Monday, April 30, 2012

What to Expect from Nestle

We all have our prejudices and opinions about breastfeeding and natural birth. At a certain point, however, it is important to try to discover the facts buried deep beneath everyone's political agendas. I was struggling with this for a few days before I decided to write this blog, and a lady jumped out from the past and told me very clearly that I have to speak out.

I was in my early twenties, traveling through Africa on my own. I was walking to get on a ferry, which was basically a very large raft kept afloat by prayers and habit, to cross a river. A woman about my age approached me. She had a baby on her back, and she swung him around and presented him to me. Because of the color of my skin, she expected me to have some knowledge, medication, or connections that would assist me to bring her baby back. He was almost dead. His eyes were glazed and dry. He had diarrhea, she explained. I had no idea what to say to her. I didn't know anything back then. I had never seen a dying baby before, and I hope you never will.

I don't think people fully understand the significance of the use of baby formula in countries where poverty is rampant, and clean water is impossible to find. Here in Canada, those women who bottle feed their infants may be at risk for being sneered at, and their babies may be at higher risk for allergies or obesity. But in Africa and all over the world, babies who are fed formula are at a higher risk of  infection, from the moment they are born until they are at least two years old.

Unicef recommendations on breastfeeding are here, and they are worth looking at. The authors suggest that "The major problems are the societal and commercial pressure to stop breastfeeding, including aggressive marketing and promotion by formula producers. These pressures are too often worsened by inaccurate medical advice from health workers who lack proper skills and training in breastfeeding support."

Nestle is one of the major formula producers in the world and has just bought Pfizer Nutrition which markets four brands of artificial formula. Nestle actively promotes its breastmilk substitutes in Africa and elsewhere, claiming that HIV positive mothers' babies should not be breastfed. This is a subject that has seen much research and discussion over the past few years and it is by no means a conclusive claim. Infection rates can go up by over 60% after six months, so perhaps a better suggestion would be (see WHO recommendations) that babies everywhere and in every situation should be exclusively breastfed for the first six months of life.

The problem with formula feeding in poverty-stricken areas are twofold: one is the lack of clean water, refrigeration, sterilizing equipment and so on. Bottles are washed in less-than-sterile water; the powdered formula is mixed with infected water; and the remaining formula is left out and breeds bacteria. WHO guidelines on the preparation of powdered formula are very strict concerning cleanliness and refrigeration. This level of cleanliness is simply not possible in many households around the world.

Nestle has been boycotted for over forty years because of its aggressive marketing of breast milk substitutes  all over the world.

This is why I was shocked to see that it is sponsoring the What to Expect When You're Expecting movie premiere, and to see that these two organizations are partnering to sponsor a contest for pregnant women. The prize is a trip to Hollywood to see the WTE movie. Visit the link: Nestle Baby.  If you try to enter the contest, you are told that only "Nestle Baby Program" members are allowed to enter. So you go to the Nestle Baby link. A tiny popup opens to let you know that breast is best for up to six months. Then you are met with a $100 coupon for free samples, including formula and bottles.

This is directly in contravention of the World Health Organization's International Code of Marketing of Breastmilk Substitues, which states that: "there should be no advertising or other form of promotion to the general public" and that "manufacturers and distributors should not provide … to pregnant women, mothers or members of their families, samples of products…" Promotion through any type of sales device, including special displays, discount coupons and special sales, is prohibited. Furthermore, no company personnel should seek direct or indirect contact with, or provide advice to, pregnant women or mothers.

I expect and encourage What to Expect to immediately sever ties with Nestle, for the sake of their own reputation, and for the sake of the health of millions of mothers and babies around the world.

Tuesday, April 17, 2012

Unassisted Childbirth

Back in the good old days, when I was a subsistence farmer in paradise, I had a friend who told me her birth story. This was before I started working with birth, but not before I had already started studying and learning, and listening to women's stories.
Friends Sharing Birth Stories

 My friend's first baby had been a breech who did not want to get her head down. The policy at that time in Italy, as in many places, was to deliver breech babies by cesarean section, especially if the woman was a primipara.

So, my friend had a c-section, and she did not feel good about that birth at all. She thought that it was probably possible to give birth to a breech baby vaginally, and she felt pushed into making a decision that did not feel right to her. She decided she didn't want to go back to the hospital again to give birth.

She became pregnant again, and decided to stay at home this time and give birth on her own terms. She looked for a homebirth midwife but at that time in Italy they were a rare breed, especially if you were living in the hills as all us organic subsistence farmers did. She prepared by reading about natural birth, and she made sure she had methergine in the house - they always had it on hand for the goats.

Labor started and she sent her husband and child out for the day. She didn't want her daughter present for what she knew was going to be an intense and possibly scary event.
This was before cell phones, and they didn't have a phone, so he planned to come back around suppertime. She labored on her own and late in the afternoon, gave birth to a healthy baby.
"Were you scared?"
"Yes, I really wanted to have someone else around. I remember when I started pushing, and I felt a cervical lip, and I gently pushed it out of the way - I really wanted someone to be there with me. But I knew everything would be okay - I had a feeling. And if it wasn't ok, then it wasn't. I did it my way."

There is a growing movement that promotes unassisted childbirth as a way to regain control over your own birth, and there are many valid reasons for not wanting anyone at all from outside your circle of family and loved ones to be present at the birth of your child. It is, after all, a natural event, more like lovemaking than like a medical procedure. The presence of a stranger, even a well-liked one, can change and disturb the process. Midwives can be regulated by laws that perhaps don't agree with a woman's perception of how she wants her birth to proceed. This site provides some interesting information about unassisted childbirth:UC

I often get calls from women who are planning to give birth without attendants. They want information, or they want to find someone to be a "fly on the wall" - who can be there "just in case". Most of these women are women who have not been able to find a registered midwife - either they didn't call early enough, or they live in the wrong area, or they are considered too high risk for a homebirth. They don't really want an unassisted birth, but they are committed to not wanting to go to the hospital unless they really have to, so they are left with unassisted birth as their only option. Because we Canadians are used to free health care, cost is also a consideration. Unregistered midwives charge around $2000 for prenatal, birth, and postpartum care (that works out to about $10.73 an hour, in case you're wondering). Many women do not feel that this amount is an option, and, again, make the choice to give birth "unassisted".

I firmly believe in a woman's right to choose what's best for her body, and for her life. If a woman chooses to give birth on her own, or just with her partner, or her sister, in her own home, then power to her! She is making an adult choice, and she is accepting responsibility. But I do feel sad when women want to have the care of a midwife and cannot.

No woman should have to give birth on her own if she doesn't want to. Midwifery care should be available, really available, to any woman. Homebirth should be an option for us all. Unassisted homebirth is only one option, but it should be an option that is actively chosen and not decided on for lack of other plans. Equally, hospital birth is only one option. Health women carrying healthy babies should not have to go to the hospital to give birth unless they actively want to. Informed choice should be a reality - it should be informed, that is, women should educate themselves and each other, and they should ask for informtaion from their care providers. And choice should be a real choice with real options - unassisted, home birth, midwifery care, hospital birth.

Let's work together to bring the woman and child back to the center of maternity care!

Wednesday, April 11, 2012

Ask the Doula: Evidence-Based Care

It's Ask the Doula time again!
Please keep sending in your questions. You can add them as comments below, or send your questions to our Facebook page, or twitter @montrealdoula.

Today I will be looking at the concept of "Evidence-Based Care". What does it mean? How does it work?

Question Number Four

"What is evidenced based maternity care?"

What is the meaning of life? may be an easier question to answer.

First, I will offer you a collection of attempts to define evidence-based maternity care:

"EBM is about tools, not about rules. Good evidence is likely to come from good systematic reviews of good clinical trials. For many reasons too much of the medical literature can be misleading, or is just plain wrong. We must be able to distinguish good evidence from bad, and to have accurate, reliable knowledge readily available and readily accessible for all. The contrast between the individual and the population as a whole - unique biology, choice and circumstance, often dictates what happens, and evidence is but one part of a complex question."

"Evidence-based care is a type of care in which the medical studies are consulted to help you and your caregiver decide the safety and usefulness of all procedures used. With evidence-based care, only procedures that are proven by research to be safe and beneficial are done routinely. Other procedures which are not supported by the medical evidence are weighed carefully, taking your personal circumstances into account. This is called "informed consent". This may seem obvious, but, for example, routine use of epidurals is not supported by the evidence. 
Birth Matters Virginia

"Evidence based health care takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information." 
Dr Nicholas Hicks

There is a never-never land that people believe we are heading towards, where our huge glut of information and meta-analyses, and  systematic reviews, and technological advances, will somehow be tamed so that we can quickly pick from any number of studies, the answer to a clinical question that is presenting itself. What is wrong with the picture is that we have become wrapped up in the science, or rather, in the scientific methods (or methods), and we have completely misplaced the person at the center: in our case, the pregnant, laboring, or breastfeeding woman.

I have in front of me an example of the type of study that is being used to support and  maintain evidence-based care. It is an "overview". This means that the researchers looked at reviews of trials. The trials are the actual clinical experiments, which are done on real people in real situations. The reviews are done when researchers look at, for example, ten different trials involving 10,000 women, and compare the results and draw conclusions.

Tuesday, April 3, 2012

Wayne Gretzky or PK Subban?

Just a minute to think outside the birth box a little today, bear with me folks.

I was waitressing at the White Spot back in 1979, making money for my trip to Africa. The White Spot was a typical Calgary steak house, just down the road from a popular bar, and it was a busy night. Two couples came in and sat in my section. I served them and catered to their every need, as you do as a waitress. I realized the other waitresses were in a frenzy and I asked what was wrong. See, I was a poet back then, an artist, a revolutionary. I didn't know about normal Canadian stuff like hockey. One of the girls let me know that I was serving Wayne Gretzky! So, whatever. I brought them the bill, Gretzky paid with a Visa (wish I'd kept the receipt - his signature was probably worth a lot for a while), and he tipped me $9.00.