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.

At last: the NHS acts on maternal mental health

Good news: in the next five years, NHS England will create 20 new specialist treatment centres for women who suffer from mental health problems during pregnancy or after birth.

This has been a long time coming. For years the government has promised to address the poor quality of mental health care for new mothers, and finally it’s putting its money where its mouth is. Admittedly it’s not very much money – the centres will be funded to the tune of £40m, which is unlikely to cope with the scale of the problem: an estimated one in five new mothers (about 120,000 women a year) experience mental health problems.

The majority of these women suffer from postnatal depression, but a substantial minority will have post-traumatic stress disorder (PTSD). The most conservative estimate for PTSD after childbirth is 1.5% (about 10,000 women a year in England and Wales), but researchers now think that the true figure is probably double that. PTSD can’t be cured with a pill: treatment, usually trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) takes several weeks, and is expensive.

Having spoken to many women suffering from postnatal PTSD, I know that it can be hard to find specialist help. It’s not unusual for women to have to wait months for treatment, during which time they suffer the stress of flashbacks, nightmares, anxiety and terror. They are often frightened to leave the house and avoid contact with other new babies, making them isolated on top of everything else. All of these things have an impact on their relationship with their baby and with their partner. It’s not surprising that ­– according to the Guardian report of the NHS’s plans – perinatal mental health problems cost the UK £8.1bn a year.

So while I welcome the new centres as a step in the right direction, much more needs to be done to make sure that women with PTSD and other mental health problems receive the support they require. Even more importantly, I would love the NHS work towards preventing these mental health problems from arising in the first place. Most women with postnatal PTSD believe that it was caused, not solely by a traumatic birth, but by the feelings of helplessness and lack of control during the experience, and by the casual and sometimes even cruel attitude of healthcare professionals looking after them.

Some of this can be addressed by better recruitment and better staff training. But the NHS also needs to adopt rigorous standards of care that hold health professionals accountable: making sure that procedures aren’t carried out on women without their consent, for example, or that women are denied necessary pain relief. In a 21st century health service, in a wealthy democracy these things shouldn’t be difficult, but the stories I hear from traumatised women about poor care show we still have a very long way to go.

It’s time we talked about perineal trauma

Today’s Victoria Derbyshire programme had an excellent film about perineal injuries during childbirth. You can read the associated article and see the film here (it’s about 15 minutes long). Four women shared their experience of having third or fourth degree tears during childbirth, resulting for some of them in urinary or bowel incontinence.

One of the striking facts in the film was that between 2000 and 2012, the rate of severe tearing during vaginal delivery increased from 2% to 6%. Although the programme was careful to state that this was “very rare”, in practice this translates into about 30,000 women a year. This huge increase in the rate, an obstetrician told the programme, was down to three main factors: the older age at which women have their first baby; an increase in the size of babies being born; and women themselves being bigger and heavier. But this isn’t necessarily the full explanation: the increase may simply be down to better recognition of tears as a result of the implementation of standard classification.

The programme also read out text messages from viewers. What was sad was the clear variability in treatment available. Although some women said their injuries had healed, others said they had been fobbed off when they complained about their perineal injuries, or that the injuries had persisted over months and years. One of those interviewed on the programme was effectively told that it was all in her head.

The good news is that the professionals are now taking this seriously: the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) have developed an intervention package to reduce tearing in childbirth. The package is really just a simple change to the recommended way in which midwives deliver the baby, which has been shown to reduce tearing. It is being piloted in a number of hospitals and will eventually be rolled out throughout England.

Nonetheless, it’s shocking that in this day and age that a problem affecting so many women isn’t talked about or even taken particularly seriously. It was clear from the programme that many doctors aren’t adequately trained to deal with perineal tears. That – as well as better care during delivery – needs to change.

Too posh to push? I think you’ll find it’s a bit more complicated than that

A story last week claimed that caesarean sections were on the rise because women are demanding them.

The Times story, headed “Hampstead mothers are behind rise in caesareans” began like this:

“Caesarean sections are twice as common in some NHS hospitals than others, according to a report that suggests some doctors are more willing to give in to women’s demands for the procedures.”

Middle-class women – and middle-class mothers in particular – seem to be a particular focus of hate for a lot of the press, which is odd, given that middle-class mothers make up much of their readership. “Hampstead mothers” is a real dog-whistle phrase, conjuring up as it does posh, entitled women who have the nerve to think they should be able to deliver their babies whichever way they want, rather than meekly doing what the doctor tells them. (Let’s assume the Times doesn’t want us to believe that women living in Hampstead are literally behind the rise in caesareans throughout the country.)

There’s even a faintly disapproving quote from Louise Silverton of the Royal College of Midwives: “Some women do opt for a caesarean section because they can’t cope with the uncertainty. They control the rest of their lives, but they can’t control labour.”

What a bunch of feeble losers, eh?

Or could there be another reason why women have caesareans? Both Susanna Rustin and Hadley Freeman in the Guardian do a good job of showing how ridiculous this story is. Freeman points out that the rising age of women giving birth and the growing size of newborns are both factors in the growth in caesarean sections.

But we should also remember that most caesareans aren’t carried out as a result of the woman demanding them. The national c-section rate now stands at 26.2%. Half of those are emergency caesareans, carried out when something has gone wrong and the procedure needs to be performed urgently to save the life of the mother or the baby.

The other half are “elective” or “planned” sections – a misleading name, because they imply that the woman has elected to have them. In practice, “elective” simply means that the caesarean has been scheduled in advance, almost always for medical reasons: placenta praevia, which means the birth canal is blocked, and the baby cannot be born vaginally; a breech presentation, which makes a vaginal delivery more difficult; or the woman has had a previous caesarean, and a vaginal delivery might be dangerous.

Sometimes women do choose a planned caesarean (and sometimes doctors refuse – it’s not a given that obstetricians will agree to perform the procedure). Why? Well, not because they’re entitled or pushy or hate uncertainty. Very often it’s because they’ve had such a traumatic experience the previous time that having a caesarean feels like the safer, less frightening option. Or perhaps they’ve had a caesarean before and don’t want to risk rupturing the scar (a small risk, but nonetheless a real one with potentially fatal consequences). Perhaps they suffer from tokophobia – an extreme fear of childbirth.

For what it’s worth, I’ve never met a woman who has opted for a caesarean because she “can’t cope with the uncertainty” or is “too posh to push”. Giving birth is almost always going to be an intense and painful experience, however the baby comes out. It’s time to stop making women feel worse by berating them for supposedly giving birth the wrong way.

Maternity Review: the good, the bad and the not quite sure yet…

Today saw the publication of Julia Cumberlege’s Maternity Review, Better Births. Commissioned in the wake of the Kirkup investigation into the deaths of babies at Morecambe Bay, its remit was to improve the outcomes of maternity services in England.

I’ve had a look and there’s some good stuff in there. The personal maternity care budgets have been grabbing the headlines, but there are some recommendations that have been overlooked. These include:

  • Thorough, open, multi-team investigations when something goes wrong, such as a baby dying
  • A national, standardised process for investigating mistakes
  • Collection of data on the quality and outcomes of maternity services, so that maternity teams can measure their own performance and compare it against other maternity teams
  • Multi-professional working, with teams of midwives and obstetricians working together in the best interests of mother and baby

These all represent a huge step forward. One of the big problems at Morecambe Bay was the lack of communication between midwives and obstetricians, and an apparent “them” and “us” mentality. There was also an unwillingness to investigate when things went wrong, so that the same things kept going wrong, time and time again.

It’s very important that people are able to learn from their mistakes. The aviation industry was able to slash the number of air accidents by adopting an open approach to errors: encouraging staff to report their own mistakes without fear of being blamed and to come up with suggestions for improvements. But there has long been a culture of blame and cover-up in the NHS – time and again I’ve heard stories from women of trusts that failed to acknowledge their mistakes and sought to put the blame elsewhere. A remarkable number of trusts manage to “lose” a woman’s maternity notes as soon as a complaint is made. So a move towards acknowledging mistakes and putting steps in place to rectify them is long overdue.

On the other hand…

There are other elements of the maternity review I’m less sure of.

The recommended change to payment systems needs to be treated with caution. The review wants to “shape the payment system to reflect the different cost structures of different models of providing care” and also to “incentivise community deliveries where clinically appropriate”.

It suggests “working with providers to undertake a bottom-up costing exercise and proposing adjustments to the existing tariff in light of this so as to more accurately reflect relative costs. This could include potentially introducing different prices for home births, freestanding midwifery units, alongside midwifery units and obstetric units.”

Obviously it’s important that women have the choice to give birth at home or in a midwife-led unit if they prefer. But there is a danger that trusts will try to save money by encouraging women towards those options when they’re not clinically appropriate. As soon as you offer financial incentives, you also offer an incentive to cast clinical judgement aside in favour of saving money.

Personal budgets – too many unanswered questions

Finally, we’ll have to wait and see what happens with personal budgets, but it’s difficult to see how they will work in practice. Personal budgets have been used successfully for people with long-term conditions, but giving birth is unpredictable: if you use your budget up on antenatal classes and hypnotherapy, what happens if you suddenly need an expensive emergency caesarean? Or if you want to sue your private provider, paid for by a personal budget, who pays – the provider, or the NHS?

More fundamentally, women need good quality care, and the opportunity to choose between a number of poor options is not really a choice at all. So, while I’m not totally against personal budgets, I’d really need to see a lot more detail before I’m convinced they’re the route to delivering the best outcomes for women and their babies.

Therapy can help – and it should be available to every new mother who needs it

The children’s author Louisa Leaman has an excellent piece in the Guardian about how cognitive behavioural therapy (CBT) helped her recover from a traumatic birth. Louisa’s experience sounds harrowing:

“A diagnosis of placenta previa major – a serious obstetric complication – meant that by the time Emil was delivered via emergency C-section I’d had 14 haemorrhages, three blue-light ambulance rides, four blood transfusions, five weeks in hospital and two months of bed rest.”

Both she and her baby, she was told, could have died.

It’s not surprising that, after such an awful experience, she suffered from post-traumatic stress disorder (PTSD).

What’s encouraging about Louisa’s story, however, is that she lived in a part of London where new mothers with mental health problems are referred to therapy, and she was lucky enough to see an NHS therapist specialising in CBT. After 10 sessions – at which Louisa was allowed to bring her baby – she felt much better. As she puts it: “No more flashbacks. No more crazy paranoia. No more guilt.”

So many of the stories from women who have suffered a traumatic birth are ones where there is no resolution, no happy ending. Some women live in parts of the country where there is no automatic referral to a therapist of any kind, let alone one who specialises in perinatal health. Women offer suffer symptoms – those flashbacks, that paranoia – for years. Louisa’s story shows that it doesn’t have to be like that: good therapy from a sympathetic, qualified therapist can work wonders.

Which is why we must hope that David Cameron follows through on his promise to provide specialist psychological support for women who suffer mental health problems related to giving birth. At the moment, it’s not clear what this support will involve, nor where the money is going to come from. But there’s absolutely no doubt that it’s needed. As Simon Stevens, chief executive of the NHS, is quoted as saying in the Guardian report:

“At the moment about 40,000 women who are pregnant or within the first year of having their baby have a severe mental health problem. But of those 40,000 only about 10,000 are at the moment getting access to specialist perinatal mental health services. Three out of four are missing out. But by the end of the decade we are going to make that a universal offer, so all 40,000 will get access to a local specialist team.”

Traumatic births: women tell their stories

It can be hard for women to speak out about their traumatic birth experiences. There’s a widespread perception that all that matters is a healthy baby, and that women should be grateful for a modern system of medical care that means they are unlikely to die in childbirth.

Of course, it’s great that most of us don’t die in childbirth any more. But not dying is setting the bar pretty low for our expectations for medical care. If we go into hospital for surgery, for example, we do usually expect a bit more from the care we receive than simply “not dying”.

So I welcome it when women are prepared to talk about what happened to them in childbirth and to highlight some of the poor practice that still exists. A new photo series called Exposing the Silence gives a voice to women who have experienced shockingly bad care.

The women in the photos speak of having procedures such as episiotomies or membrane sweeps performed without their consent or of being able to feel themselves being cut during caesarean-sections. A lot of the women speak of the trauma they felt after having their preferences ignored or dismissed.

These stories come from the US, but I’ve heard similar experiences in the UK. The story recounted by one of the women is not, sadly, uncommon:

“‘Do you understand you are doing this without my consent?’ As they are putting needles into my arm, I’m telling them, ‘You are doing this against my will.’ Their response, even as my strong contractions grew faster and I was in active labor, was, ‘I can’t wait all night, and we are doing this now.’ Less than an hour later, he was born, taken from me before I could hold him longer than a minute or two, and not returned until almost three hours later, even though he had no complications. I cried every minute and couldn’t stop thinking, this isn’t supposed to be like this.”