The drug that could cut deaths from postpartum haemorrhage by a third

Every year, about 100,000 women die from haemorrhage after childbirth. Most of these deaths are in poorer countries such as Somalia or Sierra Leone where many give birth at home, without access to medical care. Even women who haemorrhage in hospital may still die, though sometimes doctors will perform a life-saving hysterectomy.

In Western countries, although postpartum haemorrhage (PPH) is relatively common (in England, 13.8% of women haemorrhage after childbirth), most women who need it will receive an instant blood transfusion. Deaths from PPH are rare.

So it’s extremely good news that a new trial has shown that administering a simple, cheap drug called tranexamic acid, which works by stopping blood clots from breaking down, could potentially save the lives of about a third of women who currently die from PPH. The study was carried out by the London School of Hygiene and Tropical Medicine in collaboration with 193 hospitals in Africa and Asia.

The most extraordinary part of this story is that tranexamic acid was discovered in the 1960s by a Japanese husband-and-wife research team, Shosuke and Utako Okamoto. They were unable to persuade doctors to perform a clinical trial, so the drug has mostly been used as a treatment for heavy periods and to reduce bleeding as a result of trauma.The WHO currently recommends its use for PPH as a second line treatment if the first line treatment of uteronics (drugs to contract the uterus) fails. This new research shows its efficacy as a first line treatment.

Even though its impact will be smaller, it is also good news for women in developed countries. Many women who suffer from PTSD after childbirth trace it back to their experience of severe PPH, and the terror of believing they were about to die. If administering tranexamic acid eventually becomes standard practice to reduce haemorrhage, then for those women, birth will become a less frightening experience.

Why do so many babies die – and why aren’t we doing something about it?

Why, asks an article in the Telegraph, do 2,000 babies die needlessly during childbirth every year?

It’s a question that ought to bring us up short. Two thousand deaths is a huge number: compare it to, say, the number of people killed in road accidents in the UK, which is now down to about 1,700 a year.

The article’s writer, Mary Riddell, is talking about needless deaths: in total, there are 3,600 stillbirths a year in the UK, representing one in every 200 births. Some deaths can’t be avoided. So why aren’t we doing more about the ones that can?

It’s curious how complacent we are as a society about the problem of medical negligence. In the US, a study has estimated that medical errors are the third leading cause of death, behind heart disease and cancer. Somewhere between 210,000 and 440,000 patients who go to hospital in the US each year “suffer some type of preventable harm that contributes to their death”. As far as I know, however, no similar study has been carried out in the UK.

Childbirth injuries and deaths can be avoided

We do know that NHS doctors and midwives make mistakes during birth. According to the Telegraph article, compensation claims for childbirth errors have tripled in 10 years. It compares figures for England with those for Sweden:

“In the last five years, Sweden has reduced the number of serious birth injuries from 20 per 100,000 babies to five, compared with the English rate of 30 in every 100,000 babies.”

The Swedish figures show that many injuries and deaths relating to childbirth are avoidable. The Telegraph article goes on to look at a hospital that has got it right: Southmead Hospital in Bristol, which it describes as “probably the safest place in the world to give birth”. Fifteen years ago, Southmead introduced Practical Obstetric Multi-Professional Training, or PROMPT – a method of collaborative working and learning from mistakes. During that time, there has been a 50-70% reduction in common birth injuries.

How the PROMPT approach works

What PROMPT does is to make sure that all members of a team – obstetricians, midwives, anaesthetists – are on the same page when it comes to responding to a medical emergency. A representative group of professionals receive the training together and then take it back and train other staff in their own hospital. It means that if, for example, a baby’s shoulder becomes stuck, everyone knows what to do.

The only extraordinary thing about this is that it’s not already universally applied: you’d hope health professionals would all know exactly how to respond to any likely childbirth emergency. But in the less effective maternity units, that doesn’t seem to be the case – the Kirkup Review into failings at the maternity unit of Furness General Hospital exposed an apparently casual attitude towards safety. In James Titcombe’s account of his son Joshua’s death at Furness, it was striking that none of those involved seemed interested in understanding why he had died or putting measures in place to stop anything similar happening again.

A fundamental change in approach is needed. Everyone makes mistakes, but human error can be minimised if agreed best procedures are in place; and a culture of openness where people are encouraged to own up to, and reflect on, their mistakes enables everyone to learn and improve their practice in future. This is how the aviation industry treats mistakes, and it works well.

The government’s proposed rapid resolution and redress scheme, in which litigation claims could be settled quickly without recourse to the courts may help to end the culture of secrecy and cover-up and bring about a more open approach. The proposals are not without their flaws (safeguards need to be in place to make sure that rapid redress is also accompanied by a desire to learn from mistakes – which isn’t a given), but they are surely a step in the right direction. Certainly many families will be grateful for not having to wait years for compensation while litigation drags on.

It could be that we are finally on the cusp of a change that campaigners have been fighting for over many years. If so, we may look back on those 2,000 baby deaths every year and wonder why we ever tolerated it.

Thinking positively about childbirth – why did Milli Hill’s article provoke such an angry response?

 

Two weeks ago, Milli Hill published an article in the Telegraph about why we shouldn’t focus on pain when we talk to pregnant women about childbirth. Originally published under the clickbaity headline (which Hill didn’t write, and has since been changed), “The myth of the painful birth – and why it’s not nearly so bad as women believe”, the article argued that by emphasising the pain of childbirth when we talk to women, we are “setting them up to fail”.

The article provoked a number of responses challenging Hill’s view, including my own piece in the Independent, a characteristically robust blogpost by “skeptical OB” Dr Amy Tuteur in which she accused Hill of “gaslighting” women and an article by Cath Janes in Standard Issue, which talked about her own experiences of a painful birth that triggered severe PND and PTSD. Cath’s piece was, as is her style, both dark and funny – but Hill didn’t like it and asked Standard Issue to take it down. The magazine initially complied, and then republished it minus one sentence that Hill had particularly objected to, and also gave Hill a right-of-reply. The whole saga also provoked a debate on Mumsnet about who was right, with Tuteur, Janes and Hill all weighing in.

There is probably not much hope at this point of a calm, rational debate about the issue. Hill, I think, was taken by surprise at the impassioned response to her article – she thinks of herself as one of the good guys, whose sole aim is to help women have a better experience of childbirth. So what is it about her piece that made women so angry?

Minimising women’s pain

Judging by comments I’ve seen on Mumsnet, Twitter and Facebook, the answer is that, for many women, their experience is the opposite of what Hill describes. Rather than going into childbirth frightened, they went in feeling positive and upbeat – and were then shocked that the experience was much more painful and unpleasant than they expected. Instead of feeling that the pain of childbirth was overstated, they felt it was minimised. When women have had a particularly traumatic birth, they often find that other people play down their experience and tell them that it can’t have been as bad as they thought, that they must be exaggerating, that the health professionals who let them down during labour had their best interests at heart – and in any case, they have a healthy baby, so what else matters? This is why Hill’s article touched a nerve – if you’re already used to having your experience minimised by others, the idea that you shouldn’t talk about the pain of childbirth feels like yet another attempt to get you to shut up.

Think positive!

People also took issue with Hill’s article argument that going into labour with a more positive attitude can help women have a better experience. In her words: “At the moment, we simply do not know what birth would be like for women if they were given more positive messages and went into labour feeling strong, confident and capable.”

The idea that “positive thinking” can help create a different reality is one of the most pervasive – and pernicious – ideas of our times. Even cancer patients are exhorted to think positively about their illness, as if mere thinking can banish one of the most deadly of diseases. It’s a view that Barbara Ehrenreich has magnificently demolished in Smile or Die: How Positive Thinking Fooled America and the World.

For anyone on the receiving end of this view, it’s worse than exasperating – being told that a positive attitude can reduce pain has an unspoken corollary, which is that if you felt pain anyway, it must have been your fault for not being positive enough. The most inflammatory part of Hill’s piece reads: “…when you talk to women who are prepared to break with convention and say their labour was not painful, words like ‘intense’ and ‘powerful’ come up again and again. It suggests that it’s the way that these women talk and think about these sensations that’s different, rather than the sensations themselves.”

Well, no. What it suggests to me is that women have vastly different experiences of childbirth – some women experience “intense feelings” while others feel extreme pain. Even the book of Genesis, written 3,500 years ago, talks about the pain of childbearing, with no word from God, unfortunately, about focusing on the positive.

No wonder some women, reading Hill’s article, felt that their desire to tell their own story was, once again, being undermined. It’s a wearily familiar pattern: a news report in the Telegraph this week reveals that women reporting gynaecological problems to their GP are often ignored or belittled.

So, here’s my bold suggestion: why not listen to what women actually say about their experiences, rather than telling them how they ought to feel? If we all, health professionals included, do that, there’s a chance, just a chance, that women’s experience of childbirth will improve.

 

 

 

 

 

Should we think of birth as normal, or as dangerous?

 

A few weeks ago I gave a talk to a group of health professionals about the impact of a traumatic birth on relationships. At the end of the talk, an obstetrician in the audience took me gently to task for using the phrase “when birth goes wrong”: problems such as retained placenta or postpartum haemorrhage were so commonplace, she said, that they were a routine part of the experience, rather than a sign of something going wrong. She added: “The day she gives birth is – apart from the day she’s born – the most dangerous day of a woman’s life.”

It was a striking comment, and one I’ve been thinking about ever since. There is an alternative view of childbirth, which is that it’s a “normal, physiological process”. It’s a view that’s endorsed by the Royal College of Midwives (RCM), and some NHS trusts have appointed midwives to act as “normal birth leads”, helping women to “achieve” a normal birth. Many midwives believes that an important part of their job is to support women to give birth “normally” – that is, without a caesarean section or intervention such as forceps or Ventouse. Proponents of normal childbirth would argue that an over-cautious approach to risk is in itself damaging, leading to unnecessary interventions that result in a more traumatic experience for mother and baby.

Childbirth is possibly unique amongst medical specialisms in that it is dominated by two professional groups who to some extent have competing views of what the job is about. Obstetricians see risk and danger; their job is to make sure that mother and baby come out of the process alive and, ideally, unharmed. Midwives see their job as supporting women to do what their bodies are designed to do: women have, after all, given birth for the entirety of human existence, and are therefore quite capable of doing so today.

You can see, of course, that both arguments have merit. Lots of women do have straightforward births, with minimal intervention. In the past, certainly, unnecessary medical intervention (the eagerness to induce labour, or speed it up artificially, or to give women episiotomies as a matter of routine, or to force them to give birth lying down) worked against the female body’s ability to do what it is designed to do, which is to push a baby out.

On the other hand, you can’t deny that, left to labour without intervention, things don’t always go according to plan: the baby is in an awkward position, or the birth canal is too narrow, or the baby’s shoulder gets stuck on the way out, or the placenta is retained and the woman haemorrhages.

Are women’s expectations too high? Or too low?

I hesitate to suggest there should be a happy medium, because I don’t know what a happy medium would look like. But what bothers me about all this is that women are caught in the middle of two competing narratives. Obstetricians at the talk I gave expressed the view that the reason some women find birth traumatic is that their expectations are too high: they think that they can give birth “normally”, with minimum intervention, and are then disappointed to find that that isn’t the case.

But where does that expectation come from? Not, surely, from an innate sense of hubris or over-confidence, but from imbibing the message that it’s possible to achieve a normal, problem-free childbirth by taking a positive mental attitude: if you believe in your own body’s capacity to give birth, the argument goes, then you’re much more likely to have the birth you want than if you approach it fearfully.

Thus are women caught in a Catch-22: going into birth in the hope and expectation that your experience will be “normal” means that you are more likely to be traumatised when things don’t work out as planned; going into birth with an awareness of all the potential problems and risks mean potentially that your own feelings of fear and anxiety will make the experience more difficult and painful.

And women get the blame. Women’s choices are mocked: they are “too posh to push”, for example, or they are “selfish” for wanting a home birth, free of intervention. They are naïve or silly for imagining they can give birth naturally; or they are wasting the NHS’s money by demanding a planned caesarean. A woman’s place is in the wrong, James Thurber once wrote: and if we’re talking about giving birth, then Thurber hit the nail squarely on the head.

 

 

 

 

When childbirth goes badly wrong: one woman’s account

Nilufer Atik has written a striking account of her experience of PTSD after childbirth. Atik was in labour for 53 hours, after which she was given an emergency caesarean.

But it shouldn’t have happened like that. Atik’s labour started with contractions that were “sharp and hard, beginning four minutes apart and lasting between 50 to 90 seconds each time.” The hospital – St George’s in Tooting – told her not to come in because she wasn’t in active labour. She stayed at home in increasing pain for 19 hours until eventually she could stand it no longer. At hospital:

“I was taken to a pre-delivery bay and more torturous hours passed with the contractions increasing in intensity and frequency. I cried out for pain relief and was given the powerful painkiller pethidine four times (most women are only allowed two injections) but it did little to help. With no sleep, food or water, and feeling so exhausted I could barely speak, I became fearful that, if the baby did come, I wouldn’t have the energy to push him out.”

She was eventually given an epidural, followed by a caesarean section when the baby appeared in distress. But the most remarkable part of her story is this:

“Poor Milo was in a bad birthing position with his back against mine and his head hyperextended. It meant not only that my labour was much more painful than it should have been, but I would never have been able to deliver him vaginally. His head was blocking my cervix from dilating, which was why I was having contractions for so long with no progress.”

The time that Atik spent in labour was wasted – physiologically, she wasn’t able to give birth. Why staff at St George’s didn’t realise this is an interesting question, but it may have been to do with the fact that when Atik arrived at the hospital in labour, the maternity ward was extremely busy.

Two weeks ago an NCT survey found that, in the Guardian’s words, “A chronic shortage of midwives across the UK means women in labour are left feeling unsafe and frightened or as if they are being treated ‘like cattle’ or ‘on a conveyor belt’.” It’s not just lack of midwives, it’s a lack of space: one woman even described giving birth on the antenatal ward, because there was no room on the delivery ward.

It’s been said so often that NHS services are at breaking point that perhaps nobody takes it seriously any more. But cases like Atik’s show that the seriousness and the urgency of the problem. When midwives are overworked, the quality of care for women is never going to be good enough. Women will suffer unnecessarily, as Atik did, and may as a result experience physical trauma or psychological trauma that will need treatment later on. Sometimes, babies will die.

 

 

Piers Morgan is wrong

I know the words “Piers Morgan is wrong” are about as remarkable as “The sky is blue” or “Winter is cold” but this time he’s excelled himself.

In brief, Lady Gaga told an interviewer that she suffered PTSD as the result of being raped when she was 19. Morgan managed a double dose of wrongness, first by casting doubt on whether she’d been raped, and then by stating that PTSD was something suffered by “soldiers returning from battlefields” (and by implication, not by people who have experienced other forms of trauma).

We should all of us, even talentless self-publicists, be aware by now that victims of sexual assault don’t tend to report it – largely because they fear not being believed. In that, they are right. Of the hundreds of children and women assaulted by Jimmy Savile, most kept the attack private. The few who did report it found themselves either ignored or accused of lying. If their reports had been taken seriously, Savile would have ended up in prison years ago, and many of his victims would have been spared. The fact that Morgan refuses to believe Lady Gaga now pretty much proves the point.

And if he knows anything at all about PTSD, he should know that soldiers are only one of the groups who suffer from it. Victims of sexual assault, people who have been in a car crash, people who have been attacked by a partner or a stranger, refugees fleeing terror, paramedics who have witnessed a violent death and, of course, women who have been through a traumatic birth can and do suffer from PTSD.

So which are the biggest groups of sufferers? Not soldiers. Rape Crisis reports that 97,000 people in England and Wales (85,000 women and 12,000 men) are raped each year. We know that about 50% of rape victims experience PTSD – that translates into nearly 50,000 people a year, so they may well represent the biggest group. But then there are also victims of domestic violence, asylum seekers and children being sexually abused. A rough estimate suggests that 2% of women giving birth experience postnatal PTSD, equivalent to about 20,000 people a year in England and Wales.

Whichever way you look at it, that’s a lot of PTSD sufferers. A huge number of people experiencing a major mental health problem that is under-diagnosed and under-treated. And what they don’t need, what they really don’t need, is an irresponsible idiot with a high media profile telling them that they’re lying about their experience and lying about their illness.

Severe tearing in childbirth – not just a physical problem

NB I’ve edited this post in response to a comment.

A traumatic vaginal birth involving severe tearing can cause mental health problems, including post-traumatic stress disorder (PTSD), according to a new study from Hans Peter Dietz and Liz Skinner.

About 90% of women experience tearing during childbirth, but most are first or second degree tears, which are relatively mild and heal quickly. Approximately six percent of women have third or fourth degree tears that can damage the anal sphincter.

Dietz and Skinner have done a lot of work in this area, which I’ve written about before. They both feel that the problems of a difficult vaginal birth tend to be overlooked in the drive to reduce caesarean sections, which are usually perceived as more risky for both mother and baby.

The study identified 40 first-time mothers with major pelvic floor trauma and interviewed them one-to-four years after they gave birth. Just over half (22) of the women had “major obstetric anal sphincter tears.”

Of the 40 women, 35 had “Multiple symptoms of pelvic floor dysfunction” causing lifestyle alteration. These symptoms included “urinary or fecal incontinence, prolapse, chronic pain, dyspareunia [painful intercourse]”.

It’s hardly surprising, then, that 27 experienced PTSD symptoms, including “poor baby bonding, flashbacks during sex, dissociation, avoidance, anxiety”.

Probably the most worrying themes to emerge from the study were the lack of awareness or communication from health professionals:

  • 36 women said there was no information provided by clinicians on potential postnatal pelvic floor morbidities
  • 36 said that there was no postnatal assessment of their injuries
  • 26 said that they experienced “dismissive reactions from poorly informed clinicians to maternal injuries. One woman said: “The midwife said that this was OK… but I knew that it was not normal… The doctors really did not understand the situation… I was in shock – devastated and unable to get any health professional to understand.”

Although the study was carried out in Australia, I’d be surprised if a UK study didn’t find something similar. I’ve now heard numerous stories about obstetric tears not being treated properly or women having their concerns dismissed as unimportant. One of the problems is that midwives often don’t see the consequences of tearing in childbirth – women are only under midwife care for 10 days after birth, so if a tear has failed to heal properly weeks, months or even, shockingly, years after birth, they’ll be dealt with by another group of health professionals entirely. So midwives may well assume, wrongly, that a tear during childbirth has healed without problems. And that may lead to an unjustified confidence that obstetric tearing isn’t a significant problem.

As I’ve already reported, the RCOG is now campaigning for better understanding of obstetric tearing in childbirth, and better care for the women who experience it. But we still have a long way to go – and In the meantime, a lot of women are suffering in silence.