A Response to Dr Gawande

Dr. Atul Gawande's article in the New Yorker, "Slow Ideas"  has been spreading like wildfire on Facebook and elsewhere in the birth world.These are important ideas about change in maternity care and care for women and children overall. Everyone likes his ideas about woman-to-woman communicating and grassroots movements and bringing change one woman and baby at a time.

I read the article and I had serious problems with the language, first of all, but also with the overall set of assumptions about how "we" care for women and their unborn or newborn babies.

Here are my thoughts:

Why did Ibu Robin Lim win the CNN Hero of the Year award in 2011?

Ibu Robin has been working for nearly twenty years in Indonesia, offering free maternity care to women who would otherwise be giving birth at home, in unsanitary conditions, and possibly without attendance. She is on excellent terms with the hospitals in her area, and has single-handedly changed the face of childbirth in Indonesia.

While the goals of the Better-Birth Project are laudable, the inconsistencies in Dr. Gawande’s approach to better childbirth practices need to be addressed. First, there are several simple facts that are misrepresented in his article (“Slow Ideas”, July 29, 2013). For example, it is simply not true that “many babies cannot take their first breath without assistance”.  About 10% of newborns need assistance with their first breath, and around 1 to 2 percent need resuscitation ("Most newly born babies are vigorous. Only about 10% require some kind of assistance and only 1% need major resuscitative measures (intubation, chest compressions, and/or medications) to survive". (Textbook of Neonatal Resuscitation, 6^thedition, American Academy of Pediatrics, p. 39).

Secondly, serious obstetric emergencies, such as shoulder dystocia (rare and potentially fatal, and often unpredictable), are lumped together with common phenomena such as a cord around the neck (around 30% of neonates are born through a nuchal cord). This speaks of an approach to childbirth that is steeped in the western belief that childbirth is an emergency that must be prevented.

It is this approach that will not bode well for underdeveloped countries and their attempts to save mothers’ and babies’ lives. Dr. Gawande describes an effective program: women on the ground, moving from village to village, teaching simple practices that will help to save thousands, if not millions, of lives. But why stop there? Perhaps we can reduce the “twenty-nine basic recommended practices” to just ten. Actually, these 29 practices are only part of an initiative sponsored by the World Health Organization, that is studying the efficacy of a checklist in reducing infant/maternal mortality. It is not yet recommended practice, or even yet proven to be effective . "The formal trial began in 2012 to measure the impact of the Checklist on severe maternal and newborn harm ... Data collection is expected to begin in 2013 and will continue for a period of three years. It is estimated that the study will be completed by 2016."

At the end of his article, Dr Gawande suggests that what made a difference, in one particular woman's life (she was a nurse), was that the expert who was making suggestions about how she could change her approach was friendly. "She was nice." A vision of maternity care that works is a vision that certainly reduces maternal/newborn mortality and morbidity. But it must also be a vision that includes respect for women and their babies, their families, and their culture and history.

I believe that Dr. Gawande’s vision must be taken one step further, and that with just a little more courage and the kind of round-the-clock dedication that I have seen at Yayasan Bumi Sehat in Indonesia, we will start to see dramatic changes in maternity care around the world. We have to reduce the fear of childbirth, and the institutionalized fear of "untrained birth attendants". We can, instead, work with what we have - integrate ten or so better practices into the TBAs practice. Create better and more efficient, low-tech tools for TBAs to carry. Integrate the technology we DO have - mobile phones are used extensively all over the African continent, for example, and find creative ways to save lives. Reduce high-tech interventions. They don't work unless the infrastructure can support them.

Turn your held beliefs on their head: It is certainly a triumph of modern medicine that we can be vaccinated against tetanus. I always keep my vaccine up to date: the old lady who lived at our house in Italy years ago died from tetanus after being pricked by a rose! It is a horrible way to die, and once a wound has become infected, it is incurable.
Newborn tetanus kills babies, every day, in many countries in the world. The tetanus bacteria enters through the umbilical cord, either from unsterile equipment or unhygienic after care.

What if we didn't cut the cord? No wound! No tetanus!!!

Let's work together to find answers to this daily tragedy: mothers and babies deserve better.

What to Expect from Nestle

We all have our prejudices and opinions about breastfeeding and natural birth. At a certain point, however, it is important to try to discover the facts buried deep beneath everyone's political agendas. I was struggling with this for a few days before I decided to write this blog, and a lady jumped out from the past and told me very clearly that I have to speak out.

I was in my early twenties, traveling through Africa on my own. I was walking to get on a ferry, which was basically a very large raft kept afloat by prayers and habit, to cross a river. A woman about my age approached me. She had a baby on her back, and she swung him around and presented him to me. Because of the color of my skin, she expected me to have some knowledge, medication, or connections that would assist me to bring her baby back. He was almost dead. His eyes were glazed and dry. He had diarrhea, she explained. I had no idea what to say to her. I didn't know anything back then. I had never seen a dying baby before, and I hope you never will.

I don't think people fully understand the significance of the use of baby formula in countries where poverty is rampant, and clean water is impossible to find. Here in Canada, those women who bottle feed their infants may be at risk for being sneered at, and their babies may be at higher risk for allergies or obesity. But in Africa and all over the world, babies who are fed formula are at a higher risk of  infection, from the moment they are born until they are at least two years old.

Unicef recommendations on breastfeeding are here, and they are worth looking at. The authors suggest that "The major problems are the societal and commercial pressure to stop breastfeeding, including aggressive marketing and promotion by formula producers. These pressures are too often worsened by inaccurate medical advice from health workers who lack proper skills and training in breastfeeding support."

Nestle is one of the major formula producers in the world and has just bought Pfizer Nutrition which markets four brands of artificial formula. Nestle actively promotes its breastmilk substitutes in Africa and elsewhere, claiming that HIV positive mothers' babies should not be breastfed. This is a subject that has seen much research and discussion over the past few years and it is by no means a conclusive claim. Infection rates can go up by over 60% after six months, so perhaps a better suggestion would be (see WHO recommendations) that babies everywhere and in every situation should be exclusively breastfed for the first six months of life.

The problem with formula feeding in poverty-stricken areas are twofold: one is the lack of clean water, refrigeration, sterilizing equipment and so on. Bottles are washed in less-than-sterile water; the powdered formula is mixed with infected water; and the remaining formula is left out and breeds bacteria. WHO guidelines on the preparation of powdered formula are very strict concerning cleanliness and refrigeration. This level of cleanliness is simply not possible in many households around the world.

Nestle has been boycotted for over forty years because of its aggressive marketing of breast milk substitutes  all over the world.

This is why I was shocked to see that it is sponsoring the What to Expect When You're Expecting movie premiere, and to see that these two organizations are partnering to sponsor a contest for pregnant women. The prize is a trip to Hollywood to see the WTE movie. Visit the link: Nestle Baby.  If you try to enter the contest, you are told that only "Nestle Baby Program" members are allowed to enter. So you go to the Nestle Baby link. A tiny popup opens to let you know that breast is best for up to six months. Then you are met with a $100 coupon for free samples, including formula and bottles.

This is directly in contravention of the World Health Organization's International Code of Marketing of Breastmilk Substitues, which states that: "there should be no advertising or other form of promotion to the general public" and that "manufacturers and distributors should not provide … to pregnant women, mothers or members of their families, samples of products…" Promotion through any type of sales device, including special displays, discount coupons and special sales, is prohibited. Furthermore, no company personnel should seek direct or indirect contact with, or provide advice to, pregnant women or mothers.



I expect and encourage What to Expect to immediately sever ties with Nestle, for the sake of their own reputation, and for the sake of the health of millions of mothers and babies around the world.