Tag: postnatal

A strategic plan integrating community development concepts for the trans and non-binary childbearing population in perinatal services.

[Originally submitted as an assignment for MPH @ University of Manchester]

Community and Public Health Issue

The community in focus is the England’s transgender male and non-binary[1] childbearing community. Trans people are individuals whose gender identity falls outside the stereotypical gender norms of their biological sex. No definitive figures exist for how big the trans community is due to lack of research, fear of reprisals, no standardisation in definitions, and outdated data systems lacking recording capability[i] [ii] [iii] [iv] [v]. An approximation suggests around 600,000[vi] trans people live in the UK. We can assume the number of trans people is likely rising due to the increase in referrals to gender dysphoria clinics[vii]. Therefore, the trans childbearing community is likely rising too – although subject to the same recording and accuracy issues as the wider trans community – meaning providing gender-inclusive perinatal care is becoming more of a pressing concern for service providers.

Trans individuals are likely to have had previous negative experiences within healthcare settings and suffer from healthcare professionals (HCPs) not understanding their specific needs adequately[viii]. The trans childbearing community are trying to access services created for heterosexual ciswomen[2][ix] so information, clinical space and HCPs are usually heavily gendered, making it more difficult to access services from outside that binary. If trans people are unwilling or unable to adequately access perinatal services their and their baby’s health is risked. A public health central tenet is to prevent disease and improve health by offering services accessible to all; therefore ensuring gender-inclusive perinatal services is a public health issue.

Theory of Change

Problem:

Perinatal care is essential for the perinatal dyad; without it there are increased risks of adult and child morbidity and other serious adverse outcomes[x]. Trans people are at increased risk of not accessing healthcare services due to real or perceived stigma, discrimination and bias from HCPs, lack of cultural competency, systemic barriers such as inadequate IT systems and sociocultural barriers such as increased mental health challenges[xi] [xii] [xiii]. This is particularly an issue in perinatal healthcare where services are largely created by and for ciswomen, adding an additional cis-centric dynamic to accessing care, and where it is possible any experienced gender dysphoria can worsen.

Long-Term Goal:

Strategic aims of this health plan are to:

  • Reduce the real/perceived stigma faced by trans childbearing people that stops them accessing perinatal care
  • Improve the experience of the trans childbearing community accessing perinatal care
  • Improve the health of trans childbearing individuals and their infants through the perinatal period.

These goals will be met when all trans childbearing people who want to access perinatal care do so, and in doing so no harm is caused emotionally or physically to the dyad.

Key Audience:

Stakeholders involved in this strategic plan will be trans childbearing individuals, perinatal care workers (including midwives, obstetricians, infant feeding workers, health visitors), and other HCPs e.g. endocrinologists, together with representation from Clinical Commissioning Groups and the VCSE sector.

Backwards Map from Goal:

Examination of the preceding stages from the long-term goals necessitate a collaborative approach from all identified stakeholders so all necessary changes before the goal can be met are considered.

To reduce overall stigma and improve the experiences of trans individuals accessing perinatal care there needs to be:

  • Reduction of internalised stigma
  • Reduction of healthcare stigma from individual practitioners
  • Reduction of structural stigma

Which needs:

  • Motivation to change from the institution and HCPs within it
  • Belief from trans childbearing individuals that cultural change can occur

Which leads to accessibility of perinatal services for trans people through:

  • Improved understanding of the challenges faced by the trans childbearing community leading to an increase in desire to help overcome these challenges
  • Equipping HCPs with the skills and competencies needed to support the trans childbearing community
  • Cultural changes in the behaviour of HCPs which leads to a visible awareness for the trans childbearing community
  • Improvement in the existing structural systems
  • Motivation of individuals to access a changing system for health gain

No change is independent of any other or relates only to one long-term outcome; they are symbiotic in nature therefore it is unrealistic to assume that a singular change will lead to a singular outcome. Coproduction is a vital part of the plan to ensure that the assumptions and underlying logic of approaches are valid and fit for all stakeholders, but particularly the service users.

Strategies and Interventions:

There is a paucity of research about trans childbearing experiences of pregnancy care in England; what little exists are small-scale qualitative studies, often undervalued in the medical world[xiv]. This failing of research existence results in organisations having little solid evidence to base the redesign of services on[xv].

A key principle underpinning all strategies is that they will be developed through true coproduction with relevant stakeholders including service users, to ensure they best fit the needs of the community (while recognising that the trans childbearing community has not one homogenous voice).

Strategies which have been published can be broadly grouped within the following themes.

                Culturally Competent Training

HCPs often lack understanding and awareness of the trans childbearing community and the specific problems they face when accessing highly gendered healthcare services. To help alleviate this, cultural competence education including use of appropriate language should be given to staff[xvi]. Cultural competency can help staff interact with people they care for in a way that does not cause mental harm; for example, using correct pronouns, not deadnaming[3], misgendering or conflating gender identity with sexual orientation[xvii]. Fit-for-purpose cultural competency training can ensure HCPs provide appropriate medical care rather than subjecting trans individuals to superfluous and sometimes voyeuristic practices[xviii], or giving incorrect medical information[xix].

Cultural competency training would be included in this strategic plan to help meet the long-term goals. Training would be offered firstly to all core perinatal HCPs and then rolled out to affiliate HCPs. The training would impact on:

  • improving understanding of challenges faced by the trans childbearing community by HCPs
  • increasing HCPs’ skills and competencies to deal with diverse challenges
  • increasing vocalness and visibility of trans rights and needs in pregnancy making perinatal care more accessible for the trans childbearing community
  • reducing healthcare stigma, discrimination, and bias
  • improving the experience of trans individuals accessing perinatal care
  • improving the health of the trans childbearing community.

Limitations recognised by the strategic plan of this intervention are that:

  • the trans childbearing community are not a homogenous group therefore their needs may be disparate; poorly designed training courses may give HCPs the impression that a one-size-fits-all approach is possible
  • this specific type of education is relatively new; no research exists to evidence its efficacy other than anecdotal feedback. However, it is likely that it will have the same level of positive impact on patient outcomes as other types of cultural competency training[xx].

Assumptions made regarding training as a strategy to meet the long-term goal of this strategic plan are that:

  • HCPs are not transphobic and any failings in service provision come from lack of understanding which can be overcome
  • HCPs are motivated to better their awareness and understanding of the challenges faced by the trans childbearing community
  • HCPs have the time to do additional training outside their caseloads
  • the interpersonal skills needed to enable HCPs to provide care to trans people are teachable
  • there is a supportive space for HCPs to learn in and competent experts to provide the training.

Although there may be logistical challenges in staff finding time for training these are not insurmountable, and it is likely an organisation considering such training will be supportive of people in that learning sphere. It is probably best to assume the good intentions of all workers to be motivated to do better unless proven otherwise[xxi] – which can be dealt with under an organisation’s disciplinary policy.

Individualised Care

The trans childbearing community are not a homogenous group and cannot be treated as such, needing a heterogeneric approach to care to match their diverse experiences. Personalised care is an integral to the NHS’ Long-Term Plan[xxii] and should be prioritised for the trans childbearing community through proportionate universalism.

One individualised approach needed is regarding language used. Some trans individuals have a definite preference for their gender identity, some are comfortable with a variety of terms (e.g. male, female-to-male, transman, assigned-female-at-birth)[xxiii]. Alongside this is pronoun choice; trans people have a more positive healthcare experience – and therefore less exposure to mental harm – when correct pronouns are used[xxiv]. There is also the degree of ‘outness’ both in terms of gender identity and pregnancy to consider: for some, being seen as male but not pregnant is critical to good health, for others being out as male and pregnant is important, for others passing as a cisgender woman while pregnant is how they feel safest[xxv]. Birth tends to be pathologised in England[xxvi] and it is possible that being trans in itself may put individuals onto a high-risk pathway even if there is no medical indication, increasing intervention rates with the potential of increasing physiological and mental harm[xxvii].

Specific interventions within this strategic theme to be implemented are:

  • ensure individualised care through thoughtful conversations between pregnant person and culturally competent HCPs
  • reduce the need for the “trans story” to be repeated (thereby causing mental trauma) by having continuity of carer, a strategy which itself improves perinatal outcomes for parent and child[xxviii]
  • have language needs clearly identified “at a glance” on notes so professional contact remains consistent and accurate[xxix]
  • not place on an obstetric pathway for trans status alone[xxx].

The impact on the strategic plan’s long-term goals is to:

  • reduce stigma for the individual by building a close, personable relationship with a small team of carers
  • increase the belief that ‘the system’ can meet the needs of a subjugated community, therefore making it more likely individuals within the trans childbearing community will seek future healthcare
  • improve individuals experience within the perinatal system, reducing mental distress
  • improve the health of the perinatal dyad by ensuring accessibility to fit-for-purpose services and staff.

The limitations of these interventions within this strategic plan may be that:

  • self-identity is complex and may change as a pregnancy progresses, and may need more time, patience, and experience than an HCP has to give
  • the maternity system is not resourced adequately to staff a pathway that requires more time; although continuity of carer pathways should be implemented for “most” birthing people by 2021[xxxi] there are already severe shortages in midwifery[xxxii] that means this is not happening[xxxiii].

Assumptions made with these strategic interventions are that:

  • it matters to trans childbearing people how they are identified by others
  • maternity services are resourced adequately to provide continuity of care and properly individualised care – not just lip-service.

These assumptions can be overcome by conducting transparent and open conversations with each individual. Resourcing is not so easy to challenge however the financial benefits of keeping parent-and-child healthy in the perinatal period can be used as a basis for a proposal for extra resources.  

Systematic Change

The system within which perinatal services exist also needs change to meet the trans childbearing community’s need. There is institutional erasure of trans pregnant people: only one trans-inclusive maternity policy exists in England[xxxiv], IT systems do not have capacity to accurately record gender[xxxv] [xxxvi], physical space is aimed almost exclusively at women[xxxvii], and educational literature features predominantly heterosexual ciswomen.

Interventions which may positively impact on this area and will be included in the strategic plan are:

  • creation of perinatal guidance and policies which are gender-inclusive
  • redevelopment of physical space and literature to ensure representation
  • upgrading of IT systems so perinatal gender options are representative.

The interventions would:

  • improve the environment in which trans childbearing people access perinatal services, making services more accessible
  • make it easier to accurately record a true gender identity, helping increase visibility and break down stigma, both individual and structural.

The limitations of these interventions are that:

  • it may be costly to implement wide-scale change on infrastructure that is nationally devolved
  • systematic change takes time
  • there is likely to be resistance from people who lack education around the trans community[xxxviii].

Assumptions made regarding the implementation of this strategy are that:

  • there are resources to implement wide-scale change
  • there is appetite to do so on a wide-scale; national change needs a top-down approach and if the most senior leaders do not understand the importance of change it cannot happen at the scale it needs to.

Mental Health Focus

Poor mental health is a common theme for trans people navigating healthcare systems, especially perinatal services, therefore it is imperative that action is taken to improve the trans childbearing community’s mental health status.

Gender and genitalia dysphoria before pregnancy, antenatally, intrapartum, postpartum, and longer-term postnatally including infant feeding choices is a big concern for trans childbearing people, and a situation that can shift and worsen significantly as a person passes through these experiences[xxxix] [xl]. It is essential that culturally competent carers understand the impact of dysphoria during the perinatal period and that there is access to culturally sensitive specialist counselling[xli], interventions which are included in this strategic health plan. Alongside professional support is the value of peer support: feelings of isolation cause great distress for trans childbearing people[xlii] and appropriate, specific peer support can be invaluable – HCPs need to be able to signpost this support effectively[xliii].

These interventions would help:

  • reduce internalised stigma through visibility, reducing isolation and improving access to health education in an informal setting
  • improve mental health leading to greater accessing of healthcare and reducing poor physical outcomes.

The assumptions underlying these interventions are that:

  • trans people will want to access perinatal services if mental health is nurtured
  • specific peer support is accessible.

Mitigating these assumptions may take time and resources to increase knowledge and earn trust, and there may be a chicken-and-egg scenario of trans childbearing people peer support not being ‘lumped in’ with generic LGBT support groups – there needs to be volume to necessitate support but without such support the true volume of need may not be known.

Responsibilities:

Providing the space (physical and mental) and resources for the interventions listed to be adequately provided are the responsibility of the HCPs responsible for this strategic plan. The community will decide whether this is enough for them to overturn previous negative experiences and engage with perinatal services, however it is noted that it takes time for underserved communities to develop trust and engagement with a service that has historically overlooked them. There must be an element of goodwill belief from the trans childbearing community that things can change; while this will be true of some there will be others who make a choice never to engage.

Outcome Measures:

Strategic interventions will be measured and evaluated through a framework of user experience data-collection tools. Baseline data prior to the implementation of intervention will be needed so outcome metrics can be tracked against implementation.

  • Friends and Family Test[xliv]
  • CQC Maternity Services survey[xlv]
  • Locally designed Maternity Voices Partnership care survey[xlvi].

Wider benefits should also be seen in health outcomes for both parent-and-child, increasing positive outcomes in maternity dashboard[xlvii] figures generally.

Programme Narrative

The needs-based approach to health improvement of the trans childbearing community holds the assumption that the community face disparity in health outcomes during the perinatal period. This has been evidenced through an assumptive approach based on the wider trans community’s relationship with accessing healthcare and the limited research available on the trans childbearing community and perinatal care experience.

A big limitation of the programme is that the trans childbearing community in England is unknown due to systematic failure of data capturing and heterogeneous approaches to self-identity, exacerbated by fear of stigma, discrimination, and bias. The trans community is growing and even if not the trans childbearing people deserve to have access to appropriate healthcare.

Within the framework of perinatal services provided by the NHS in England, the programme will adopt an integrated approach to improving the health of the trans childbearing community which places individuals from the community at the heart of the proposed strategic interventions. The programme will take a symbiotic approach to the interventions of cultural competency training, individualised care, systematic change, and a focus on improving mental health.

Through partnership working of all stakeholders and in particular collaboration with the community using (or intending to use) the service, the programme will implement strategies that increase awareness and understanding of the additional vulnerabilities and challenges the community face, ensure supportive care that meets the unique needs of the community, changes the system within which perinatal care currently exists, and ensure mental health is as protected as physical health. This will allow broader goals of reducing real and perceived internalised, healthcare, and structural stigma; improve the experience of navigating the service, making it more accessible and giving HCPs the skills needed to provide care to a vulnerable and diverse community; and improving the long-term health of parent-and-child, impacting not just on them as individuals but the wider communities they exist within. Long-term one of the benefits of the programme is that this underrepresented in healthcare community group will be more likely to access perinatal care as they know their community is understood and represented.

Although the strategic themes have been identified through this programme this truly will be a collaborative community health programme and relevant stakeholders but especially the trans childbearing community themselves will coproduce the final programme strategy, implementation, and evaluation methods to ensure they are flexible and adaptable to maintain community relevancy through emerging and changing needs, priorities and in response to any future published evidence.

Sustainability of the programme will be supported through participatory actions of the community themselves and by ensuring that interventions are measured against the long-term goals of the programme with a mechanism for future growth and development of the programme as the long-term goals are achieved.

[1] For the purpose of this essay the umbrella term ‘trans’ will be used throughout unless specifically noted.

[2] A woman whose gender matches their assigned sex at birth.

[3] Using the birth (or legal name if not yet changed) of a trans person even though it is not their preferred name. This can be accidental or intentional.

[i] Nolan IT, Kuhner CJ, Dy GW. Demographic and temporal trends in transgender identities and gender confirming surgery. Transl Androl Urol. [Online]. 2019;8(3):184-190. [Accessed 26 April 2021]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626314

[ii] Office of National Statistics. Trans data position paper. [Online]. 2009. [Accessed 26 April 2021]. Available from: http://www.ons.gov.uk/ons/guide-method/measuring-equality/equality/equality-data-review/trans-data-position-paper.pdf

[iii] House of Commons, Women and Equalities Committee. Transgender Equality. [Online]. 2016. [Accessed 26 April 2021]. Available from: https://publications.parliament.uk/pa/cm201516/cmselect/cmwomeq/390/390.pdf

[iv] Brighton and Sussex University Hospitals. Perinatal care for trans and non-binary people. [Online]. 2020. [Accessed 26 April 2021]. Available from: https://www.bsuh.nhs.uk/maternity/wp-content/uploads/sites/7/2021/01/MP005-Perinatal-Care-for-Trans-and-Non-Binary-People.pdf

[v] Public Health England [Online]. Ensuring pregnant trans men get equal quality care. 2020. [Accessed 26 April 2021]. Available from: https://phescreening.blog.gov.uk/2020/03/13/pregnant-men-best-care/

[vi] Stonewall.org [Online]. How many trans people are there in Britain at the moment. [Accessed 26 April 2021]. Available from: https://www.stonewall.org.uk/truth-about-trans#trans-people-britain

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[x] Royal College of Obstetricians & Gynaecologists [Online]. Antenatal care should be standardised to the minimum targets set out in the new guidance, say professional bodies. 2020. [Accessed 28 April 2021]. Available from: https://www.rcog.org.uk/en/news/antenatal-care-should-be-standardised-to-the-minimum-targets-set-out-in-new-guidance-say-professional-bodies/#:~:text=Maternity%20care%20has%20been%20shown,and%20other%20adverse%20perinatal%20outcomes

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[xvii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017;17,332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xviii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017,332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xix] MacDonald, T, Noel-Weiss, J, West, D. et al. Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth [Online]. 2016,106. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-016-0907-y

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[xxix] Brighton and Sussex University Hospitals. Pronoun stickers. [Online]. [Accessed 1 May 2021]. Available from: https://www.bsuh.nhs.uk/maternity/documents/pronoun-stickers/

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[xxxi] NHS England. The NHS long term plan. [Online]. 2019. [Accessed 1 May 2021]. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

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[xxxiii] Care Quality Commission and NHS England. 2019 survey of women’s experiences of maternity care. [Online]. 2019. [Accessed 2 May 2021]. Available from: https://www.cqc.org.uk/sites/default/files/20200128_mat19_statisticalrelease.pdf

[xxxiv] Brighton and Sussex University Hospitals. Perinatal care for trans and non-binary people. [Online]. 2020. [Accessed 26 April 2021]. Available from: https://www.bsuh.nhs.uk/maternity/wp-content/uploads/sites/7/2021/01/MP005-Perinatal-Care-for-Trans-and-Non-Binary-People.pdf

[xxxv] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xxxvi] Berger AP, Potter EM, Shutters CM, Imborek KL. Pregnant transmen and barriers to high quality healthcare. Proceedings in Obstetrics and Gynaecology. [Online]. 2015;5(2):3. [Accessed 28 April 2021]. Available from: http://ir.uiowa.edu/pog/

[xxxvii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xxxviii] Vine, S. Vilified by armies of woke…for being a woman. Daily Mail. [Online]. 13 February 2021. [Accessed 4 May 2021]. Available from: https://www.dailymail.co.uk/debate/article-9257865/SARAH-VINE-Vilified-armies-woke-woman.html

[xxxix] MacDonald, T, Noel-Weiss, J, West, D. et al. Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth [Online]. 2016,106. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-016-0907-y

[xl] Brandt, J, Patel AJ, Marshall I, Bachmann, GA. Transgender men, pregnancy, and the “new” advanced paternal age: A review of the literature. Maturitas. [Online]. 2019.

128,17:21. [Accessed 1 May 2021]. Available from: https://www.sciencedirect.com/science/article/pii/S0378512219305845

[xli] Ellis SA, Wojnar DM, Pettinato M. Conception, pregnancy, and birth experiences of male and gender variant gestational parents: it’s how we could have a family. J Midwifery Womens Health. [Online]. 2015;60(1):62-69. [Accessed 4 May 2021]. Available from: https://pubmed.ncbi.nlm.nih.gov/25196302

[xlii] Ellis SA, Wojnar DM, Pettinato M. Conception, pregnancy, and birth experiences of male and gender variant gestational parents: it’s how we could have a family. J Midwifery Womens Health. [Online]. 2015;60(1):62-69. [Accessed 4 May 2021]. Available from: https://pubmed.ncbi.nlm.nih.gov/25196302

[xliii] Berger AP, Potter EM, Shutters CM, Imborek KL. Pregnant transmen and barriers to high quality healthcare. Proceedings in Obstetrics and Gynaecology. [Online]. 2015;5(2):3. [Accessed 28 April 2021]. Available from: http://ir.uiowa.edu/pog/

[xliv] NHS England. Friends and family test (FFT). [Online]. 2020. [Accessed 4 May 2021]. Available from: https://www.nhs.uk/using-the-nhs/about-the-nhs/friends-and-family-test-fft

[xlv] Care Quality Commission and NHS England. 2019 survey of women’s experiences of maternity care. [Online]. 2019. [Accessed 2 May 2021]. Available from: https://www.cqc.org.uk/sites/default/files/20200128_mat19_statisticalrelease.pdf

[xlvi] National Maternity Voices Partnership. http://nationalmaternityvoices.org.uk/

[xlvii] Maternity Services Dashboard. https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/maternity-services-data-set/maternity-services-dashboard

Breastfeeding, And Why Smugness Came Before A Fall

This was originally written for Professor Amy Brown who was compiling one of her books. I don’t think it’s been used in print and I’ve re-discovered it on my hard drive so I thought I’d share here.

When I got pregnant with my first child I went into research-mode and looked for THE best way to do every single aspect of pregnancy and baby-care. (Unfortunately, I was also a smug first-time mom to be and didn’t hold back in telling everyone why my way was going to be THE best way and questioning why on earth wasn’t everyone doing the same as me. God I cringe so hard. Sorry, everybody I came into contact with then!)

A huge part of this was, of course, how I was going to feed my baby. Breast is best hun, so despite having no clue whatsoever of what breastfeeding entailed I decided that was that and I was going to breastfeed my son. I wasn’t breastfed myself – a fact I knew only because my mom took great delight in telling everybody that I never cried as a baby and just stood in my cot waiting for a bottle. We’ll just skip past that little attachment issue in waiting there…In fact, to the best of my knowledge I only ever saw one person breastfeeding during my childhood; a friend of my mom’s giving her newborn twins milk. Now I look back and know how much hard work that would have been and I’m slightly in awe!

Of course, smugness goes before a fall. Literally, in my case. I fell down the stairs on my due date and damaged my coccyx which set the scene for a really traumatic-feeling end to my pregnancy, and my labour couldn’t have deviated further from my birth plan if it had tried. It traumatised me so much it nearly stopped any future children from being considered, and it definitely impacted on my ability to bond with my son in those early days. Frankly, I wanted nothing more than to hide in bed until all the pain went away. So having a baby who didn’t immediately latch on and do something “natural” was more than I had the ability to cope with at that point. I just didn’t have the stamina or desire to add fighting to feed my baby into the mix – and it really did feel like a fight. He wouldn’t latch, every position hurt, my nipples hurt, my coccyx hurt, my stitches hurt, I was too anaemic to sit upright. In my drug, hormone and tiredness addled state I thought expressing would be the best option in the short-term. So that’s what I started to do. My very first time at the pump produced about 10mls of colostrum which would have been great except it was red, so of course I thought I was poisoning my baby with infected milk. It really wasn’t easy this parenting lark.

I carried on pumping, putting baby to the breast as often as I felt I could which in hindsight is nowhere nearly enough to have done anything particularly useful. And I carried on pumping. And I carried on thinking that we’d crack breastfeeding soon. And I carried on pumping. And I started to think that perhaps one of us just couldn’t do it. And I carried on pumping. And I stopped putting him to the breast. And I carried on pumping. And I carried on pumping.

Thankfully I responded well to the pump. I could nearly always keep up with his demand, despite him taking so much milk each day. He was diagnosed with reflux and drank milk to soothe the pain, invariably vomiting it across the room in an exorcist-style propulsion of milk and mucous. When your hard-pumped milk was so rapidly discarded there really was a point in crying over spilt milk.

I don’t know how I kept up the regime of expressing for 5 months. One of the overriding memories I have of those early months with him is frantically rocking his bouncer to stop him crying while I urged my boobs to be faster at filling those bloody bottles. It was intense. Having gone through the newborn period with two subsequent children I’m filled with regret at how much I missed with the pump-feed-wash-sterilise routine. Even more regret that I was never told things that would have eased the intensity of exclusive pumping – like the fact you don’t need to sterilise breast pump paraphernalia! (note: current NHS guidelines have been revised to say that now it is recommended to sterilise breastmilk equipment).

My husband was as supportive as he could have possibly been and made it as easy as he could possibly have made it (apart from that one fatal misunderstanding where he binned an entire freezer drawer full of milk stash – that one still smarts!) but he didn’t ‘get’ it. It would have been really nice to be able to talk to people who had been there. People who had breastfed, people who had expressed, people who I didn’t mind being vulnerable in front of. But there was nobody. None of my friends had yet had children and my family weren’t breastfeeders. Even the most well-intentioned support doesn’t quite hit the spot when it’s from somebody with no experience of the issue.

Years have passed and more babies have happened. After success feeding my second-born I trained as a breastfeeding peer supporter and have been volunteering at community support groups for several years. She was breastfed until the hallowed WHO guidance of 2 years, self-weaning shortly after her birthday. My third-born is showing no signs of stopping, we’ll address weaning if and when it becomes a problem. A small, irrational part of me probably thinks longer-term breastfeeding makes amends for the fiasco that was my son’s first months. The bigger, more rational part of me knows that’s bobbins and I did the best I could have done, which is all any of us can do, really, isn’t it?

You and Your NICU Baby

Having a baby in nicu is a strange old time in ways that many people don’t get.

You become fiercely protective of them but you have to put your trust in others to look after them.

You often have to inhibit your natural instincts to hold and comfort them because they need more treatment than you can give. You’re often told when to cuddle, when to feed, when to visit…but they’re YOUR baby and they need you there more than ever.

You need to be looked after because you’ve just given birth but you don’t want to spend time thinking about yourself, only your baby.

Life moves on outside the artificial environment of nicu and you don’t feel quite like you belong with all the bright lights, noises and people…but you don’t feel quite like you belong among the doctors, nurses and equipment either.

We were lucky. Our time in nicu was short and either through family-friendly practice or our own sheer bloody mindedness we didn’t leave the unit. Other people aren’t in the same position and the impact on their lives, minds, attachment is immeasurable.

Baby Stockport NICU

Ten Years Ago I Became A Mother. And I Became Friendless.

Becoming a mother was one of the hardest things I’ve ever done. Not just birth, although that left me wishing the baby would disappear halfway through the experience and I could go back to not having a baby at all thank you very much. But the act of becoming a mother, that transition time between having a baby and being a competent parent (ok, I’m still not sure I’m that some most of the time), the time where we grow into our roles. Jeesh that was hard.

I was overwhelmed. We had no family support close to us. We had no friends with children to learn from. We only had books like The Baby Whisperer  and Gina Ford  to tell us what to do. We had the narrative from society that babies should be seen and not heard, but only sometimes, when it was convenient and as long as they didn’t interrupt your plans. The rest of the time it felt like they were supposed to be shut into a drawer and forgotten about so you could go back to doing the things you used to do in that mythical time BC. We were promised we would make lifelong friends at NCT classes and Early Days groups but they passed in a blur of trying not to cry because you’re exhausted, wishing desperately our babies were sitting quietly like the others, and wondering if you left early could you time the nap with lunchtime so you could actually eat that day.

The initial flurry of visitors post-birth soon stopped. The token gestures of still being invited out with childless friends came to an end. The resentment that they didn’t understand that I had a 4 week old, or a 2 month old, or a 4 month old, or a high needs baby, and hadn’t slept properly for more than a hundredbillionty years built. The photos of them going out enjoying themselves without me appeared. I didn’t want to see them ever again. Dumped and ignored. Meeting up with other new moms happened, but these passed in a blur of poo and sleep issues and much as friendships with colleagues stall as soon as you leave the company, there was an expectation that these wouldn’t last either.

The reality was my life HAD changed from what it was before, and going backwards is never an option. Their lives hadn’t. My world had ripped apart and theirs was exactly the same. And that wasn’t their fault. And it wasn’t mine either. Becoming a parent can be hugely overwhelming but it’s compounded by the expectation we put on ourselves. We expect babies to slot right in and for us to carry on as normal. We expect a week of no sleep and then it becomes a problem to be solved. We expect to feed our babies a lot but we only have what the side of a tin tells us is the right schedule. We buy cots and Moses baskets and we expect our babies to sleep in them. From before a baby is even born we’re sold the idea that babies will be satisfied with milk, burp and a nappy change before going to sleep (like a baby ) and we can continue our lives with wild abandon.

And when we find out that we need to do more than that, and it’s relentless and gruelling and lonely, when we need friends more than ever just to get through the hardest part of our lives, just as we’re finally ready to raise your head above the parapet and come blinking into the world again, that’s when the cruellest trick happens and we realise that the world has carried on turning and although our own plot line has changed dramatically everyone else is still playing out their own movie. And their movie doesn’t have babies. Being the mature, resilient person I am  I didn’t talk this through with my friends, who would no doubt have been devastated to hear what I was feeling and would have done what they could to counter it but a tired and traumatised brain doesn’t think logically.

Finding out I had a lifelong chronic condition at the same time, exacerbated the loneliness, hurt and worthlessness I felt. It felt like my body was doing it just out of spite but the reality is it was my body’s way of dealing with the trauma I’d gone through. The reality is if I’d not shut down, if I’d opened up a bit I’d have found it all easier. But that’s the quirks of the human brain, isn’t it?

Telling someone in the throes of this that it doesn’t stay like this forever is useless. But it doesn’t. Slowly you realise that those fabled friends-for-life that you make at NCT really are becoming your trusted confidantes and are willing to step into whatever emergency you throw at them. Slowly you understand yours and your baby’s rhythm and can adjust to it. Slowly you start getting sleep on a regular basis and can commit to an evening that doesn’t feature an 8pm bedtime. If you’re lucky you’ve thrown the baby books away and are parenting peacefully with the baby you have, not the baby the books tell you that you should have. And those friends who have loved you since school and who have suffered you pushing them away when life got hard will accept the baby steps you make back to friendships and welcome you with open arms.

It gets better. Open your heart and let people in. And if you’re on the other side of it, check in with your friends who have had babies – they might just be glad of that friendly text (even if they do bail on plans at the last minute and sleep instead!)

Photo credit Hazel Hughes Photography