

[xxiii] Corbett, G. A, Milne, S J, Hehir, M P, Lindow, W, & O’connell, M P. Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic. European Journal of Obstetrics and Gynecology and Reproductive Biology (Vol. 249, pp. 96–97). Elsevier Ireland Ltd. https://doi.org/10.1016/j.ejogrb.2020.04.022. 2020

[xxiv] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxv] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxvi] Karavadra, B, Stockl, A, Prosser-Snelling, E, Simpson, P, & Morris, E. Women’s perceptions of COVID-19 and their healthcare experiences: A qualitative thematic analysis of a national survey of pregnant women in the United Kingdom. BMC Pregnancy and Childbirth, 20(1). https://doi.org/10.1186/s12884-020-03283-2. 2020

[xxvii] Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford. 2019

29 Knight, M, Bunch, K, Cairns, A, Cantwell, R, Cox, P, Kenyon, S, Kotnis, R, Lucas, N, Lucas, S, Marshall, L, Nelson-Piercy, C, Page, L, Rodger, A, Shakespeare, J, Tuffnell, D, & Kurinczuk, J. Saving Lives, Improving Mothers’ Care Rapid report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK Maternal, Newborn and Infant Clinical Outcome Review Programme. Available from: www.hqip.org.uk/national-programmes. 2020

[xxix] Su Q, Zhang H, Zhang Y, Zhang H, Ding D, Zeng J, Zhu Z, Li H. Maternal Stress in Gestation: Birth Outcomes and Stress-Related Hormone Response of the Neonates. Pediatr Neonatol. 2015 Dec;56(6):376-81. doi: 10.1016/j.pedneo.2015.02.002. Epub 2015 Apr 20. PMID: 26363772

[xxx] Berthelot N, Lemieux, R, Garon-Bissonnette, J, Drouin-Maziade, C, Martel, É, Maziade, M. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstetricia et Gynecologica Scandinavica, 99(7), 848–855. https://doi.org/10.1111/aogs.13925. 2020

[xxxi] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxxii] Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study BMJ 2020; 369 :m. 2107

[xxxiii] The Royal College of Midwives, Royal College of Obstetricians & Gynaecologists. Information for healthcare professionals Coronavirus (COVID-19) Infection in Pregnancy. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/2020-10-14-coronavirus-covid-19-infection-in-pregnancy-v12.pdf. 2020

[xxxiv] Dunkley-Bent, J. NHS England. [Online]. Available from: https://www.england.nhs.uk/2020/06/nhs-boosts-support-for-pregnant-black-and-ethnic-minority-women. [Accessed 6 November 2020]

[xxxv] Multiple authors. 2020. Personal Conversations from [redacted] [Accessed 6 November 2020]

[xxxvi] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxxvii] Osanan, G C, Vidarte, M F E, & Ludmir, J (2020). Do not forget our pregnant women during the COVID-19 pandemic. In Women and Health (Vol. 60, Issue 9, pp. 959–962). Routledge. https://doi.org/10.1080/03630242.2020.1789264. 2020

[xxxviii] Coulter, A, & Richards, T. Care during covid-19 must be humane and person centred. In The BMJ (Vol. 370). BMJ Publishing Group. https://doi.org/10.1136/bmj.m3483. 2020

[xxxix] Temmerman, M, Khosla, R, Laski, L, Mathews, Z, & Say, L. Women’s health priorities and interventions. BMJ (Clinical Research Ed.), 351, h4147. https://doi.org/10.1136/bmj.h4147. 2015

[xl] Jaleel, G. Liverpool Echo. [Online]. Available from: https://www.liverpoolecho.co.uk/whats-on/family-kids-news/mums-dreading-giving-birth-liverpool-19050290 [Accessed 6 November 2020]

[xli] Sealy, R. Action for Equality: The time is now. University of Exeter Business School. Available from: https://www.nhsconfed.org/resources/2020/09/action-for-equality-the-time-is-now. 2020

[xlii] Kapila, M. Trading-off human rights with public health in the name of COVID-19. Flesh & Blood: The Blog of Mukesh Kapila. Weblog. [Online] Available from: https://mukeshkapilablog.org/2020/09/25/trading-off-human-rights-with-public-health-in-the-name-of-covid-19/ [Accessed 2 November 2020]

[xliii] Mikhailova, A. Daily Mail. [Online]. Available from: https://www.dailymail.co.uk/news/article-8726417/Covid-rules-forcing-thousands-mothers-endure-labour-without-loved-ones-side.html [Accessed 6 November 2020]

[xliv] Kassova, L. The Missing Perspectives of Women in COVID-19 News A special report on women’s under-representation in news media. Available from: https://www.iwmf.org/women-in-covid19-news. 2020

[xlv] Kimani RW, Maina R, Shumba C, Shaibu S. Maternal and newborn care during the COVID-19 pandemic in Kenya: re-contextualising the community midwifery model. Hum Resour Health. 2020 Oct 7;18(1):75. doi: 10.1186/s12960-020-00518-3. PMID: 33028347; PMCID: PMC7539267. 2020

Vitamin K & The Newborn

V I T A M I N  K  A N D  T H E  N E W B O R N

Babies are born with proportionally low vitamin K. We don’t know why yet, although there’s a few theories that it could be due to babies being born without all their systems fully functioning, or some kind of residual consequence of some other mother-baby mechanism. As mothers need to be intaking high doses of vitamin K for it to pass through breastmilk in sufficient quantities to protect their baby it seems unlikely to be an evolutionary response although my anthropological days were left behind at uni so, I may well be wrong.

Vitamin K helps blood to clot and prevent uncontrolled bleeding. Due to low vitamin K in babies, they’re at risk of something called ‘Vitamin K Deficiency Bleeding’ or VKDB. Some of these at risk babies have known risk factor but about a third don’t. This includes what type of birth the baby experienced, as it had been mooted at one point that assisted deliveries and caesareans increased the risk.

We started giving babies vitamin K after a Swedish study in 1944 was released which showed a 5 times reduction in newborn deaths of 2-8 day old babies due to uncontrolled bleeding. Manufacturing and commerciality interests pushed the dose given higher which triggered their own problems in the baby, so the dose was reduced back down and remains at 1mg although this is still twice as much as was given in the original study. At this time it was only being given to babies with suspected risk factors of bleeding, however in 1978 a study was released which discovered that late onset VKDB was a problem for exclusively breastfed babies and very quickly it became policy to universally offer to administer vitamin K. A small study did indicate that parents who refused to give their babies a vitamin K dose could raise the levels of vitamin K sufficiently to pass through breastmilk at protective quantities by the mother taking a supplement of at least 5mg daily.

Vitamin K is usually given via one injection within 24 hours of birth, although parents have the option to have oral doses given instead. If given orally this is done over the course of 3 doses, 2 of which are normally given to the parents to give at home. Side effects of the injection are a potential allergic reaction to the ingredients, or a small reaction at the site of the injection, plus of course a small amount of pain when carrying out the injection itself. The oral dose isn’t quite as effective at minimising the risk of VKDB and there’s the potential for further doses to be forgotten to be given in the sometimes chaotic environment of a newborn household.

One of the concerns some parents have about vitamin K doses is that a 1992 study was released that indicated an increased risk of cancer in children. Helpfully most UK health authorities and authoritative bodies made no official statements to help families make their decisions but instead fence-sat and passed the buck spectacularly to parents. Further studies showed that the risk of tumours remained the same whether children received vitamin K or not, however remained unclear about the increased risk of developing leukaemia. However, the most recent studies and reviews have concluded categorically that there are no links between vitamin K and an increase of cancer of any types.

So what are the actual statistical risks we’re looking at? The most recent studies show the numbers as follows:

  • Untreated babies risk of developing VKDB: 4.4-10.5 per 100,000
  • Oral treatment: 1.4-6.4 per 100,000
  • Intramuscular treatment: 0-0.62 per 100,000

Although small risks anyway, by choosing vitamin K to be given by injection the risks are all but eliminated.

If you choose to decline vitamin K there are things that you should watch out for in your baby. These are:

  • Active bleeding from the nose, mouth, gums, umbilical stump or any treatment site (heel prick test for example)
  • Blood present in urine, faeces, or vomit
  • Unexplained bruising or bigger than expected bruising (at a vaccination site for example)
  • – The fontanelle (soft spot of the head) appearing different to normal (which could indicate bleeding on the brain)
  • If baby starts acting differently; although this is a particularly difficult one as baby’s not been around long enough to have a ‘norm’.

As an aside, some trusts will refuse to divide a tongue tie if your baby hasn’t received vitamin K, so something to bear in mind.

As ever, this is my interpretation of what I’ve read and understood, and so any mistakes are my own only. My resources for this topic are below.

NICE Guidelines

Evidence Based Birth

Article with paediatrician E Hey in BMJ

National Homebirth Day

HOMEBIRTH SAFETY

The biggest question for most people when thinking about home birth is ‘is it safe’?

Generally birth is safe in this country, especially if you’re low-risk in pregnancy.

Up until now home birth was considered a safe option for low-risk pregnancies but with a statistically significant increase in risk for first time mothers. However, a very recent study, published in August 2019 by McMaster examines the risk of death either at birth or within the first 4 weeks after birth and has found no statistically significant difference between hospital or home. The study looked at over 500,000 intended home births to come to the conclusion.

Transfer rates for first-time mothers from home are around 45% which is a significant number, *however* the transfer rate from an along-side maternity unit (like the one at Stepping Hill) is 40% so really, the numbers are quite similar when looking at the right comparator. It’s worth mentioning that, again, we’re likely looking at a significant number of women who haven’t prepared for birth and perhaps might not understand the physiological changes the body goes through while giving birth which can affect the way a person births.

Transfer rates for women who already have a baby are much lower at 12%, which again is a similar figure to those from an AMU.

While producing very similar statistics for the most serious outcomes, birthing at home significantly reduces the need for an emergency caesarean, forceps or ventouse delivery, episiotomy or epidural – all of which have their own risk factors and health consequences.

ADVANTAGES OF BEING AT HOME

Apart from the different ways that being at home can affect the health and wellbeing of you and your baby there are other significant advantages to giving birth at home.

Your own space: Being in your own space is immeasurably beneficial. You’re not confined to one room or area of the hospital, you have everything you own on hand in case you need it (without dragging 3 suitcases to hospital with you in labour), you feel safe and secure which aids the labour process, you can dress the birthing area however you want to (laminated affirmations a-go-go!). There’s also a fundamental difference in attitude as well. When you walk over the threshold of the hospital you take on the role of patient, no matter how person-centred the unit tries to be. Your attitude changes as subconsciously you hand over some of the responsibility of your labour – and for some people that’s exactly what they need but for most people your subconscious needs to fully own that autocratic decision-making. When you welcome midwives into your home they’re on your turf not you on theirs, and it makes a difference.

You labour where you birth: It’s so common for contractions to drop off a bit during that journey to hospital and the settling in session when you get there. It’s no wonder, because your oxytocin vibe is disrupted. Without that journey you can stay inside your birth bubble doing your wondrous labouring. And there’s no need to worry about petrol in the car, change for the car park or accidentally giving birth on the A6!

You’re not in hospital: Well duh. But actually it’s a really huge one, this! Tokophobia is rising, birth anxiety is rising, birth trauma is rising as well as the non-birth related fear of hospitals and doctors that some people have. For some people being in a hospital is triggering, and removing the medical element can reduce anxiety levels which helps people give birth.

Childcare is sorted: Now some families won’t want to have their children at home while they give birth regardless, but for others it solves a childcare issue or means that the whole family is around ready to welcome its new member to the household.

Your own bed: I cannot emphasise enough just how amazing this is after giving birth. Your own shower. Your own toilet. Your own bed. With only the people you choose to be there; no noisy ward neighbours, midwives or babies (apart from your own). Literally worth a million pounds.

WHAT DO I NEED AT A HOMEBIRTH?

Really you need very little. A pregnant body and that’s about it. Realistically you’ll probably want to plan to have a little bit more than that!

  • Something to cover the floor, whether that’s old towels, cheap shower curtains or tarps
  • Something comfortable for the floor; old bedding or towels
  • Something easy to slip on and off if you get cold and hot, like a dressing gown
  • Something to keep baby warm, like a towel or blanket to go over you both
  • A birth pool if you want a water birth (and if you do, get a sieve)
  • A head lamp or torch (although there’s some controversy over this one! The idea is that the midwife may need extra lighting to check you over afterwards but in reality I know some midwives who have never needed a miner’s lamp to do post-birth checks so…)
  • Bin bags to clear up after.

The midwifery team will either bring a homebirth kit prior to you going into labour, or on the day itself, with everything they need.

And that’s pretty much it! Everything else you’ll have handy anyway, like food and drink, music, hypnobirthing tracks, more food… 

WHAT ABOUT THE MESS?

Genuinely one of the most frequent questions I get about home birth is about the mess.

IT’S FINE!

Honestly. What comes out is mostly contained to one area or the pool (the previously mentioned sieve serves its purpose here!) and because you’ve protected the area it can all be wrapped up and binned or washed.

By the time your own post-birth checks have been done and you’ve had a shower, got into clean PJs and into bed your house is back to its normal state. The only evidence that a birth has happened recently is that tiny mewling little human in your arms.

LOCAL HOMEBIRTH RESOURCES

There are regular home birth meetings across Greater Manchester run by Greater Manchester Homebirth​

To find out about their upcoming planned events follow this link.

They also run the Manchester Community Birth Pool Hire Scheme​ and the Cheshire Community Birth Pool Hire Scheme, as well as the group Greater Manchester Homebirth Support Group. You can find all of them on Facebook.

Edit: This blog post was updated followed the publication of the McMaster study August 2019

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Advanced Maternal Age and Stillbirth

This is an interesting subject to write about because nobody likes to think that they’ve crossed over into the advancing age category. Remember before we start you’re only as old as you feel (which in my case sees me hitting oldest ever living person age, especially as we’re halfway through a rainy half term!)

I’m talking here specifically about maternal age and stillbirth, but there areother things to be thinking about it you’re older than 35, including genetic risks and miscarriage. It’s also really, really, really, really, really important that when you read this or any discussion of risks, you remember that these are stats made up (usually) from studies looking at one thing. Your own individual circumstances and risk factors have a big impact, as does your own personality, values and experience to date.

One of the largest reviews of evidence happened in 2008 where Huang et al took 31 studies and largely found that there was a consistent risk of stillbirth in an older mother of 1.2-2.23 times higher than in younger mothers. There are, however, concerns that have been raised with the results including:

  • What age they used as their cut off date between younger and older (some used 35, some 40)
  • Categorising risk in binary ‘older’ or ‘younger’ categories, which failed to show slowly increasing risk making it look instead like a substantial jump at a particular age
  • Definitions of stillbirth
  • The age of the study, as medical care has changed considerably over recent years.

So this seems to be a case of yes there is an increased risk but…

In 2000, Jolly et al released the following figures as a result of their study:

  • Women aged 18-34 had a stillbirth rate of 4.7/1000
  • Women aged 35-40 had a stillbirth rate of 6.1/1000
  • Women aged 40+ had a stillbirth rate of 8.1/1000

In 2006, Reddy et al looked at whether the increased risks were for all women over a certain age, or if it was first time mothers. They found the risks were (all out of 1000):

  • Women under 35: 3.72 (first time mothers) /  29 (given birth before)
  • Women between 35-39: 6.41 (first time mothers) /  99 (given birth before)
  • Women aged 40+: 8.65 (first time mothers) /  29 (given birth before)

They also found that if a woman was healthy her chances of stillbirth reduced but were still higher than her comparator of a younger person.

Now, the reason I’m writing this now is because one of my clients has had a conversation with her consultant about being induced on or soon after her EDD due to her age.

Reddy et al found that there is a difference in the age of the mother, length of gestation and risk of stillbirth. But, perhaps, not one that is quite so clear cut a trajectory as you’d imagine. Their research showed that:

  • The largest spike in number of stillbirths in all age groups was between 38-39 weeks pregnant, while the lowest was between 32-33 weeks
  • For those aged under 39 the number of stillbirths decreased from week 40-41
  • For those aged 40+ the number of stillbirths continued to rise (to 2.48)

Evidenced Based Birth found that induction rates are around 20-24% regardless of maternal age (although bear in mind that current UK induction rates are around 30-40% nationally) however caesarean rates rose from 29.5% (aged 25-29), 33% (30-34), 45.5% (40-44) to 57.1% (45+) Again, this is US data from 2014 so a slightly different climate to the UK today, where midwifery-led care can bring its own benefits and good birth outcomes.

A small UK study by Walker in 2016 looked at whether there was a rise in caesarean rates in older women who had been induced. The study found no difference in caesarean rates between induced and not-induced groups but caesareans increased with maternal age. Interestingly complication rates were similar across groups so it seems as though the caesareans happened because of maternal age rather than maternal age influencing complications which led to caesareans. All other comparators were very similar too including maternal satisfaction, birth weight and baby’s health. There’s another but coming though and that’s because the study was a really small sample and although showed some interesting things there just aren’t the numbers to get good quality evidence from.

One of the thought-to-be causes of stillbirth in women over 40 is hypoxia, which is not enough oxygen for baby (Pasupathy et al). However, one of the risks of induction of labour from an artificial oxytocin drip is hypoxia. Sara Wickham calls this a birthillogic. Induction of labour and caesareans all have their own risks associated with them so we need to loop back to the very start of these 1000 words (this was meant to be a whatsapp message to quickly answer a question, by the way. Succinct is and never has been my strong suit!) where I said this has GOT to be YOUR decision and to be able to make YOUR decision you need transparency of information. Being told your risk increases because of your age may well be true, but you can’t make a decision without understand what the risk is, how it applies to your own situation, and what the risks of action you may agree to are.

Most of the data I’ve looked at has come from Evidence Based Birth and any misinterpretations of the data are mine. I would encourage you to read the original as there’s loads more information there than I’ve written in this post. I’d also suggest reading Sara Wickham’s article about this, and also the RCOG guidelines for Induction of Labour At Term In Older Mothers.

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