Category Archives: public health

Health for All Children, 5th edition

I’m delighted to be able to plug the latest edition of Health for All Children (5th ed), edited by Alan Emond, particularly because I co-authored one of the chapters (on Opportunistic Surveillance in Primary Care).

I was very pleasantly surprised but happy to be asked to co-author the chapter with Prof. Philip Wilson from the University of Aberdeen, with whom I first interacted after my blog post of 2013 about Triple P (still the piece of writing I’ve done which I’d say has had the most impact, in terms of comments, quotes, links, and opportunities for connections such as this one). I found the co-authoring process really positive and very much enjoyed it (despite a few early pre-work starts and use of annual leave to get it done – not something I’d recommend!). We met up and discussed what we wanted to include (as this is a topic which had not appeared in previous editions of the books, so we had a pretty blank canvas), and then divided up sections between us. I then started the chapter, sent it to him for comments, edits and for his further input, and then we pretty much batted it back and forth between us till submission. This continued after we had received first editor and then stakeholder comments, and so I can say that it was a truly collaborative effort where the joins between the two authors’ writing isn’t immediately obvious!

The chapter summary is as follows:

This chapter:
* looks at the opportunities that clinicians in the primary care team have to identify and assess problems in child development in contexts other than scheduled assessments, when parents may not themselves have identified a developmental concern
* describes the domains of child development in which clinicians might identify problems opportunistically, how opportunities for identification can be maximized, and how common problems might be picked up and confirmed.
* considers how practitioners need to be aware of, and alert to, concerns about physical and social/emotional development, as well as signs of maltreatment and neglect and the quality of parenting.

It has been a while since I was involved in any significant academic writing, having left academia in 2015, so I was a bit apprehensive and nervous about writing this, but my co-author was very supportive and believed in the contribution I could make, which helped enormously. Also helpful was the fabulous PhD by Caroline King (currently based at Glasgow Caledonian University) critiquing the previous edition of the book in the context of a qualitative study of health visitors, which gave me the mental and intellectual headspace to get back into an academic as well as practice-based mindset. And whilst I am not likely to do lots more in the way of academic writing, the opportunity to use my brain and critical faculties in examining and evaluating the relevant research was a very fulfilling experience. I hope that the chapter, and the book more widely, is useful for primary care practitioners working in the area of child health.

Thoughts on World Breastfeeding Week 2014

I have been on a bit of a blog hiatus; in November last year I gave birth to a beautiful baby and I have been experiencing the roller-coaster of parenthood ever since. I am still on maternity leave and hadn’t particularly intended on blogging while off work, but a couple of things have appeared in the media over the last week or so which started to get the rusty braincells stretching again. For this post I want to concentrate on World Breastfeeding Week 2014, which is this week.

I hadn’t particularly given awareness days/weeks/months any critical thought up till a couple of years ago, probably because I have not been particularly affected by the issues demanding awareness. However, I remember reading a blog piece (I think on Feministing although I can’t find the exact post now) one October about the onslaught of pink that Breast Cancer Awareness Month brings each year. This piece, from the perspective of a woman who (if I recall correctly) had had breast cancer herself, pointed out that for people like her, and her loved ones, they were all more than aware of breast cancer, that merely giving something a pink wrapper will change nothing, that buying pink products may make people feel they have ‘done their bit’ even though they don’t know where their money is being donated, or what proportion of their money is being donated, or whether the charities receiving the funds from the pink goods are focused on research, treatment and/or ‘awareness’. Not to mention the infantilising and gender-dubious nature of a lot of the pink products themselves. I also saw comments from a friend (now cancer-free) who talked about hating the annual promotion of ‘Race for Life’ as it was a constant reminder of the cancer she had experienced and could potentially face again. In addition I think that Dr Margaret McCartney’s concerns in the BMJ about the annual Movember campaign are a useful contribution to the debate about ‘awareness’ and what it is trying to achieve, as well as potentially unintended consequences: BMJ.

As a health visitor I was (and am) always totally committed to supporting breastfeeding. This year though I have the extra experience of being a mother, and not only that, but a mother who has had real struggles with breastfeeding. Without getting into too many personal details, I had poor milk supply from the beginning (I suspect a combination of medication I had to take antenatally till about 8 weeks postnatal, recovery from Caesarian section, stress and who knows what else) meaning that from day 2 I had to start mixed feeding. I have never ever felt guilty about this, as I know that it was the right thing to do for my daughter (watching your baby not thrive is not an experience I’d wish anybody). I have though, always felt so very disappointed – breastfeeding was the one thing I so so wanted to do and for it to go well, and it not going well still makes me really upset. It didn’t help that I beat myself up for it – as a health visitor I have supported I don’t know how many people with breastfeeding, including having mothers telling me they would have given up without my help; I have done the UNICEF Baby-Friendly training; I know what to do, and yet it just wasn’t happening for me. I had a ton of help and support from health professionals (and have to say that the staff at Forth Valley, both in the hospital and community, are an absolute credit to the NHS, I was so impressed with them) and also a breastfeeding support group which was, and remains, a lifeline. It seemed like the whole world had observed me feeding and thought that the positioning and attachment was fine, but even despite the supplementation with formula it took a few months before my daughter started putting on decent amounts of weight, which was a real worry. Although I never experienced problems like mastitis or thrush I did experience awful pain for the first few weeks, and all in all it has to be said that it was nothing like the beautiful Zen-like experience that I had hoped for and (if I’m honest) expected.

Eight and a half months later, against the odds, I am still doing some breastfeeding at each feed. I am also topping up with formula milk at each feed, but I am really proud of myself for getting this far and still giving some breastmilk (most of the people I have talked to have said that they would have given up long ago). I have though been doing a lot of thinking about the messages we send as health professionals about breastfeeding, and I hope that this experience will make me a better and more thoughtful (and critical) practitioner.

Checking out the World Breastfeeding Week tweets on twitter has been a bit depressing, I’ve thought. I appreciate that a 140-character medium isn’t going to be the best for subtle and nuanced consideration of the issues and the message is distilled down in the most part to ‘it’s wonderful, with the right support and correct positioning anyone can do it, breast is best’. But I had tons of support, from both health professionals and certified lactation consultants, got positioning and attachment right (bad habits crept in later, not least thanks to De Quervain’s tenosynovitis which meant that I had trouble bringing the baby to the breast and it is infinitely less painful to do it the other way round), I knew all the tricks in the book (having studied the damn book enough!) but it still just didn’t work the way it is always presented. I never had the sensation of my milk ‘coming in’ on day 3 (or at any point after that), I have never felt any sensation of milk ‘let-down’ at the start of a feed, I never managed to express more than a few mls at any one time (yet another disaster to make me feel even crappier!). In the worst first few weeks I looked up all I could about breastfeeding problems, and found a research paper on breastfeeding idealism which was basically the research project I would have loved to do if someone hadn’t already done it: Hoddinott et al 2012. This research talks about the gap between education messages about breastfeeding and the messy reality. More recently I read Burns et al 2012 which is about how midwives talk about breastfeeding and the effects of the language used. Both have got me thinking about how I could best as a practitioner support women who want to breastfeed without resorting to one-size-fits-all messages or trite soundbites. I think we do parents a great disservice by presenting breastfeeding as easy, natural and ‘best’ while denying that many women find it difficult, heartbreaking, painful and stressful. If nothing else, I really hope that my less-than-ideal experience with breastfeeding leads to me being more use to families I may work with in the future.

But what about breastfeeding awareness and World Breastfeeding Week? This piece by Hollie McNish is a reflection for World Breastfeeding Week on some of the reactions she got to her poem on breastfeeding going viral online earlier this year. I am lucky that I have never (to my knowledge) faced any disapproval for breastfeeding in public, but know that negative attitudes are still common. And while anyone thinks that it is acceptable to compare breastfeeding with sex or urination/defecation, or that breastfeeding will turn baby girls gay and baby boys sex-crazed, then yes absolutely we need breastfeeding awareness, and not just for one week a year. There is work to be done on so many fronts. Let’s just think about how we can do it in a way that doesn’t trivialise, or infantilise, or fetishize, this complex, beautiful, difficult, wonderful process.

On being paid to breastfeed

There’s been a fair bit of coverage today of this story that a trial is beginning in a couple of deprived areas of Yorkshire of paying new mothers up to £200 in shopping vouchers to try and encourage them to breastfeed for 6 months, with a view to extending the scheme if it proves successful. Breastfeeding is a subject currently high up in my consciousness, as I have just started maternity leave (no baby as yet though! 🙂 ) and do intend if possible to breastfeed if I can. I have really mixed feelings about this initiative.

In my last post I ranted about people constantly referring to breastfeeding as “free”. As I said there, it is only “free” in the sense that money doesn’t change hands the way it would if milk was bought and sold. The demands on a woman’s (and wider family’s) time, work, health, etc are not to be sniffed at, and there are plenty of economic implications. Breastfeeding doesn’t always work out quickly, sometimes it can take several weeks to get properly established, and in that time the woman might experience pain, stress, and complications requiring help from health staff and/or medication – all of which cost money (OK not to the woman directly, but they have to be paid for somehow and it is the health services that pick up the tab). Even if it does work out, for someone exclusively breastfeeding the physical costs of feeding every few hours day and night are not to be taken lightly. And on return to work, if you are still feeding whilst the baby is in childcare, there is a cost to the employer of providing facilities for expressing breastmilk (a private room and a fridge, as well as time).

So part of me kind of welcomes the monetary aspect of this – I don’t necessarily think it is a bad thing that the financial aspects of breastfeeding are explored and discussed. Having said that, I suspect that would be an unintentional outcome of the initiative – I don’t think the vouchers are there to extend the debate, just to simply act as an incentive. Incentives in themselves aren’t necessarily a bad thing – it would be great if breastfeeding rates could improve, and nationwide they appear to be quite stubbornly not growing currently. However, I am not convinced at all that this is the way to go.

I have a number of concerns. One particular red flag in the BBC article linked to above was the sentence “Midwives and health visitors will be asked to verify whether the women are breastfeeding.” It reminded me of the concerns that lecturers had/have in higher education about having to verify whether foreign students are attending lectures and reporting back; if we had wanted a police role we would have trained to be police officers, not nurses/lecturers. As it is, health visitors are often already seen as the breastfeeding police (and not in a good way! – I think a common perception is that we will bang on about breastfeeding regardless of whether the woman wants to continue or not, and are unsupportive to families who choose to formula feed), and I don’t think that this will particularly help the therapeutic relationship that we all strive to build with families. I want to offer support to families to feed in the way they choose, not police whether they are meeting the criteria for a particular benefit/incentive. Also, this scheme does nothing to address the gaps in service which might lead to women not being supported – yes by all means give vouchers, but if there are not enough appropriately trained health professionals to offer support when the going is tough, the vouchers aren’t going to solve breastfeeding issues.

There is also the class issue to consider – this initiative is currently aimed at a more deprived, lower socio-economic area, with the assumption appearing to be that money is therefore an appropriate incentive to offer. There are plenty of so-called working-class women who breastfeed, and plenty of affluent women who choose not to, and I worry that the use of monetary incentives in deprived areas could act in a way to stereotype further the people who live there. I think that it would be better to provide more funding to train more health professionals to high standards in the full range of infant feeding, for all families who want/need that support, and provide the ongoing support needed instead of simply being the Breastfeeding Police monitoring who’s claiming the money.

The politics of infant feeding

I read a couple of articles about breastfeeding recently which got me thinking about infant feeding more generally, and the messages that society and professionals give about it. This is not a post detailing the benefits of breastfeeding (although I happen to think breastfeeding is great when it works, and would be my personal choice if possible, it’s not always that simple, and there are plenty of other places where that is debated), but is more about the judgment that other people make on women’s choices.

First up, this News Shopper article from Bromley, about a breastfeeding mother who was made by a Job Centre worker to leave the meeting she was in because she was breastfeeding. I don’t have much to say about the actual story – I happen to think that the Job Centre worker was absolutely out of order, and if they found breastfeeding really that disgusting they should have left and found someone (a manager?) who could continue the meeting. What I found more interesting/depressing were the comments that follow the article. There is a lot of class judgment being expressed (the mother is on benefits, and has 5 children), but also a lot of pro/anti-breastfeeding posts – asking if she’s “one of these militant breastfeeders, that whip it out and stick it on, with the aim of shocking as many people as possible”, and referring to her as “a breeding machine” and “an exhibitionist”. One of the comments says that given the circumstances she should have expressed her milk into a bottle in advance (as if it were always that simple), and another asks if those supporting and promoting breastfeeding in public are the same people objecting to the objectification of women and the display of their breasts (for example on Page 3) in the media (as if taking these two stances somehow makes the person hypocritical, as breasts in public – whether for feeding or for titillation – are the same thing).

Quite apart from the obvious sexist and classist judgments being made here, what on earth gives people the right to pass comment on a mother’s choice of how to feed her baby in public? I am aware of people who wanted to breastfeed but for various reasons were unable, who have also faced such judgment and disapproval when they took the bottle out to feed their baby, so it is not just breastfeeding women who deal with this issue. I hope when I was health visiting that I was supportive of people’s choices and not judgmental – whilst there are certain milks on the market that I think are less than optimum, and I wouldn’t have a problem suggesting more appropriate milks for a young child, choices about which milk to feed a child are about so much more than the milk, personal hopes or beliefs about the milk’s effects, or financial issues. Family habits/pressures, societal dis/approval, advertising messages and professional messages all play their part, and I do think that as both a health professional, researcher, woman and member of the general public I need to reflect on the messages I give (verbally and non-verbally) conveying my dis/approval, judgments or opinions, and take real care to be sensitive and non-judgmental.

Secondly, I saw this post retweeted a few times a few weeks ago, in response to this New York Times opinion piece by a columnist called Nick Kristof about a young mother in Mali he introduced to a doctor and who taught her to breastfeed, thus allegedly saving the baby’s life. The blog post critiques Kristof’s column beautifully, and I couldn’t really add much to her points (and of course I am glad that the child in the story appeared to thrive, although the quick recovery does strike me as a bit too Hollywood), but I do want to reiterate what she says about the economics of breastfeeding – it is only free in the sense that money doesn’t (usually) have to change hands in order to get the milk. I’ve worked with enough families in my time where breastfeeding has taken weeks of hard work and a hell of a lot of lost sleep to be established (or not, in some cases) to know that it isn’t a bed of roses, and doesn’t come without cost, whether that be to the mother’s time, relationships, job, ability to plan activities in public (see case above) and all the rest of it. Proclaiming it as “free”, no-cost, easy, and the obvious choice, makes no acknowledgement of all the myriad of factors which can affect whether it happens or not, or that it is the woman that bears the bulk of the burden. Again, whether approving or disapproving of breastfeeding, it is a woman’s choice which is judged by outsiders, and again as a health care professional I need to check myself and make sure that I’m not just adding to the chorus of dis/approval but actually enabling women to make the best choice for them and their baby/ies.

I’m not sure that the professional focus on “breast is best” is always helpful in the debate. As I started to write this post I saw a BBC article on twitter, about a health authority’s bid in England to tender for an infant feeding service. I do think that such services are really helpful, and it’s great if women who want to breastfeed have access to professional support rather than being left to sink or swim on their own. But Dr Ellie Lee’s concerns expressed in that BBC piece need to be heeded – the problem with a lot of health education/professional messages are that they are a list of benefits, regardless of the evidence, and any attempts to find out more about the evidence-base are shouted down or assumed to be dangerous and anti-breastfeeding. I don’t think the health services do themselves any favours by shouting about claims for breastfeeding, some of which have more questionable evidence bases than others, and ultimately the impact will be in increased cynicism and reluctance to try, and increased suspicion of those of us keen to promote breastfeeding where it is possible. Surely it can’t be that difficult for us health professionals to be more nuanced and balanced, more academically critical of the claims of evidence, and less judgmental of women and their choices?

All about my thesis

My thesis

My thesis

I realise I haven’t said much here about the biggest bit of research I have done to date, namely my PhD thesis. It is a qualitative study of sexual and reproductive health in Romania and the Republic of Moldova, looking primarily at the contexts in which sexual and reproductive health services are provided and the barriers and opportunities identified by people working in this area in a number of sectors (state medical, voluntary sector, international donor, etc). The thesis also incorporated a review of media coverage in the two countries around sexuality, reproduction and sexual and reproductive health. I chose to work in Romania and Moldova for initially quite practical reasons (I speak the language, and had previous contacts and experience in both countries), with the focus on health reflecting my professional background in nursing. The end result is very different from my original research proposal, which was much more rooted in social policy, mainly as a result of the eventual decision to focus more specifically on sexual and reproductive health. This led me down a number of fascinating roads, relating to gender, nationalism, sexuality, religion and morality alongside the original health/policy focus, and caused me to reflect towards the end of the process that the thesis chose me as much as the other way round – I don’t think I could have got as passionate and committed to my originally proposed research as I did to the thesis as it ended up.

The thesis itself can be found in the University of Glasgow thesis repository – this link is to the thesis abstract and the thesis is accessible from there (pdf format). I chose not to place the thesis under embargo, as I have decided that although I do think there is an academic book in me somewhere I feel that practically it would make more sense to concentrate on writing shorter journal articles for now. I am planning on reducing my clinical hours in the new year so I can spend some time writing a number of articles drawn from this thesis, in order both to try to make my list of publications more attractive to potential employers, and to give me the opportunity to write in depth about a number of quite random and disparate issues which although of considerable interest could only be touched upon briefly in the thesis itself. One of the advantages of my thesis and its findings is that it is applicable in a number of academic fields – sociology, public health, development studies, area studies, social policy, gender studies, media studies/discourse analysis as well as qualitative research methodology and other academic sub-areas (sociology of health and illness being a particularly obvious one) – which means that I have a number of articles on several different topics just waiting to be written. One of the disadvantages of that is that I could write for journals which are important and high-impact in one discipline but which for other disciplines are much less relevant and impactful, so over the next couple of months I am going to sit down and plan a strategy for prioritising my writing. As for that book – well, I have ideas for a future research project which I think would ultimately lend itself much more easily to an academic monograph. The other priority for next year is to investigate possible funding for that future research, something else which having more publications under my belt will help, of course.

Yesterday via the #phdchat discussion on Twitter I came across a blog post where the author summarised his work in 100 words. That is a challenge I might think about for a future post, as I know one of my writing problems is not using 1 word when 10 will do!