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First do no harm

2/23/2022

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One of the things we often have to weigh up, as health professionals, is the balance between risk and benefit.
For example, IF we make a decision towards planning an early birth, there are decisions that involve weighing risks and benefits of doing that. These include, the potential risk of stillbirth if the pregnancy continues, and if labour is induced, the risk of intervention such as forceps and epidural and informing parents that the baby born before 39 weeks is at slightly increased risk of developmental delays that could affect school performance. Because we are talking in terms of risks rather than certainties it is always challenging to have discussions such as these. They are made even more challenging because sometimes, with the benefit of hindsight, it can be seen that a less harmful decision could have been made at the time.
Maternity care providers have risk versus benefit conversations during pregnancy ALL the time. Information that is shared can be consciously or unconsciously affected by their own biases and fears. One such fear prevailing at present is the fear of Covid. I have to tell you that fear of Covid in Western Australia is palpable, AND in my view  the response is very much out of proportion to the level of risk. I have heard phrases like “DEFCON 1” and “Ebola like management ” so I know I am not the only person who thinks we are going to extreme and quite unnecessary lengths to “keep safe.”
“Safety “ is a euphemism for death so lets have a look at recent stats concerning the “risk of dying” from Covid in Australia according to age, sex and vaccination status. 
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​Its pretty obvious from this Australian research that even if you are not vaccinated at all that your risk of dying from Covid is incredibly low especially if you are under the age of 70. For example, if you are an unvaccinated male between the ages of 50 and 59  your risk of dying is only 11 per 10,000 cases and once triple vaxed this drops to 4 in 100,000.
You can also see from this chart that if you are an Australian  woman of childbearing age that the risk of dying from Covid is less than 1 per 100,000 especially if you have had any kind of vaccination.
Shouldn’t we be careful ? I hear you ask. I agree we should be careful and I ABSOLUTELY agree that we should be doing all we can to protect our elderly AND 1 in 100,000 young people dying is one too many BUT here is my point.
“how much harm are we prepared to cause to prevent that one death?”
Current approaches to managing  Covid in maternity settings is doing WAY more harm than good, in my view. To borrow from another campaign “Covid is a word not a sentence”.  
While there are physical harms being caused that I have talked about before on this blog I am also becoming more and more concerned about the long term emotional and psychological scarring we are undoubtably causing. I think that it won’t be too long at all before we look back in horror at our treatment of birthing families during Covid and ask “what were they thinking?”
Pregnancy and Birth is a special time and the experience can’t be regained or memories changed. Anxiety during pregnancy is common and Birth trauma is real, even when everything is apparently fine. Parent / Child bonding can be fragile and the negative, long term sequalae of disordered attachment is well known. What happens during pregnancy and birth is remembered and reflected upon for the rest of that persons’ life ask any 80-year-old mother!! There is much to be concerned about for pregnancy and birth during covid including:
  • Fathers not being allowed to enter a maternity hospital or if they are allowed in, there are MANY barriers including mask and vaccination mandates, and time limits
  • Fathers seeing ultrasound in a hospital car park via facetime
  • Requirement for support people to wear full PPE during those very first precious moments when greeting the new baby and establishing attunement which necessarily involves the parent and baby’s WHOLE face.
  • Siblings being denied entry
  • Extended family members being denied entry
  • No support person allowed in antenatal clinic. There are many situations that can arise in pregnancy when bad news might need to be broken and immediate comfort and support needed. NOT TO MENTION having another pair of ears in the room when explanations are given and another person to ask questions not thought of by the other person.
  • Time limits for support during birth   
I could go on but that’s more than enough to make my point!
 It may be, that even now, some people will look at this very limited list and say “surely that isn’t happening!” It seems draconian, heartless and cruel doesn’t it? While I think stopping people at the door of a nursing home and perhaps even a general hospital where there are sick children or adults is probably necessary, I take you back to my original point, care providers are sworn to “first do no harm” and as far as I can see we are doing tremendous harm to our birthing families for very little benefit.
So, can someone with a brain and a heart STOP this insane approach before we do any more immeasurable harm…. PLEASE! 
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Wouldn’t it be lovely?

2/12/2022

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Today I was sad to see that my fears expressed on this blog in April 2020 were confirmed with this story in the Sydney Morning Herald. Reporting that we now know stillbirths in NSW rose to their highest rate in more than a decade during the first year of the pandemic.
Professor Jonathan Morris (Professor of obstetrics) said the rate was up from 8 per thousand in 2019 to 9.1 per thousand in 2020. Describing this rate rise as “slight”. Later in the article it was pointed out that this equates to 100 more families in NSW alone who suffered a stillbirth in 2020 than in 2019. I don’t know about you but I’d be willing to bet that none of those families , nor indeed anyone of us who has suffered a stillbirth, would describe a 100 more deaths in just one State as a “slight” rise
Why did this rate rise occur? The usual suspects are blamed including the move from face-to-face consultation to telehealth, strain on maternity services  and my favourite (NOT) the mothers fault delaying ‘presentation” to hospital because of being  “anxious” to attend.  The report adds that it was “too early to pinpoint a cause”
This is where I beg to differ. Far from it being too early it is WAY too late to try to pinpoint a cause. Why? Because the rate data is two years old. Even if a cause was pin pointed and mothers were        blamed for delaying presentation what can be done about it now? If that cause was “pin pointed” at the time then strategies and education could have been put into place. Now its WAY to late to act even if a cause could be pinpointed
I have heard time and time again a “wouldn’t that be lovely” in response to my and others requests to collect and quickly report stillbirth rate data. Jurisdictional boundaries and regulations  and MANY other issues are cited as “reason’ why we cant get data on stillbirth rate until it is WAY too late to know if telehealth, strain or anxiety have anything or everything to do with it.
But is it actually possible to get that information before 2 years has passed?  Certainly, I point you to what we know about Covid -19 by way of example. We know , rates from every jurisdiction within 24 hours, not only that we know ages of victims and even if they have “underlying conditions”. This information has enabled us to learn so much more about Covid than we would have known if all the data we had was 2 years old! The information includes what we need to look out for and how to protect ourselves. Has this information evolved over the course of the pandemic BECAUSE of our immediate access to information?  YOU BETCH YA.
 Information we have from our Covid experience tells us that we can, and indeed we MUST collect and report data about stillbirth rate FAR more frequently than we currently do and IF we do we will discover further risks and ways to protect women and families from stillbirth in time to take steps to actually address the likely problem AND to see  the effect of any changes we make !
I challenge those who are in a position to influence the collection and reporting of stillbirth data to make it available as quickly as they can in much the same way as Covid deaths are reported.  Daily if possible, weekly at the outside. This will have the combined effect of raising community awareness of stillbirth but also allow us to make any changes to the way antenatal care is delivered across Australia in response to real-time data rather than trying to shut the stable door 2 years after the horse has bolted.  
 
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    Still Talking

    Talking openly about all aspects of stillbirth.

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