Chief Midwife Says Women Shouldn't Have Epidurals? Does he hell.

Well my rant of the day is at all those lazy Fleet Street hacks who really can't be bothered or are too ill educated to read and understand Dennis Walsh's work. The lecture is a thought provoking and thoughtful analysis of where widespread use of pain relief combined with a medicalised birth system is taking modern birth. Read it in full for yourself, then pass judgement but please for goodness sake don't judge based on how the BBC, the Guardian or any of the other hackerati have spun and distorted what DW actually said.

The Zepherina Veitch Memorial Lecture June 2009: The Challenge of Normality in an Epidural Culture

Introduction

The following story from a midwife typifies the complexity behind promoting normal birth within an epidural culture. She had taken over from another midwife, looking after a woman, having her second baby who had been in the latent phase of labour but had recently shown signs of her labour accelerating. In the short time it took to get the handover, the woman had become very distressed. The midwife rapidly tried to develop a rapport with her and gave some advice about focusing on breathing during the contractions. This was not enough and she began on entonox within a short period. The contractions were long and intense, with the fetal heart descending on the abdomen. The midwife recognised the familiar manifestation of transition but by then the women was shouting loudly ‘to go home’, ‘caesarean now’ and ‘get me an epidural’. Her distress was greater on the bed so the midwife encouraged her to get up, though she was continuously monitored because of meconium-stained liquor. She coped a little better upright or on the floor but still vocalised her distress in no uncertain terms. The midwife was faced with a dilemma. She was sure 2^nd stage was imminent but the recourse to the epidural would have calmed the woman and made monitoring the fetal heart easier as she would have been semi-recumbent on the bed. After another 15 minutes, the woman was bearing down strongly and birthed a healthy baby boy.

Later both an anaesthetist and another midwife suggested an epidural was wholly appropriate in this situation and a lively discussion ensued.

Discussion about epidurals is often linked to the broader discussion of medicalisation of childbirth because epidural typifies the ‘cascade of intervention dynamic’ that contributes to medicalisation. Public health concern has prompted the Department of Health in the United Kingdom (UK) to measure normal labour and birth outcomes as well as normal birth outcomes (ICCHS, 2008). A working definition has now been agreed as to what constitutes a normal labour and birth and rightly excludes induction of labour, epidural or spinal anaesthetic, forceps or ventouse, caesarean section and episiotomy. The difficultly of reaching agreement across a multi-disciplinary group is reflected in the fact that it can include augmentation of labour, artificial rupture of membranes, entonox, opioids, electronic fetal monitoring and a managed third stage of labour (Werkmeister et al, 2008). The fact that the Consensus Group had to compromise to accommodate the various positions of the stakeholders represented, indicates how certain procedures and drugs are now considered normal in labour. The ubiquity of oxytocin augmentation and epidural is demonstrated in Mead’s (2004) survey of low risk women when she found that rates varied between 14% and 57%. Furthermore, Symon et al (2007) demonstrated the stark contrast in low risk women’s self-reported intervention rates between midwifery-led units and consultant units – pain agents 25% in the former and 77% in the latter.

The Epidural Epidemic

Epidural rates have doubled in the UK from 17% in 1989 to 33% in 2007-8 (BirthChoiceUK, 2009). There are many reasons for this. The following are possible contributors:

· Elective epidural provision is now a benchmark of good practice in maternity units

· Two generations of women have had access to epidurals so now the mothers of pregnant women are recommending them

· Celeb birth and media portrayals of childbirth often include epidurals

· The professional project of obstetric anaesthetists (e.g. increase in the number of obstetric anaesthetist posts) promotes epidural use

· Over recent decades, there has been a loss of ‘rites of passage’ meaning to childbirth so that pain and stress are viewed negatively (Leap & Anderson, 2008)

· A techno-rationalist society considers pain as either preventable or treatable (Lauritzen & Sachs 2001)

· The pain relief paradigm is dominant in maternity services (Leap & Anderson, 2008)

· The movement to institutional birth (93% hospital v 7% home and birth centres currently) reinforces medical solutions to clinical symptoms such as pain (Walsh, 2007)

· Fragmented models of care and loss of continuity contributes to greater use of pharmacological agents in labour (Hatem et al, 2007)

· Informed choice as an ethical imperative influences practitioners’ response to maternal requests for pain relief in labour (Walsh, 2007)

· The risk discourse predisposes to childbirth intervention including the use of pain-relieving agents (Walsh, 2006b)

Several of these factors work in tandem. Techno-rationalist society (Lauritzen & Sachs 2001) is short hand for a society that equates scientific advances with progress. In relation to pain, technology and drugs have successfully either prevented pain from emerging or treated it effectively when it does. It is counter cultural in such a society to see a purpose to pain, especially physical pain related to biological function which is how traditional and indigenous societies have viewed childbirth over thousands of years. Childbirth is one of life’s great ‘rites of passage’ transitions within traditional societies (Jordan, 1993). Allied to an antipathy to childbirth pain is a risk discourse that carries within it several paradoxes. In the west, it has never been safer to have a baby yet it appears that women have never been more frightened of the processes and of what might go wrong. Hence another paradox is a high degree of risk aversion, yet a willingness to embrace medical interventions like drugs and surgery that carry risks themselves. Mixed messages coexist like a public health message to avoid any form of drug pre-conceptually and prenatally, but accept an epidemic of drugs during intrapartum care. The risk discourse has foisted on women the relative risk conundrum. How do I make choices against a backdrop of arithmetic possibilities? How do you weigh a 1 in 100 risk of a poor perinatal outcome, compared with say the risks associated with driving a car or living in a smog-filled city. The risk discourse can also overplay theoretical risks and rare negative cases in defining clinical guidelines. Finally, its puts a hierarchy on particular risks at the expense of other risks. The recent change in the NICE Guideline (NICE, 2007) regarding spontaneous rupture of membranes at term is an example of this. The risk of neonatal infection overrides others risks of augmenting women at 24 hours. A number of maternity units are noticing their intervention rates increasing in this group.

Side Effects of Epidurals

When it comes to specific risks associated with a medical procedure, epidurals have many. These have been outlined in the literature in some detail. They can be summarised in bullet format thus:

Side Effects on Labour

· increase length of 1st & 2nd stage of labour

· need for more oxytocin

· increase incidence of malposition

· increase instrumental delivery

· (Anim-Somuah et al, 2008)

· increase 3^rd/4^th degree tears (Rortveit et al, 2003)

· may increase in C/S if sited early (Klein, 2006)

Side Effects Maternal

· loss of mobility

· loss of bladder control

· hypotension, headache

· pyrexia (Yancey et al, 2001)

· up to 30% of women get partial but not complete relief

· reduces breast-feeding rate on discharge from hospital (Wiklund et al, 2009)

Side Effects Fetal

· tachycardia due to temperature rise

· neonate more likely to be hypoglycaemic

· diminishes breast-seeking and breast-feeding behaviours (Ransjo-Arvidson et al, 2001)

· Requires continuous CTG

Added to these established side-effects are the following psycho-social and midwifery practice factors:

Psycho-Social

· woman becomes a ‘patient’ in the sense that additional monitoring is required

· choice for epidural is associated with fear of childbirth, giving control over to professionals and passive compliance (Heinze & Sleigh, 2003)

· commonly precipitates cascade of medical intervention

Midwife Practice Effects

· care becomes more technical

· there is a greater need for surveillance

· psychological support needs are less demanding

· midwives are less able to utilise intuitive skills

· the whole package induces obstetric nurse ‘feel’

These latter comments reflect some personal reflections of individual midwives that not all midwives would agree with or see a problem with.

All of these negatives have to be balanced with the fact that an epidural is an excellent procedure in the following situations:

· its makes caesarean section safer

· it can make assistant vaginal birth more humane

· it is valuable for protracted, induced or augmented labours

· it is useful for some women with tocophobia or post traumatic stress disorder

Few childbirth professionals would argue against epidural availability and use in these or similar situations. The pivotal point for discussion is its role for normal labour. A related question is to what extent ‘informed choice’ has become an ethical imperative regardless of context and prior preferences. In the story at the beginning of this article, the scenario of a multiparous woman requesting an epidural in late first stage of labour has been used as an exemplar for the application of informed choice. Many UK midwives would express the tension between responding to a woman’s request in this situation and knowing that this is a transient and challenging part of the labour that will soon pass. Midwives from other countries have expressed surprise when this scenario has been presented in workshops, concluding quite unequivocally that an epidural is not appropriate.

Attitude to Labour Pain

Professionals’ attitude to labour pain is a key area to examine. Leap and Anderson have developed and written about the approach of ‘working with pain’ which addressed this area directly. They contrast ‘working with pain’ with ‘pain relief’ (Leap & Anderson, 2008). The following Table summarises the main differences between these two approaches.

Table 1

Pain Relief Approach Working with Pain Approach

- language suggestive of pain - language suggestive of pain as

as a problem normative

- paternalistic, ‘we can protect - egalitarian empowerment, ‘we

you from unnecessary stress’ are alongside you’

- techno/rationalism age, pain is - labour pain timeless component of

preventable/treatable ‘rites of passage’ transitions

- neutral impact of environment - seminal impact of environment

- clinical expertise of professional - supportive role of birth companions

carers

- special session/focus in antenatal - woven throughout labour

education preparation sessions

- ‘menu approach’ to options for - supportive strategies for

coping with pain journey of labour

- pain as a ‘management issue’ for - pain as one dimension of labour

assembly-line birth care in one-to-one, small scale birth settings

- contributes to trend of rising - contributes to trend to less

epidural rates pharmacological analgesia

- risks of pharmacological agents - ‘cascade of intervention’ dynamic

outweighed by benefits

- first birth special case for ‘menu - first birth optimal opportunity for

approach’ ‘working with pain’

- informed choice means all - informed choice within context of

options must be presented birthing plan and philosophy

(Walsh, 2007)

It is an interesting exercise for midwives to note the number of times the phrase ‘pain relief’ is used in birth settings over the course of a working week. Though the use of the phrase does not necessarily mean that the user signs up to the whole paradigm, it never-the-less conveys a meaning to all who hear it that pain is a problem.

The ‘working with pain’ paradigm is predicated on labour physiology that requires pain to be present for the release of endorphins. These naturally occurring pain easing hormones also contribute to the dynamic behind oxytocin release so that it is neither under stimulated nor over stimulated (Buckley, 2004). Endorphins effects are beautifully captured in Hannah’s birth, a short DVD produced by Sheena Byrom, consultant midwife at Blackburn. What the DVD also captures are the empathic responses from Hannah’s birth companions. Moberg (2003)in her captivating book, The Oxytocin Factor, suggests that this hormone is secreted in both men and women, especially during therapeutic touch. She highlights the necessity to bathe a birth setting in love, not fear. When this occurs, the synergy created is more than the sum of individual parts. Hence the centrality of empathic relationships to the birth process, the importance of an optimum environment and of minimising disturbance. All of this takes on an urgency in an institutional birth setting where some of these factors are already compromised.

Endorphin effects are masked and undermined by epidurals, opioids and syntocinon. If caring for a woman with an epidural is more instrumental and task orientated than intuitive and empathic, one senses a vicious cycle of oxytocin antagonism being set up. Is it any wonder that labours become dysfunctional?

The Transforming Power of Labour

One of the key questions for childbirth professionals in the 21^st century is what will happen to the narratives of transformation and growth in childbirth if normal labour is effectively anaesthetised by the epidural epidemic. These are the countless number of personal testimonies that women share about an experience of growth and empowerment through childbirth. The vast majority of these are characterised by drug-free or low intervention labours, though not all (Thompson, 2004). The most moving ones are from vulnerable women who lives prior to birth had been blighted by abuse or disempowerment. Phrase like ‘my greatest achievement’ (Esposito, 1999), ‘I can do anything now’ (Spitzer, 1995) and ‘I feel so strong’ (Walsh, 2006a) litter these stories and pose a profound challenge to the ‘pain relief’ paradigm. It is difficult to debate the topic because it implies criticism of women who chose or needed intervention, almost suggesting they could be poorer mothers because of it. Emerging evidence that normal labour and birth primes the bonding areas of a mother’s brain better that caesarean or pain-free birth adds to this perception (Swain et al, 2008). In recognition that caesarean birth may undermine birth physiology, obstetricians have been researching the so-called ‘natural caesarean’ to see if normal physiology can be harnessed in this situation (Smith et al, 2008). The advent of the ‘mobile epidural’ illustrates how obstetric anaesthetists are trying to engage with labour physiology around movement and upright posture to recruit those benefits for women with epidurals.

All these attempts to engage with childbirth physiology in the context of medical procedures that undermine them serves to highlight how science struggles to mimic precisely what is natural. The complexities behind oxytocin secretion remind biomedicine that altering one variable (skin to skin in caesarean and movement in epidural) will never reproduce the conditions for maximising physiology. That requires a whole systems approach (Downe & McCourt, 2008), examining environment, attitudes and beliefs, practices, relationships etc. If pain plays an integral role in optimising labour physiology and priming the woman for motherhood, then it is hard to see how an epidural can fit into this whole systems approach.

Elective Epidural Service

In the light of this discussion so far, a rationale certainly exists for questioning the appropriateness of an elective, ‘on-demand’ epidural service, especially if there is public health commitment to increasing the rate of normal labour and birth in the UK. However, given its embeddedness in UK maternity service provision, it would be a brave person who would take up such a position. This paper’s intent is to simply encourage debate about these issues. If the present course is pursued so that in another 30 years epidural rates are 60%, it cannot be predicted what that may mean for women, babies and families. It is unlikely that Zepherina Veitch, the founder of the Royal College of Midwives would have welcomed such a future. She was more concerned with social reform and public health and would probably have resisted the advent of drugs in normal labour.

An anecdote is told of an anaesthetist who used to refer to epidurals as ‘happidurals’. In the context of a fragmented model of care with no continuity, in a clinical environment with little resemblance to home, where women are kept on beds while continuously monitored, it is understandable that epidurals are a welcome relief. But it is important not to confuse system failure with woman’s preference. In fact all over the UK in different birth settings, women are birthing entirely drug-free, even with their first baby. This latter group can be found in midwifery-led units, birth centres and at home. First birth mothers stories of drug-free labours tend to remain hidden in small scale birth settings because they are seldom told beyond these settings. Their testimonies are so important for labour ward midwives and obstetricians to hear because they are routinely exposed to the opposite. Case reviews in maternity hospitals tend of the negative variety. Like the following anecdote from a student midwife, midwives may be losing skills. She feared qualifying because she was not sure she could be alongside women in pain without her own discomfort manifesting. She was also not sure she could spot natural endorphin effect because she had seen so few natural labours.

Conclusion

The evidence is incontrovertible that epidurals undermine childbirth physiology. That rates are now double what they were 20 years ago says much more about the context of childbirth and childbirth professionals’ attitudes than it does about the current generation of women’s ability to adjust to labour pain. In fact there is considerable anecdotal evidence that women adapt their expectations to the service provision so the rare consultant unit that does not have an elective epidural service has not seen a fall in bookings. Similarly, co-located and free-standing birth centres remain very popular. However with these, along with homebirth, representing around 7% of UK total births, the vast majority of women enter a large hospital model where epidural provision is electively available. In this context, the impact on normal birth intervention rates is profound. Addressing this context requires a rethinking of pain paradigms, attention to birth environment, and a move to more relational models of care. Finally, there needs to be a robust debate about whether epidurals really serve society and families best by being an elective choice, especially in relation to normal labour and birth.

References

Anim-Somuah, Smyth R, Howell C Epidural versus non-epidural or no analgesia in labour. The Cochrane Database of Systematic Reviews 2008, Issue 1

BirthChoiceUK (2009) NHS Maternity Care Statistics 2007-8. Available from: http://www.birthchoiceuk.com/maternitystatistics07-08.pdf [Accessed June, 2009]

Buckley S (2004) Undisturbed birth – nature’s hormonal blueprint for safety, ease and ecstasy. Midirs 14(2):203-209

Downe S, McCourt C (2008) From being to becoming: reconstructing childbirth knowledges. In S Downe (ed.) Normal Childbirth; Evidence & Debate. London: Churchill Livingstone

Esposito N (1999) Marginalised women’s comparisons of their hospital and free-standing birth centre experience: a contract of inner city birthing centres. Health Care for Women International 20(2):111-26

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2007, Issue 4.

Heinze S & Sleigh M (2003) Epidural or no epidural anaesthesia: relationships between beliefs about childbirth and pain control choices. Journal of Reproductive & Infant Psychology, 21(4):323-334

Information Centre, Community Health Statistics (2008) NHS Maternity Statistics, England: 2006-07

Jordan, B., 1993. Birth in four cultures: a cross-cultural investigation of childbirth in Yucatan, Holland, Sweden and the United States. Prospect Heights: Waveland Press.

Klein M (2006) In the literature: epidural analgesia: Does it or doesn’t it? Birth, 33(1):74-76

Lauritzen S, Sachs L 2001 Normality, risk and the future: implicit communication of threat in health surveillance. Sociology of Health & Illness 23(4): 497-516

Leap N, Anderson P (2008) The role of pain in normal birth and the empowerment of women. In S Downe (ed.) Normal Childbirth; Evidence & Debate. London: Churchill Livingstone

Moberg K(2004) The Oxytocin Factor. New York: Perseus Books

Mead M (2004) Midwives’ perspectives in a 11 UK maternity units. In S Downe (ed.) Normal childbirth: evidence and debate. London: Churchill Livingstone

NICE (2008) Induction of Labour. London: RCOG. Available from: http://guidance.nice.org.uk/CG70/Guidance/pdf/English [Accessed June 2009]

Ransjo-Arvidson A, Matthiesen A, Lilja G, et al (2001) Maternal analgesia during labour disturbs newborn behaviour: effects on breastfeeding, temperature and crying. Birth 23(3):136-143

Rortveit G, Daltveit A, Hannestad Y, Hunskaar S (2003) Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study. American Journal of Obstetrics & Gynaecology, 189:1268-74

Smith J. Plaat F, Fisk N (2008) The natural caesarean: a woman-centred technique. BJOG, 115(8): 1037–1042

Spitzer M. (1995) Birth Centres: Economy, Safety and Empowerment Journal of Nurse-Midwifery Vol. 40, No. 4 July/August pp371-375

Swain J, Tasgin E, Mayes L, Feldman R, Constable R, Leckman J (2008) Maternal brain response to own baby cry is affected by caesarean section deliviery. Child Psychology and Psychiatry, 49(10):1042-1052

Symon A, Paul J, Butchart M (2007) Self-rated ‘No’ and ‘Low’ risk pregnancy: a comparison of outcomes for women in obstetric-led and midwife-led units in England. Birth, 34(4):323-330

Thomson, G. (2007) A Hero's Tale of Childbirth: An Interpretive Phenomenological Study of Traumatic and Positive Childbirth. Unpublished PhD Thesis, University of Central Lancashire

Walsh, D. (2006a) Improving Maternity Service. Small is Beautiful: Lessons for Maternity Services from a Birth Centre. Oxford: Radcliffe Publishing

Walsh, D. (2007) Evidence-Based Care for Normal Labour & Birth: A Guide for Midwives. London: Routledge

Walsh D (2006b) Risk and Normality in Maternity Care. In A Symon (ed.) Risk and Choice in Childbirth. London: Elsevier Science

Werkmeister G, Jokinen M, Mahmood T, Newburn M (2008) Making normal labour and birth a reality—developing a multi disciplinary consensus. Midwifery, 24, 256–259

Wiklund I, Norman M, Moberg K, Ransjo-Arvidson A, Andolf E (2009) Epidural analgesia: breast feeding success and related factors. Midwifery, 25(2):e31-e38

Yancey M, Zhang J, Schwarz J et al (2001) Labour epidural analgesia and intrapartum maternal hyperthermia. Obstetrics & Gynaecology 98(5):763-70

No. of words (excludes refs and abstract) 3000

Abstract

With epidural rates doubling in the United Kingdom over the past 20 years, the impact on normal labour and birth in profound. Rates if labour and birth interventions have risen inexorably over that time. Changes have also occurred in wider birthing milieu such as the rise of a risk discourse, the diminishing of a ‘rites of passage’ meaning to birth, the growth of obstetric anaesthetic services and the advent informed choice in maternity care policy. This paper discussed the impact of these changes on normal birth, and, in particular on the attitude to pain in labour. An elective epidural service is critiqued and a call made for an urgent debate on how maternity services and ultimately society should respond to these profound changes.

Key words: epidural, normal birth, risk, pain

Author:

Dr Denis Walsh, Associate Professor in Midwifery, Nottingham University, UK

Boob Bashing Bonanza Hits Fleet Street Again!

Well here we go again, the annual Have a Pop at Breastfeeding Week begins again next week but the Daily Mail has got in there extra early with a corker of an article slating the Breastfeeding Gestapo - an idle angle on the Nipple Nazi tag of previous years. In any other profession but journalism you would be honour bound to at least debrief your own previous experience so that it didn't impair your professional judgement but Fleet Street seems to attract women with such bitter personal experiences of birth and breastfeeding that they are no longer able to differentiate between fact and their own painful memories. Worse, having been let down so horrendously by the medical profession they turn their anger on the charities and volunteers who support women to breastfeed.

I'm tempted begin each breastfeeding class now with "My name is Jenny and I am not a nipple nazi! I promise to continue to show you non judgmental, empathetic support with unconditional positive regard as demanded by the body which has provided me with more training than most midwives, health visitors or doctor you will meet in your parenting career. I will continue to give up my unpaid family time through evenings, weekends and bank holidays when every health professional has shut their surgery to offer you an opportunity to talk to someone who will listen without giving advice and to suggest practical ways to enable you to breasteed if that is what you want to do.

I am not and have never been in the business of telling people how they should parent their children. I have never felt compelled to strut about clicking my heels and ordering women to breastfeed nor have I ever tried to make mothers feel guilty for not breastfeeding. I don't actually believe women who formula feed should EVER feel guilty about not breastfeeding because all too often they have been given woefully inadequate support and information by their health service and have been brought up in a culture that neither values nor supports breastfeeding. Worse still, should they succeed, against the odds, in breastfeeding and wish to go on to support other women they get labelled in national newspapers as The Breastfeeding Gestapo or Nipple Nazis or Lactivists (actually I quite like that one).

I am not however going to lie to you and say that breastfeeding doesn't matter.
It does and there is extensive research to prove that not breastfeeding makes a big difference to mother and baby health but because we are so terrified of 'hurting mothers feelings' and 'making women feel guilty' we misrepresent this routinely as The Benefits of Breastfeeding. So most women think they are being nagged at and pushed to do something that feels alien, that their mother probably didn't do and which doesn't feel normal, never mind natural and whose value they do not clearly understand.

I do know what it feels like to give up breastfeeding, to feel like a Bad Mother, a failure for turning to formula feeding but the blame for that lays squarely with the health professionals who didn't give me accurate information or the skills to do the job, with society for destroying our breastfeeding culture in order to make money out of formula milk and yes, with myself for not informing myself of where to get accurate information support.

As a first time mother, I spent more time looking at buggies than I did finding out about how breastfeeding works and how to get good quality support locally if I was struggling. I have let myself off the guilt hook as I was terribly naive then about how the NHS works and I thought that if they were prepared to spend thousands of pounds on producing posters and pens telling me how MARVELLOUS breastfeeding is, they'd have spent a couple of quid on training their staff and putting enough of them in a town near me so that I'd have an evens chance of success. And when on New Year's Eve I sat sobbing with bleeding nipples and no midwife due to come for 3 days and no idea at all how anyone could help me it was no wonder that the lure of the 24 hour Tesco with its formula solution proved all too much.

It wasn't until 3 years later, expecting my second child sat in an NCT class - I hadn't done them first time around - that I discovered several things that all potential lactactors should know:

1- Your health service almost certainly doesn't have enough qualified personnel to support you through the early days of breastfeeding if all is not going well and you should not rely solely on this.

2 - You probably have a network of trained, expert volunteers near you which you can access free of charge. This is more difficult in London and may partly explan why most journalists on national newspapers do not seem to breastfeed but it helps if you do your research while pregnant so you are not trying to find good quality support when you are frantic with a screaming baby.

3 - Breastfeeding works very well for a lot of women BUT if you experience some of the problems there is no substitute for a qualified and experienced pair of eyes to have a look at positioning which causes about 90% of the problems in the early weeks.

4 - Breastfeeding should not hurt. Sore, cracked and bleeding nipples are not normal but if someone can help you correct baby's position then they can get better very quickly. Do not believe anyone who tells you the baby's position is right if it is hurting you, get another opinion.

5 -The vast majority of women can produce enough milk for their baby but they may have to adjust their expectations of how they will parent to accommodate the normal behaviour of a breastfeeding baby. We no longer understand what normal behaviour is because we have grown up in a bottlefeeding culture - so the breastfeeding baby who feeds hourly or cluster feeds for four hours of an evening or who wants to be carried all day or who prefers to co-sleep is seen as abnormal, a problem to be fixed.

6- It's OK to ask for help. In an ideal world we would have wise women all around us, mothers, aunts, grandmothers and friends who would all have breastfed or still be breastfeeding their own babies. We would have grown up watching other women sort out the common niggles and would not be surrounded by well meaning people who bottlefed and are managing their own feelings about it and who may not be entirely unbiased when they say "Oh just give him a bottle, it never did you any harm." Organisations like the NCT, La Leche League, the Breastfeeding Network are there trying to stick a nipple in the gaping hole caused by 30 years of relentless marketing of formula and the resultant loss of societal knowledge and shared experience of breastfeeding.

7- Not all health professionals are well trained about breastfeeding and not all counsellors or supporters have the same training. Midwifery and health visitor training about breastfeeding is improving, particularly if your local NHS hospital or trust is involved in the BabyFriendly Initiative but knowledge and skills and resources may be limited so do a bit of research beforehand to discover who is in your area. GP's have widely varying knowledge about breastfeeding. Almost without exception health professionals are not offered an opportunity to debrief their own experience and their own baggage can impact on the advice they profer.
Peer supporters or breast mates or breast buddies or whatever they are called are local mums who have breastfed and who have had 2-3 hours of training. This is not the same as a qualified breastfeeding counsellor who will have trained for 2- 3 years and an accredited qualification. That is not to say that a peer supporter can't do a fantastic job of listening and supporting but you may need more in-depth knowledge than that.

8. Breastfeeding does matter. Sometimes your circumstances make it extraordinarily difficult or your choices become extremely limited through absolutely no fault of yours. Women mother these days under all sorts of pressures and with very little suport. But the reason that we have Unicef working in this country to increase our breastfeeding rates, the reason that government gives its mealy mouthed support to Breastfeeding Awareness Week, the reason that the World Health Organisation, the NHS, La Leche League, the NCT promote breastfeeding is NOT because of some nostalgic, rosy tinted longing for the return of some mystic ideal but because as a society we would be so much healthier if babies were breastfed. Fact. And if you didn't manage to breastfeed it probably isn't your fault - but it isn't breastfeeding's fault either and it most definitely isn't the fault of your local breastfeeding supporter.

All of which is why I'll still plug on, offering my support to women both locally and on the national line run by the NCT because I'm trying to make a difference to the few I can help . I do this not because I'm some superior being trying to live out some superior race fantasy but because I was once that mum crying on the sofa who did get warm, non judgmental, mother to mother support from a volunteer when she most needed it.