Friday, 6 December 2013

Childbirth - when it doesn't follow the plan.

Any woman who has been pregnant will have dreamt of an effortless, calm birth... perhaps involving water, music, maybe even a homebirth... a few swear words and squeezes of your partner’s hand and then out would pop your beautiful baby followed by the feeling of elation, the congratulations and admiration of all around. And so you should as childbirth is not to be feared. Sadly though this is sometimes not the case and women can unexpectedly be faced with an event to make even the toughest wonder what the hell could possibly be worse in the whole world??!!!

Traumatic birth events, a serious threat to the health of you or your baby, disappointment in that the whole event did not go the way you expected, feeling powerless in the process and feeling a lack of support or poor care can all leave you with a confusion of emotions to say the least.

Recently, there have been reports on a government plan to have a mental health midwife in all maternity units by 2017. This is an encouraging move but the fact that it will take so long goes to demonstrate the shortage of trained staff available and the unfortunate neglect of maternal mental health. Post-natal depression (PND) is reported to affect as many as 1 in 7 women, but I suspect it may be even more due to under-reporting. Women may not want to admit their struggles and may feel unsupported due to a lack of continuity of care throughout the whole of pregnancy and after the birth.

While researching PND I discovered another area I was much less aware of: Childbirth-related Post-traumatic Stress Disorder. This certainly sounds quite severe and I’m sure in most cases it is, however on reading more about it I wondered how many women could actually relate to the issues surrounding its development. The condition may arise following greatly traumatic events but can also be linked to the expectations of the mother following birth. There is a general approach that the mother should ‘get over’ the ‘natural’ experience once (hopefully) all is well with the baby and you have physically recovered. A widespread lack in understanding of the psychology of birth and feelings of isolation can leave the new mother without a voice in society. If the birth has been very difficult they can feel detached and vastly dissimilar to other mothers, furthering feelings of isolation. In future months, women may avoid sex for fear of pregnancy and associations of the birth with their body. Worryingly, they may also avoid future smear tests. You may worry about the desire for future children being under threat by your new fears, with guilt and pressure building as the condition goes unrecognised. Avoiding triggers that remind you of the whole event, such as watching hospital TV programmes, talking about the birth or having to go to hospital or to see any healthcare professional may also result.

Personally I can relate to some of the above following a traumatic birth experience. Fortunately, although I experienced some anxiety and sleep problems I did not feel I was experiencing anything that I could not manage. (Although my feelings towards future pregnancies and childbirth are completed unbeknownst to me at this stage!). When the condition really warrants help the mother will be suffering from panic and fear that is interfering greatly with her life. What concerns me the most is that in seeking treatment in those that are brave enough to put themselves forward, women suffering PTSD are frequently wrongly diagnosed as suffering PND. They may then be prescribed anti-depressants to help them ‘move on’ but these will be completely ineffective in this case. Women can also suffer both PND and PTSD at the same time and so the PTSD in itself may go unrecognised.

If you feel that you are experiencing PTSD the good news is that cognitive behavioural therapy can really help. Not only can CBT introduce coping mechanisms in understanding and altering thought processes surrounding the birth, but a new study has shown that it can reverse structural changes in the brain that result from trauma (Levy-Gigi et al 2013). It is also possible to call up the maternity unit and make an appointment to discuss the medical side of your birth experience. This can help to get your head around what happened and can happen years later, perhaps if you are thinking about having another baby.  

To minimise distress to the parents and possible implications on their parenting it is important to recognise PTSD and turn to CBT as early as possible. I hope that improvements are seen in recognising this as distinct from PND and that the focus on maternal mental health will develop and increase significantly.

For more information on PTSD:

#childbirth #birth #PTSD #PND 

by Rachel Brophy

Tuesday, 19 November 2013

Why are we all on 'The Pill'?

100 million women worldwide currently use oral contraceptives (OC). With so many of us being put on ‘the pill’ as standard when we become sexually active and often continuing for 10,15,20(+?) years without questioning this, I have often wondered whether if we stop and think about it – Is this actually OK?  Yes, a reliable contraceptive method is without doubt essential. But interfering with our natural hormone levels, cycles, fertility, moods... I have to say seems like we are being almost sexist to ourselves. If you argue that it is a woman’s choice, I propose that if you offered the average woman a suitable alternative or an equally effective male alternative they would take it. With recent research linking long-term pill use to glaucoma I again question whether we can really anticipate all the future implications of interrupting our natural regulatory mechanisms and processes. Oestrogen and progesterone are anything but simple biochemicals.

Research has for some time been debating the possible link of the pill and increased or decreased risk to particular cancers. However, it is the effect on everyday living that is arguably equally if not more important. Removal of ovulation and the natural changes in hormone levels throughout the cycle can leave women feeling emotionally numb and often depressed. It’s hard to know when you are having a low period or being truly yourself or whether the pill is really affecting quality of life. Research into the pill and depression is limited; however there is suggestion that increased levels of oestrogen and progesterone (as in the POP) can cause lower levels of serotonin, the happy hormone.  On discussion with friends we have all changed brand of OC at least once over worries that our mood has been lowered by a particular pill and on reflection should have asked whether we should be on it at all. I have had a year here and there where I have decided on a break when fear of this and other serious health links (deep vein thrombosis, stroke, heart attack, cervical/liver/breast cancer) have played on my mind too much. Reasons for going back on, aside from convenience as a contraceptive method have been the positive effects on balancing out PMS, acne, period pains and hormone-related IBS as well as the ability to control when you do or do not have a period for holidays.  Attractive benefits, but most with realistic non-hormone related alternatives.

As reports of pill use for 3+years doubling risk of glaucoma currently in the press I have investigated other recent research into oral contraceptives. An Austrian study in Brain Research this month suggests that OC use may have profound effects on cognition. They detected a masculinisation of brain responses in women on the pill compared to women having natural menstrual cycles, as detected by fMRI responses to numerical tasks. Effectively, the progesterone levels caused by OC use are resulting in our brains becoming more like men than women. On top of this a German study has found that our brains respond more to money as an attractive trait in a partner when on the pill than when allowing a natural cycle, when we favour genetic benefit at times when we are most fertile. So being on the pill may be even influencing our choice of partner.

The pill is also affecting men, both directly and indirectly. With widespread speculation that oestrogen in our drinking water (from the vast quantity that is excreted in our urine) is resulting in feminisation of the male population, question over long-term effects on fertility have also arisen. Further research has shown that when women follow a natural cycle, their male partners find them more attractive around the time of ovulation compared to the luteal cycle phase. As ovulation is removed when on the pill this removes this effect and also results in the men rating themselves as feeling less attractive when the woman is on the pill. It is notable however, that there was no difference in female self-reported attractiveness.  

At a time when there is a dearth in contraceptive methods that bear the convenience and non-invasiveness of the pill it is difficult to suggest re-thinking this approach. However I do hope that research continues into this area and that further discoveries of the effect of the long-term hormone disruption on other bodily systems do not emerge. As risk of DVT does increase with age I would really reconsider staying with the pill after 35 and also to be honest about smoking as this is also a big risk factor. There is also the suggestion to look further into the different types of contraceptive pill and their reported side effects and finding the one that seems most suited to you, rather than relying on your GP to fully make the decision.

#thepill #oralcontraceptives #glaucoma #oestrogen #progesterone #contraception #hormones #the pill

by Rachel Brophy

Thursday, 14 November 2013

Vitamin supplements for all under fives – Is this the solution?

Following the release of the Chief Medical Officer’s annual report last month attention has been focussed on one area in particular. Professor Dame Sally Davies has suggested that to improve the nutrition status of children, primarily regarding the increase in rickets, all under-fives should be given free vitamin supplements. She is asking NICE to look into the cost effectiveness of this method, with the idea that prevention is cheaper than cure. However, do we really want all of our children taking synthetic compounds every day? Is this really the solution to a problem caused only by poor lifestyle and diet?

There have been mixed results from research into the benefits and safety of the use of vitamins. The concern is directed towards extra large doses, particularly when they are stored by the body. It is also generally accepted that synthetic vitamins are not metabolised as effectively as in the natural state and the absence of the context of the food they are contained in impedes their absorption. Water-soluble vitamins, for example vitamin C, are not stored in the body and so any amount over that needed per day will only be excreted –essentially, money down the drain. I have never personally been convinced of the need for vitamins taken as a day-by-day routine unless there is a medical need, for example when I was iron deficient in pregnancy. I was also uncomfortable when given multivitamin drops for my daughter when we were discharged from hospital as we had fully established breastfeeding which should naturally provide all the nutrients she required.

It is clear to see why the public might be unsettled by this ‘give them all a tablet’ solution, when the evidence for and against supplements is questionable and it may seem that only some children may need them in the first place. However, we must accept that we are society as a whole and we most definitely have a problem. The annual report informs us that up to 40% of children have vitamin D levels below the optimal level and 12% are deficient. The result of this can be rickets, hypocalcaemic convulsions and motor delay. Medical professionals have seen an increase in rickets by almost 400% in the last 9 years. I suggest that the majority of parents do not wish to cause their children harm so there needs to be improvement rather than blame and general criticism of parents by the media, public and government themselves (the report even claims that we should be “profoundly ashamed”). This is problem that may affect some groups more than others but it is a nationwide issue and it is too easy to blame immigration, moronic parents, and claim ‘it wasn’t like that in my day’ etc.  Far too little government funding is used for education and health promotion relating to diet and lifestyle. We need positivity and not shame to battle our sedentary culture.

The best way to achieve required levels of vitamin D is through safe exposure to sunshine for around 10-15minutes a day. This is easily achievable and far superior to the synthetic version found in supplements. It may be true that winter sun can be quite inadequate for achieving optimal levels of vitamin D but they can be topped up through eating oily fish and eggs. As the UK sun has not changed a huge factor coming into play in deficiency in children is the over-anxiety towards sunburn and skin cancer, resulting in children being constantly slathered in sunscreen. The obvious decrease in outdoor activity and imposition of technology into recreational time also holds responsibility.  Are we going to ignore this and allow it to worsen while hoping a quick fix supplement will work?

Free vitamins through the ‘Healthy Start’ scheme have been offered for children of low-income families with little success. Reports of poor uptake, supply and availability problems have led to an inadequate impact on deficiency-related illness. This could be evidence that in fact this method is not conducive to success. Giving children non-satisfying nutrients in this way involves commitment to a boring routine. Will offering them to all children really prove cost effective at all in that case? The theory is that in offering vitamins universally the stigma attached to hand-outs and being on benefits is therefore removed. There is also evidence of success in this approach on a smaller scale, by trial in Birmingham.

Perhaps more focus should be targeted on pregnant women taking supplements. The Department of Health recommends that all pregnant and breastfeeding women take vitamin D, however from personal experience there is little to ensure women know this or check that this is happening. A child’s vitamin D stores are established at this early stage from the mother’s own levels and so intervention at this early stage could have a measurable impact.

It makes me wonder if a universal approach is necessary when the evidence points towards greater prevalence of rickets in specific groups ie. those with darker skin or those with cultural reasons for covering up.  Is there anything wrong in checking on the nutrition status of children as a case by case matter?  Should our healthcare system not be able to detect deficiencies before they reach the disease state and intervene accordingly?

It is clear that something needs to be done to target the alarming rise in rickets in children and I suspect this is an indication of the poor nutrition status of children on the whole. The worry of how taxes are spent seems to concern people especially with expensive sounding schemes that may not bring success. However, what better to spend on than the health of future generations that will live with the consequences of a society and lifestyle that we have collectively created. Perhaps anxiety towards artificial nutrients has led to focus on this point, but should we really worry about children taking vitamins when they are already added to formula milk and fortified cereals, staples of our children’s diets. I remain unconvinced that I should be giving them to my daughter but maybe when offered universally it will be a matter of choice for parents. But would this defeat the point entirely? The debate continues...

#vitamins #children #vitaminD #vitd #rickets #vitaminsforchildren #deficiency #healthystart #annualreport #chiefmedicalofficer #underfives 


by Rachel Brophy