#hospitalbreastfeeding Part 1

On Thursday 7 May I am hosting a #WeNurses Twitter chat on Breastfeeding Support on Children’s Wards.  In advance of that, I would like to outline in a couple of blogs what is the #hospitalbreastfeeding campaign, and how it came about.

Followers of my blog will know that my younger son, David, was born with the congenital heart defect Hypoplastic Left Heart Syndrome.  This meant that he was transferred to Alder Hey Children’s Hospital at a day old, and despite having had a c-section I requested I be discharged from St Mary’s the same day so that I could be with him.  Alder Hey was therefore, to all intents and purposes, my maternity hospital or postnatal ward.  David was there until he was just over 3 weeks old, and I have written about our experiences surrounding his birth, and my breastfeeding journey with him.  He had my milk from the day of his birth (via NG tube) and I continued to express for him until he latched on to me at 4 weeks old and has been breastfed ever since.

At 5 months old David had to have a second open heart surgery, again at Alder Hey, and he was in hospital for just under a week.  I was concerned about how I was going to be able to breastfeed him post-op, as he would be fully tubed up again, including a couple of heavy duty chest drains.  In the event, I drop fed him over the cot – leaving him lying down whilst I leant over him and popped my nipple into his mouth.  Once his drains came out I was then comfortable snuggling him again and normal feeding resumed.

Alder Hey

On both of the occasions that David was an inpatient at Alder Hey it was apparent to me that there was huge variation in breastfeeding knowledge amongst the nurses, and also a huge variation in their interest in the subject.  The SALT that we saw was a lovely lady but was clearly not trained in breastfeeding support, and neither was the dietitian, who confidently told me that we would be able to move David onto a four hour routine soon enough.  As I said then, “a 4 hour routine? For a breastfed baby?!”  Or any baby for that matter.  The overall impression I got was that breastfeeding was seen as a lifestyle choice, which some nurses supported and others did not, but it was certainly not seen as an important part of paediatric care.

The day after David was discharged following his second operation, I wrote to Jonathan Stephens, Finance & Business Development Director at the hospital:

Letter of 27 Feb 2014

Extract from letter of 27 Feb 2014

Since writing that letter I have had many discussions with nurses who are very keen to provide top notch breastfeeding support and information, so I am no longer certain that the nurses should be absolved of this responsibility.  But I stand by my assertion that I have no complaint against the nursing staff at Alder Hey.

Ever aware of the controversies surrounding infant feeding choices, I was keen to make clear in my letter that “Of course not every mother will want to breastfeed. Of course the hospital should support individual’s feeding choices, especially when parents are already under pressure due to a child’s illness. But at the moment it is the mothers who desperately want to breastfeed who are being let down. And by extension their children are being let down.”  I went on to outline the benefits of breast milk and included a link to the Baby Friendly report “Preventing Disease and Saving Resources“.

I also explained “I have no professional interest in breastfeeding promotion, but I do run an online support group for mothers (membership currently 600+) so have a daily insight into the challenges and emotional impact of the breastfeeding journey. Our membership includes mothers who were not supported to continue breastfeeding when their children were hospitalised and many of them deeply regret this. Bottle feeding is not the “easy” option.”

Jonathan was prompt with his response and promised to look into the issues I raised.  Within a month, I received a letter from Liz Grady, Health Promotions at Alder Hey who, it turns out, is responsible for breastfeeding support.  I had been a breastfeeding mother in the hospital on two occasions but I had never heard of Liz let alone met with her.  Her letter was detailed in its response to my points, and she ended it by suggesting that we meet up to further discuss, should I be interested in doing so.  So meet up we did!

Since that initial meeting, I have had the privilege of working with Liz on updating the breastfeeding policies for the hospital, and we now meet every few months to catch up on the progress of the work Liz is doing to support breastfeeding mums.  It turns out that she is a knowledgeable and dedicated lady, doing her very best to support breastfeeding as part of her Health Promotions remit, which also includes numerous other areas.  She is helped in this by the Bosum Buddy Champions, most of whom are Healthcare Assistants, who work on the hospitals wards.  My supposition that no one in the hospital had a professional interest in breastfeeding had been proven wrong, although my belief that far more breastfeeding support staff are required remains.

On being asked to review and contribute to the updated breastfeeding policies for Alder Hey, I decided to take to Twitter to find out what IBCLCs and breastfeeding supporters would want to see in a hospital breastfeeding policy.  This turned into a far larger Twitter conversation than I had anticipated, and came to the attention of the lovely Kath Evans, Children’s Nurse and Head of Patient Experience at NHS England.  Kath was very encouraging of the discussions I was having, and it was her backing that led me to launch the hashtag #hospitalbreastfeeding and start what was to become a Twitter campaign.

hospitalbreastfeeding

Those initial conversations under #hospitalbreastfeeding linked me up with paediatricians, nurses, breastfeeding support workers, anaesthetists and others who all had an interest in the importance of breastmilk for sick children, and in the best ways to support families who wished to breastfeed on the wards.  I typed up the early discussions into two transcripts of around 20-30 pages, and will share some extracts here (my comments are in red):

transcript 1

transcript 2

transcript 3

A lively discussion as you can see!  I was also keen to point out and combat the perception that breastfeeding is “tiring” for sick children.  From Dr Jack Newman’s ‘The Ultimate Book of Breastfeeding Answers’ p231

Marino BL, O’Brien P, LoRe H Oxygen sats during breast & bottle feeding in infants with CHD J Pediatr Nurs 1995;10:360-4 - that's the original study as confirmed by Dr Newman

Marino BL, O’Brien P, LoRe H Oxygen sats during breast & bottle feeding in infants with CHD J Pediatr Nurs 1995;10:360-4 – the original study as confirmed by Dr Newman

transcript 4

Whilst the #hospitalbreastfeeding discussions were taking off, Liz Grady finalised the new Breastfeeding Policy and Expressed Breast Milk Standard Operating Procedure for Alder Hey.  I am honoured to have had a small hand in these, and particularly like these extracts:

Extract from Alder Hey Breastfeeding Policy

Extract from Alder Hey Breastfeeding Policy

Extract from Alder Hey Expressed Breast Milk Standard Operating Procedure

Extract from Alder Hey Expressed Breast Milk Standard Operating Procedure

Extract from Alder Hey Expressed Breast Milk Standard Operating Procedure

Extract from Alder Hey Expressed Breast Milk Standard Operating Procedure

Extract from Alder Hey Expressed Breast Milk Standard Operating Procedure

Extract from Alder Hey Expressed Breast Milk Standard Operating Procedure

Liz has also got breastfeeding procedures and tracking included onto the computer system for the new hospital which is opening in September of this year.  She is currently finalising a booklet of breastfeeding information, based on the new policies, that can be given to all breastfeeding families on their admission to Alder Hey.

In order to further spread the message of #hospitalbreastfeeding, I decided that I wanted to produce information targeted at HCPs, explaining why families might be so desperate to breastfeed their sick child, and how breastfeeding can actually compliment other areas of paediatric care.  In November 2014 I launched http://resources.heartmummy.co.uk/which has posters to download for free, explaining the benefits of breastfeeding to those caring for a sick child.  It also has links to the evidence on which the posters are based, and other useful breastfeeding information.

Nurses poster from www.heartmummy.co.uk

Nurses poster from http://www.heartmummy.co.uk

I was delighted at the response to the website, particularly when the UNICEF Baby Friendly Initiative chose to publicise it in their January mailing:

BFI January mailing

BFI January mailing

It amazes me that this is where it all got to in fewer than twelve months.  I have to thank Kath Evans for encouraging me, and Liz Grady for allowing me to get involved with what is happening at Alder Hey.  The first months of 2015 have seen further developments, but for that you will have to wait for Part 2.

Follow the campaign on Twitter #hospitalbreastfeeding 

Thank You

Anyone who has been following my blog will know that I have had a few things to say about maternity care.  And anyone who follows me on Twitter will know that I also have a few things to say about breastfeeding support and health visiting.  And a few other things too….  Basically, if I see an area of the NHS that I feel needs improvement I am not afraid to say so.

But the NHS has also been incredible for my family.  Amazing, inspiring, awesome…… life saving.  So in the middle of gentle but firm proddings to encourage some areas of our health service to make themselves better, I would like to take a moment to say

thank-you

Thank you for providing my family with a wonderful health visitor, Anna Embleton of the Sale Moor team, and for our outstanding GP practice.  These two services alone have done a huge amount for me, for my husband and for our children.  Advice, compassion, the ability to listen and never appear as busy as they actually are.  Warm welcomes, home visits, concern and genuine care.

Thank you to University Hospital South Manchester for the gentle and understanding care your staff provided to me during my miscarriage and separate minor operation in 2012.  Compassion once again, an immediate understanding of the emotional care I would need, in addition to the first class medical care.  Humour, warmth and respectful practice.

My immediate and extended family had benefited from the NHS for many years, and then in 2013 we had our second baby and he has a congenital heart defect, Hypoplastic Left Heart Syndrome.  Now we saw the full extent of the NHS at its most fantastic.  Once again,

thank you note

For a start, the cardiac surgeons at Alder Hey Children’s Hospital have saved David’s life.  Twice.  Once when he was 5 days old when Prem Venugopal performed the Norwood Procedure on a heart about the size of a walnut.  And again when he was 5 months old when Ram Dhannapuneni did the “Glenn” or Cavo-Pulmonary Connection.  This is the two men that we can never thank enough:

Ram Dhannapuneni, Prem Venugopal and Cardiac Liaison Nurse Gill McBurney

Ram Dhannapuneni, Prem Venugopal and Cardiac Liaison Nurse Gill McBurney

So many people at Alder Hey provided unrivalled care to our little boy.  The nurses on K2, the cardiac ward, the team on ICU, David’s cardiologist Dr Caroline Jones, the cardiac liaison nurses, the healthcare assistants, the doctors, the people whose job titles I have never got to grips with but who performed scans, X-rays, echos…..  All free at the point of delivery and all with compassion and a smile.

Not forgetting either the people who brought David into the world, before he was transferred to Alder Hey.  He was born at St Mary’s Hospital and the person I always mention first is FMU midwife Della, because the care and quite frankly love she provided us with for those days of diagnosis and birth was above and beyond.  We took David back to see her when he was discharged from Alder Hey, and again the day before his 1st birthday.  We will never forget her – she made a difficult experience bearable.

David and me with midwife Della the day before David's 1st birthday

David and me with midwife Della the day before David’s 1st birthday

A big thank you also to Dr Stamatios Capadopoulos, anaesthetist Andrew Heck, Patience, Sarah H, Sarah B, Helen P and all of the team who delivered my boy safely into this world.

The thing that really stands out for me about our journey with David as far as the NHS is concerned, is that we have never been alone.  Having a child with a serious, incurable, heart condition is a frightening business.  But not once have we been abandoned to cope on our own.  We are welcome to call K2 any time, day or night.  I can email David’s cardiologist or the CLNs with all manner of queries and frets and they always respond.  We have open access to the Starlight Ward at University Hospital South Manchester, courtesy of David’s paediatrician Dr Vemuri.  So in an emergency, or seeming emergency, we do not have to wait in A&E – we are straight onto the children’s ward.  I have used this facility three times – and every time it has transpired that David has nothing more than, well, basically a cold.  Not once has any member of staff at UHSM suggested that I am neurotic, time wasting, an inconvenience – they have always been kind, reassuring and prompt in their care.

UHSM also provided David with the incredibly costly Synagis injections – palivizumab to help him to combat bronchial issues during the first winter of his life.  These injections cost a fortune in themselves.  For these alone we would have had to pay through the nose in another country.  Add to that the flu vaccinations, that have been provided not only to David but to his brother, to me and to my husband, so that the whole family is protected because our little lad is so vulnerable.

During the first 5 months of David’s life he had to be weighed twice a week and have his oxygen saturations (Sats) checked twice a week.  This brings me to my final huge

thank_you_air-580x399

The weights were done by the health visiting team, and I think I have now met nearly all of the Sale Moor HVs as a result.  Always prompt, always lovely and unhurried, always ready to chat and see how I was coping.  The Sats were done by the Trafford Children’s Community Nursing Team (CCNT), David’s named nurse being Melissa Curley.  The two services worked together, and worked with Alder Hey, and I felt safe in the knowledge that communication between the teams was working so well.  This was all part of Alder Hey’s Home Monitoring System, which meant that David didn’t have to return to that hospital every week.  It also meant that during the vulnerable and frightening period between surgery 1 and surgery 2, I had two healthcare professionals visiting me twice a week, and that was always far more for my benefit than for David’s (his weight and Sats being satisfactory on almost every occasion).

That safety net has not disappeared now that David has had his second surgery.  The CCNT still come out to see us once a month to check his Sats – 84% at last count for those who are interested in these details – and they remain committed to his wellbeing, phoning me up to check on him if there is the last concern about his health.  I also know from experience that my health visitor remains ready to visit and support our family at a moment’s notice.  We really are very fortunate.

I know that this is not everyone’s experience of the NHS.  I know that not every family of a “heart” baby receives this level of care, let alone the families of children who are ordinarily healthy.  I am all too aware of the shortcomings and “could do betters” of the system.  But for us, from the moment David was born, we have never been alone.  And for that I can only say

Thank_You_Beach_620

#MatExp Survey – The Results Are In!

As you will have seen, I have been sharing maternity experiences on this blog from women I know.  Some good, some bad, some unacceptable.  But all anonymous.  And it occurred to me that this was somewhat unfair on the birth professionals working to support pregnant women, many of whom I have become friends with on Twitter.  So I thought it would be good to be able to share the other side of the story, the thoughts and views of the birth professionals, who have also been afforded the luxury of anonymity.  Thus the #MatExp survey was born!

Just F****** Do It!

Just F****** Do It!

As with everything I do, I JFDI it one evening (thank you for that phrase Florence Wilcock!) and popped it up on Twitter.  To my great delight, I have had 150 responses from midwives, student midwives, independent midwives, doulas, obstetricians, anaesthetists, antenatal teachers and other birth professionals.  Thank you to everyone who has taken part, your input is much appreciated.

This is the split of respondents:

Question 1

Question 1

We also had responses from a neonatal registrar, a perinatal psychiatrist, three midwifery lecturers / educators, a research midwife, two hypnobirthing instructors, an anaesthetist and three antenatal teachers.  Many are new to their profession, many have been supporting women for one, two or three decades, and one respondent has been a birth professional for 43 years.

The first thing I wanted to know was “What is the best thing about your job?”  The vast majority of respondents talked about the women they work with and being able to support them as being the best part of their role.  One student midwife caught the general mood with the comment “Supporting women and being there for them no matter what.”  Responses included:

“Witnessing the women I support find their strength and power. Witnessing the love between the couple and the birth of a new little family.” (Doula)

“Being a part of a woman and family’s journey into parenthood.” (Independent Midwife)

“Being part of the transformation of woman to mother” (NHS Midwife)

“Supporting and empowering women, whatever the outcome of their pregnancy” (Obstetrician)

“Making a difference to women. To be present & witness to most beautiful time in life” (Student Midwife)

“Seeing women empowered and birth partners knowing their role and both having calm births” (Hypnobirthing Instructor)

“Privileged to be part of the miracle” (Obstetrician)

Unsurprisingly, the independent midwives found that being able to offer continuity of care and build a relationship with the women they support to be one of the best parts of their job.  Many of the obstetricians felt that the best part of their role was “averting danger”, “saving lives”, “helping women to have as healthy a pregnancy and birth as possible”, but also “working with women caring for them at such a life changing moment in their lives” and “being able to reduce anxiety with appropriate explanation”.  A fair few of the doulas talked about “witnessing the women I support find their strength and power” and “empowering women”.  One explained that the best part of her job is voluntary work “with vulnerable women – asylum seekers, poverty, isolation – who may not otherwise feel worthy of advocacy”.

The word “support” comes up a lot in the responses of NHS midwives, and wonderful comments such as “Making a special time, simply awesome!!!”, “Having the honour and privilege of being a part of a very special time in people’s lives” and “working with the women through an amazing experience”.  The student midwives made similar comments, but I particularly liked these two responses:

“The list is endless, but one that currently stands out is being able to turn it around when a woman is panicking in labour and giving them confidence in their own body to give birth! Saying a few words of reassurance and visibly seeing the change is incredible.”

“Supporting women on their journey whatever their circumstances or choices and feeling a sense of fullfillment when you know you’ve made a difference to someone’s pregnancy/birth.”

So from these inspiring comments from people who clearly adore their jobs, we move on to the question “What is the biggest challenge currently facing your profession?”  Overwhelmingly the response was NOT ENOUGH MIDWIVES!  My recent blog post explores the experience from a woman’s point of view when a unit is short staffed. This really is the biggest challenge as far as these respondents are concerned.  Closely followed by fear – “The fear of litigation and professional accountability. The wake of the kirkup report savages midwives and their portrayal is unfair. We may all be tarred with the same brush. Normality is under attack again.”  For midwives, morale is also a concern – “we are CONSTANTLY being told what we are doing wrong. Such a culture of fear.”

For obstetricians the challenges are different.  Comments included:

“Letting the lawyers decide what information we say and letting them take an additional cut. When the press report a 5.2 million payout the lawyers award themselves a further 6 figure payout.”

“More and more ‘high risk’ women embarking on pregnancies.”

“Too much focus on everything EXCEPT caring for patients!”

“Unnecessary obstetric intervention”

For doulas, they are struggling with a lack of awareness of their role and “dispelling the myth that only the wealthy can afford us”.  Lack of awareness from families – “People understanding what support we can provide and the value of it” – and from medical professionals – “Being misunderstood – doulas work alongside NOT in place of HCP”.  Some respondents even felt that there is resistance to doulas amongst the medical community.

Where student midwives are concerned, the biggest challenges include:

“Feeling left alone and overwhelmed when its busy because my mentors are rushed off their feet.”

“Bullying… NHS culture”

“Working with midwives who don’t use up to date evidence such a optimal cord clamping”

“Guidelines that seem to have very little evidence base.”

“Bad attitudes, both to those in our care and to each other!”

The over-medicalisation of birth was also mentioned by many respondents.

So what can birth professionals do to meet these challenges? The #MatExp campaign is all about action, and everyone being able to make a difference.  Respondents were asked “What do you feel you personally can do to face that challenge?”

Whilst some said “not a lot”, “not sure” and “nothing”, most felt that they had ways to meet the challenges they faced.  Answers included the simple “keep on caring”, “keep going” and “raise awareness”.  Others said:

“By empowering women to have a voice and question these [hospital procedures]. Also, working together with OBs and MWs to also understand their point of view and what challenges they face. So we can all change this together.” (Doula)

“With 3 colleagues I have set up a social  enterprise to provide a caseload midwifery service through NHS commissioning at tariff – the battle is to get it accepted by those who resist changing the status quo” (Independent Midwife)

“Keep going, keep trying to provide compassionate, excellent, evidence-based care, serve the women in my care as best as I can doing my best every shift” (NHS Midwife)

“Not resign myself to that’s how things have to be, think about ways to improve and make suggestions, continue to make every contact with women as positive as possible” (NHS Midwife)

“Show by example how important it is to respect and listen to a woman at all stages of antenatal, labour and postnatal care.” (Doula)

“Ensure that I act within my own values despite others in my environment, find support and positivity from like minded individuals. I love Twitter for that!” (Student Midwife)

“Train our midwives to the highest level to avoid litigation. Test their knowledge to ensure they’ve learned from the training.   Keep on asking for more staff and bigger units. Never give up!!” (NHS Midwife)

“Trying to individualise care and support women’s choices  Positive birth” (Obstetrician)

“I need to remember I’m a student and should be supernumerary. I need to speak up more to make sure I’m learning each day rather than doing what I know or making beds.” (Student Midwife)

“Continue to practise in the best interests of women rather than defensively and vote against abolition of supervision” (NHS Midwife)

“Try as far as possible to support ‘normal birth’, educate women about the risks of high BMI pregnancies etc.” (Obstetrician)

“Be prepared with an abundance of solid evidence” (Student Midwife)

“Keep my heart strong, separate the bigger picture from the day to day interactions of care, do mindfulness, be compassionate to self, inspire trust in women’s bodies” (Student Midwife)

On a personal note, I particularly like the doula who is determined to be “rigorously evidence-based, and relentlessly compassionate.”

I was keen to see how many of the respondents were aware of the #MatExp Campaign.  Many would be of course as the survey started out being publicised to people I knew on Twitter, many of whom I have linked up with due to #MatExp.  It gradually worked its way out of that community though, and by the time the survey closed the split was as follows:

Awareness of #MatExp

Awareness of #MatExp

The orange line is “I have heard of it but don’t know a lot about it”.

I then outlined the aims of #MatExp as they appear on the NHS Change Day website

NHS Change Day

NHS Change Day

Aims of #MatExp

Aims of #MatExp

The next question was “What do you feel you can do to support these aims?”  Many respondents felt that renewed or continued work with their MSLC (Maternity Services Liaison Committee) was the answer.  Others simply want to “spread the word” and “let mums know”.  Other comments included:

“I encourage women to speak up about things they’re not happy with. Raise it at a higher level if you have to, use the SoM or similar. Empower women so they don’t feel intimidated by professionals telling them what they are and are not ‘allowed’ to do.” (Doula)

“Ensure patient feedback is received acknowledged and acted upon. Continue daily ward visits” (NHS Midwife)

“Support AIMS [Association for Improvements in the Maternity Services]” (Independent Midwife)

“Keep banging the drum for parity of esteem for maternal mental health” (Perinatal Psychiatrist)

“Keep raising awareness on Facebook, hold antenatal classes, tell all the women I come across everything is in their power – try to banish the word ‘allow'” (NHS Midwife)

“Probably the friends and family questionnaires would help and I can make sure these are handed out.” (Student Midwife)

“As a researcher I can help to make maternity service user views more visible and I am also doing a lot of work around ways to increase opportunities for service users to get involved in research/maternity service improvement activities.  I am also very interested in the idea of co-creation in research (so working alongside service users and frontline staff to develop, do and use research). Part of the work I am involved with at the moment involves empowering pregnant women and midwives to use research evidence more effectively.” (Research Midwife)

“I’m an increasing Twitter user. Social media seems to be the way forward” (NHS Midwife)

The next question looked at the specific areas that the #MatExp campaign covers, including the area for which I am one of the champions: “Life with a new baby”. The full list is:

Skin-to-skin – see Jenny Clarke’s video

Optimal cord clamping – meet Amanda, optimal cord clamping champion

How does lithotomy feel as a woman in labour – read about obstetrician Florence Wilcock’s NHS Change Day lithotomy challenge

Language used towards pregnant women (e.g. “failed induction”, “poor maternal effort”) – this area is championed for the campaign by Leigh Kendall

Life with a new baby – including perinatal mental health and breastfeeding.  Read about Rosey PND&Me and also the blog post that Emma Sasaru and I put together on supporting breastfeeding.

Informed Choice – see this example of risk being explained in a user accessible way

Respondents were asked to rank these areas in order of importance and the results were:

Order of importance

Order of importance

A couple of respondents had (very fair) specific comments on the above question, namely “our unit is already changing skin to skin and delayed cord clamping, hence their low ranking, otherwise I would have placed them higher, my next project is to reduce the use of lithotomy” (Obstetrician) and “it is impossible to rate these in order. In general they each impact on each other, by improving informed choice you are creating a healthier postnatal environment etc. so rankings don’t mean that skin to skin is the least important” (NHS Midwife).

The response to the next question was fairly definite!

Importance of feedback

Importance of feedback

Finally, I asked “If you could change one thing about maternity care in the UK what would it be?”  Staffing levels were mentioned again by a lot of respondents, as was caseloading / one to one care.  Many of the answers were also indicative of the tensions between different birth professions and professionals:

“For more medical staff to witness natural birth.” (Doula)

“Doctors and midwives respecting each other” (NHS Midwife)

“Obstetricians” (NHS Midwife)

“If we loved and treated our colleagues better, collaborated and supported each other, we’d be a happier, more efficient more compassionate and passionate workforce- and this would filter through to the women we support” (NHS Midwife)

“Reduce obgyn lead care.” (Doula)

“NCT didn’t have such a negative influence on women. No one failed because they didn’t have a vaginal birth. A lot of what is taught is inaccurate and based on personal opinion which is not informed choice.” (NHS Midwife)

“Slow down the relentless overuse of induction…encourage/ optimise midwife led care home birth and birth centres and caseloading model of care.” (Student Midwife)

“Don’t always go and try to enforce your procedures. Listen to women. Use of language for the purpose of influencing a labouring woman into accepting the best thing for hospital such as I witnessed: ” This baby has had enough” is very detrimental, and to say the least, manipulative.” (Doula)

“I would offer a single additional session to antenatal classes/NCT classes etc about the reasons for medical interventions in labour and the risks and benefits. It is unbelievable that in an age of information, when women have spent time with midwives and NCT instructors, we still regularly see birth plans that say “don’t want forceps unless necessary”! It immediately disadvantages obstetricians and puts them on the back foot, as we not only are seen as “the bad guys” for forcing these interventions on women, but often have a matter of minutes to explain the risks and benefits in an urgent situation, which is frankly laughable. Obstetric trainees should be involved in antenatal education; just a single group session on the what, when and why of CTGs, forceps, FBS and Caesarean would I think remove a lot of the fear from women and help those for whom labour does not progress smoothly to feel more empowered and informed.” (Obstetrician)

“More trust in women to make the right choices for themselves. Less bullying and misinformation.” (Independent Midwife)

“Obs and midwifery attitudes to each other.” (Anaesthetist)

I would also like to highlight this heartfelt plea from an NHS Midwife: “I don’t even know where to start… Let’s be compassionate again – let’s treat EVERY woman like our sister. Even the smelly, rude, unpleasant ones. Let’s try.”

Along with a number of #MatExp participants on Twitter, I have been saying that respect and compassion are two vital elements of a positive birth experience, regardless of vaginal birth, c-section, place of birth and so on.  This comment from a doula certainly chimes with my personal view on what could change in UK maternity care: “I’d like it to be less of a lottery, some professionals are kind, supportive, informed, happy to discuss options with women. Some are not. On the same wards, in the same hospitals too. I’d like the good experiences that many have to be normal for all. The feedback I get is this comes down to how the woman is treated rather than the final outcome of the birth experience.”

Maya Angelou

Maya Angelou

The full results of the survey have been passed to Florence Wilcock, #FabObs of the #MatExp campaign.

#MatExp at 36+2 – dangerously understaffed

One final blog post in this initial round of #MatExp feedback from my Facebook group.  Once again, this story is told in the mum’s own words….

“I had a very straightforward pregnancy and was expecting to to go overdue (I was born 14 days late).

My waters broke at 36 + 2 with absolutely no warning, I’d had some indigestion earlier in the day but that had gone by the evening and I was out for dinner with my partner, his Grandad and his Grandad’s friends. We live in Manchester and the meal was in Wakefield, my waters going was very obvious and completely mortifying but luckily I was wearing black jeans and restaurant floor was pretty dark. We called Pinderfields Hospital (a couple of miles from the restaurant) who said to come in as my waters had gone before 37 weeks.  I got to the hospital at about 9.30pm and I was hooked up to a monitor for 2 hours which confirmed that the baby’s heartbeat was fine. They were clearly very busy but at about midnight I was examined and they also confirmed that I was not in labour, I wasn’t having any pain at this stage. They said that because I was early I would have to be induced within 24 hours if it didn’t happen naturally or I could go back to Manchester where they have a different policy and they’d let me go to 37 weeks (not sure this was true). They said they couldn’t advise us to move to Manchester but they didn’t think it would be a problem.  I felt pretty confident as I wasn’t having any contractions and I’d been reassured by the monitoring. I was also worried about the baby being small and so I was keen to go to 37 weeks if possible. All my notes, stuff for hospital etc was all in Manchester. 

St Mary's Hospital, Manchester

St Mary’s Hospital, Manchester


We decided to leave and waited 2 hours for a discharge letter (during this time we drove to a nearby garage for water and haribo) eventually they said they’d call St Mary’s instead and we left, the journey only took about 40 minutes and we got to St. Mary’s at 3.30am. I’d started to feel pains in the car and by the time we arrived at St Mary’s these were 3-4 mins apart. They weren’t strong and seemed quite bearable but I had no idea whether they were ‘proper’ contractions. I told them this when we arrived and they were quite dismissive, they said someone would talk to me about pain relief after a doctor had seen me and I couldn’t do anything before seeing a doctor as I was now high risk.

I was then told to wait in a small, hot triage room and my partner was sent home (an hour round trip) for my notes. Over the next three hours nurses came in periodically (never the same one twice) and I was put on a monitor for a while. I asked if I could moved to a room with a pool (as in my vague birth plan) but we were told we couldn’t have one, then I asked for a normal bath or shower but I was told I couldn’t have anything until a doctor had seen me. It felt like I was left for a really, really long time. I didn’t have anything practical with me (other than my kindle) and was still in my jeans and boots. Contractions were getting more frequent, I kept sending my partner out to see if someone could come and either no one was there or they told him no one was free, a nurse eventually gave me two paracetamol. 

Finally, three hours after we arrived I told him that he had to make someone come, I still didn’t know whether I was properly in labour and I wasn’t sure I would be able to cope with the pain. I felt like I needed the loo but it was a huge effort to make it down the corridor to the patient toilets. I was starting to think that I was in labour, but if not I definitely wanted all the pain relief available! I’d had about 20 minutes of quite serious pain and I had heard stories of people being in labour for days. Finally, at about 7 am a doctor arrived to examine me and told me I was fully dilated (which was a huge relief) and then it all happened really fast. 

I was rushed round to the birthing suite where there were two midwives, they hooked me up to gas and air but then said I couldn’t have it as I had to push. I was flat on my back and in quite an uncomfortable position, I felt like it was too late to move and no one asked if I wanted to, even though I was staring at a ‘natural birth positions’ poster all the way through. The pushing was quite painful but much easier to cope with as I knew it would be nearly over. I heard a loud pop and (I think) I cracked a rib. That was the most painful bit. The pushing stage was very short and in 15 minutes the baby was out. I had a second degree tear but didn’t feel it at all at the time. As I was pushing the midwife told me that I was going to tear which I didn’t find particularly helpful. 

They put the baby straight on me and it was amazing, I felt much less tearful than I had expected as I think I was in shock. After about 5 minutes we looked and saw that she was a girl (we didn’t know beforehand). To our relief, she was obviously not tiny even though she was early and when she was weighed we were told that she was 7lb 5oz. I think I had an injection and the placenta was out very soon afterwards, I wasn’t paying much attention. The next few hours were brilliant but then I did start to get sore, they were still waiting for a doctor to sew me up and in the end it wasn’t done until 4 hours after the birth. I had gas and air while the local anaesthetic was going in.

The stiches felt fine until the local anaesthetic wore off and then the pain was unbelievable, far worse than any part of the labour, I fainted and then lost a lot of blood. I was given paracetamol (again) without being examined and told, quite patronisingly, that I could expect it to hurt for a while. I tried to explain that it was too much pain to cope with but probably wasn’t very coherent. At this point my partner had baby (with no real clue what to do) and was trying to get someone to help as I kept fainting. I didn’t want to take her as I was so shaky I was worried I’d fall off the bed. Eventually, after a couple of hours a midwife looked at my stitches and said that there was a haematoma the size of her fist (nice) which was pushing out all the stitches. They said this would have to be drained and my stitches redone but by that time I didn’t care, I was just so happy that they were going to do something about the pain. I was told that I could have an epidural (finally!) for the procedure. I was supposed to be waiting for a slot in theatre but another midwife came in to borrow some equipment and noticed that I had lost a lot more blood. She went to get someone who was looking after me and then they said I would have to have a general anaesthetic because of the blood loss. I was rushed round to theatre where I was knocked out. They sorted out the stitches and gave me a blood transfusion.

I came round a few hours later and spent the first night on the high dependancy unit. This was (comparatively) brilliant as I had my own room and a nurse there most of the time. I had drips in both hands and my ribs and stitches were very, very painful so it was fantastic to have someone help lift my daughter out of the cot. Unfortunately after that we were taken to the ward and that was just awful.

My little girl hadn’t been able to breastfeed as she had a tongue tie, this was recognised straight away but we didn’t see the same midwife twice and they kept saying that she might manage it anyway. Because she was early she was being cup fed formula as they were monitoring something (possibly blood sugar) and my milk hadn’t come in. I ended up staying in for 5 nights trying to establish feeding but baby just wasn’t interested and when she did latch on she couldn’t suck. We were told she had to be either breastfeeding successfully or bottle feeding, we couldn’t go home cup feeding. I was so exhausted after 4 nights on the ward that we just decided to bottle feed her to get out of hospital. 

The time in hospital seems like such a blur as I was just so tired, my partner, mum etc all helped as much as they could during the day but I was still left alone from 8pm until 10am every night with almost no support. Sometimes there was a midwife around to help during the night but often not and with painful ribs/stitches I did feel like I needed help. Baby didn’t settle unless she was on me (which I knew was totally normal) and I fell asleep like that several times. Being back home was amazing, I was finally able to sleep for more than 20 minutes and I was able to enjoy my baby. 

The midwives that looked after me were all lovely but they were dangerously understaffed, I rarely saw the same one twice and I think this caused problems afterwards, I had to explain about Anna’s tongue tie every time someone tried to help with feeding and almost everyone mentioned that residual pain relief from labour was probably causing her feeding problems without bothering to look and see that I hadn’t had any. 

Being on the ward with no support was dangerous, I would never have fallen asleep with my baby on me in such a precarious position at home because I could have had her in the bed with me and I would have had support, or someone to take her so I could nap for 20 minutes. 14 hours is too long to have to look after a newborn with no help and in unfamiliar surroundings. Allowing partners to stay overnight would have changed the whole experience for me, even having a shorter period with no partners/visitors (e.g 12-6am) would have been so much better, 6 hours is manageable. 

I’m very aware that I was incredibly lucky to have an ‘easy’ birth (and my daughter is heathy and wonderful) but I’m still so angry about how I was treated, I think a lot if the fear and difficulty I had was purely due to the treatment in hospital and not the birth process at all – so unnecessary.” 

#MatExp – Caught in the Middle

I am very grateful to yet another member of my Facebook group for providing me with her maternity experience to share with you.  In her own words…..

OnetoOne Midwives

OnetoOne Midwives

“My antenatal experiences with my NHS midwife and one consultant led to me transferring to the One-to-One Midwifery Service from about 30 weeks into my second pregnancy. The main issues I had with the NHS were:

    The cold and distant manner of the midwife
    The total lack of concern or questioning when I declined the breastfeeding DVD (as a natural term breastfeeder with my older son, with intention to tandem feed, I felt I didn’t need it – the midwife simply moved on to the next item and made no attempt to find out why I didn’t take the DVD. I found this shocking.)
    At a consultant appointment the consultant informed me that she had booked me in for an induction on my due date, due to my maternal age. No discussion. told her that that would not be happening.
    I had my heart set on a MLU, natural water birth, and I raised the issue of booking an induction without discussion or my consent issue with my MW. Her response was that I will do as the consultant decides. At this point I referred myself to One-to-One.
    Final point – one slightly raised blood pressure reading triggered off me being designated a high risk pregnancy, so I would have found myself on the consultant led side of things to give birth. Another big driver to move service. My BP was fine throughout the remainder of my pregnancy (with the help of Labetelol).

The whole experience was very ‘tick boxey’, with little or no consideration of the overall picture i.e. my health and fitness, my wishes, previous birth etc. I was very disappointed by the apparent lack of breastfeeding promotion.

So I had my second baby by natural home water birth, with the support of One-to-One Midwives. I ended up in hospital for ten days postnatally with HELLP Syndrome. One issue arising there was the strained relationship, and lack of joined up care provision, between the NHS staff and One-to-One. Before transferring myself to One-to-One, I had heard from a fellow NCT Refresher class Mum, that she had had a bad experience in this regard also.

Arrowe Park Hospital

Arrowe Park Hospital

I was transferred via ambulance to Arrowe Park Hospital following the birth of my daughter in April 2014, with what turned out to be HELLP Syndrome. My daughter came with me. We were in for a total of ten nights.

Although I was a patient, my daughter was not. This became a problem when she needed to have her 72 hour check. In the initial stages, my partner was doing the communicating with my One-to-One midwife; and she told us that my baby would have to be taken to an alternative venue for the check by noon on the Saturday. I was in no fit state to add to the discussion, being quite poorly and ‘not with it’.

Ostensibly One-to-One staff were not allowed on the hospital premises to carry out the check; NHS staff could not do it as my daughter was not a patient. I did become involved in the discussions when Saturday morning arrived, my partner was trying to arrange child care for our older child (not easy as we have no family close by), and it dawned on me that my newborn baby was about to be taken away from me. Breastfeeding aside, that would be traumatic for all involved – baby, me and Dad!

Bearing in mind that the main issue for me was dangerously high blood pressure at that point, I was drawn into having direct telephone conversations with One-to-One, and quite heated talks with NHS staff – who made out that there was absolutely no way One-to-One could come into the hospital to do the checks – no insurance I think was the issue from memory? As my baby was not a patient then they definitely could not perform the check – to do so would generate a second NHS number for her, which I was told would have the potential to cause us problems when trying to register her birth. The systems would not be able to cope with it. We felt that systems were taking priority over the well-being of our newborn baby.

In the end a One-to-One midwife did come into the hospital to do the check. There was an uncomfortable atmosphere between the two sets of staff.

On a side note, my daughter was diagnosed with a mild tongue tie and a referral supposedly made. In fact no appointment ever came through. Fortunately the tongue tie was never an issue.

My One-to-One midwife came to see me in hospital on a number of occasions; each time I picked up on tension between the parties.

Apart from the stress around my daughter’s check, I have to say that the majority of the care I received on the labour ward was fantastic. Apart from one incident where I suffered a huge loss of dignity and lack of respect or concern for my personal space and being. In fact I felt totally humiliated. It happened on my final night at Arrowe Park (so day ten of my stay); I was rushed down from the maternity ward to the labour ward as my blood pressure was so high. I was given intravenous drugs to bring it down; it would have been a trip to the cardiac unit if this had not worked. I needed the toilet – and not just a wee. I was told I had to remain on the bed and my request to use a commode was refused. So I had to use a pot under the sheets. Except the sheet was inadequate and I knew that I wasn’t covered up. So I tried to throw my dressing gown over my knees. People were coming and going in and out of the room. I had a sudden moment of realisation of the total indignity of the situation – people could well have been able to see me trying to have a poo, knees up in the air, largely uncovered. I cried. I just wanted to go home, with my baby.”

Pause in the pursuit of happiness

I would like to pause for a moment.  And be happy.

Just Be..... Happy

Just Be….. Happy

I have already written a lot on this blog, and before I started this site I was still talking about maternity care, breastfeeding and parenting every day.  I have a blog post lined up discussing my mental health experiences, and lots more maternity experiences to share.  So it’s easy to get caught up in what is wrong.  What needs to be fixed.  Where things can be improved.  Who is to blame.  Who needs to be persuaded of a new point of view.  Whose point of view you should consider.  What you need to learn.  How much you don’t know.

When you discuss maternity experiences all the time it’s hard not to dwell on your own.  My children sometimes seem to be the sum of their birth “vital statistics”:

Edward

Edward

David

David

But when I’m away from social media and spending time with my children I remember that they are SO much more than that.  And in fact they don’t have any concept of those things at all.  They are wonderful individuals, with personalities totally separate from the method and circumstances of their birth.  Edward is an inventor, a thinker, an observer, with so many ideas and plans in his head.  He is also a 4 year old, full of beans, energy, attitude and excitement.  David is a communicator, a social animal, never happier than when he has an audience…. (can you guess who he takes after?).  At 18 months he is most interested in farm animals and being read to.

A woman’s maternity experience is one of the most important times in her life.  Her birth choices, her feeding choices, her journey into motherhood and the amount of support she receives, these are vital areas of discussion and I feel privileged to be a small part of these conversations.  And every woman has something about those early days and weeks with her babies that she regrets or feels guilty about – guilt comes as part of the motherhood package.  It would be so easy to let those concerns become THE story of our children.  But the wonderful thing is that our children write their own stories.

I didn’t find the newborn months particularly pleasurable.  I tell people I don’t really “do” babies, and I am so happy every time I look at my boys and realise neither of them is a baby anymore.  But that’s not to say that I don’t have happy memories of those times.  A friend shared this blog post the other day which I think sums it up well, and which is a great response to those people who tell you to “enjoy every moment”.  You don’t have to enjoy every moment, not with babies, not with toddlers, not at any time in your life.

But what I urge you to do is to make a note of the wins.  Those days that are filled with magic, the happy times, the GOOD days.  Photograph them.  Write about them.  Keep a record of them.  They will sustain you in the down times, in the times when you need reminding that it’s not all bad, that not all parenting takes place at 3am when you are being screamed at and covered in vomit.  That the whole of life is not a campaign, it isn’t all a battle.

This Easter Bank Holiday was a win for me.  So I am taking a moment to just……. be happy.

Edward the adventurer

Edward the adventurer

David with an Easter treat

David with an Easter treat

Mental Health – and Money

I have realised that in telling you all about myself I have missed out quite a large area, which is my mental health.  I have been following Rosey @PNDandMe and #PNDChat almost since the moment I started on Twitter, and I should probably tell you why.

My family has always been very open about mental health, because a number of my relatives have struggled with it including my father, so I was fortunate in that I never had any idea of stigma.  I just always knew that mental health was the same as physical health: you had a problem, you tried to get it fixed, you talked to the professionals.  Unfortunately though, that doesn’t make it any easier to identify what you are actually struggling with yourself.

Looking back, I can see that I have had anxiety for a very long time, probably since my teens, and a little bit of depression thrown in there as well.  I was certainly struggling at university, but it is easy to overlook that perhaps because when you are at university you can blame it on too much alcohol, not enough sleep, chaotic relationships – all kinds of things that when you’re young can seem to be the reasons why things are a bit odd.  But looking back I think anxiety was a big issue.

Easy to blame problems on partying when you're young

Easy to blame problems on partying when you’re young

When I was in my twenties I had my first experience of counselling.  I had been with Phil (now my husband) since I was 22, and I am not sure what age I was when we decided that I needed a bit of help, but it was certainly before we got married.  I was struggling with anger, mainly, which stemmed from anxiety – I had bouts of anger, could be very cruel to Phil and to myself, and just be unpleasant to be around and clearly unhappy.  We found a counsellor locally through my GP, and we paid for me to see her a few times. She was helpful.  It was the first time I had started to sift through everything and obviously by the time you are in your twenties there is quite a lot to sift through, so it was the tip of the iceberg.  I can’t remember how we afforded it, I suspect we had some help from my parents, but it was useful.

The next time I had any professional help was just before we got married.  I was struggling with what I now know is social anxiety – I remember a particular incident when we were at a friend’s wedding and I just found it so difficult.  I was opting out of social situations, I was wandering off, I was leaving situations early, I was going away without saying goodbye – I just remember so many times when I behaved in what must have been quite an odd fashion, because I just didn’t know how to cope with these situations.  I was having, if not physical panic attacks, then certainly that feeling of “I can’t cope with this and I must leave this situation”.

So Phil looked into Cognitive Behavioural Therapy (CBT) and I went to see a private therapist called Patrick who was very helpful.  It was my first experience of CBT and it was fantastic.  Really helped with the social anxiety.  I can’t remember how many sessions I had but once I was signed off by Patrick I knew I couldn’t go back to see him because he was moving back to Ireland.  Once it was over I took the theory of it with me, but I didn’t practice any exercises afterwards.  Which was fine, because I can’t believe now I ever struggled with social anxiety, that is not something I would say I have a problem with anymore.  So CBT worked for that, but I didn’t keep up with the idea of using the techniques more generally.

And then we come to the point where I had children.  Before you have children, you have a number of coping strategies – wherever you are in your life, we all have issues and things that make life difficult for us, and we have our coping strategies.  Some of us have sleep – sleep was one of my big ones, if I could rest and get a good night’s sleep things were easier, and if things were particularly difficult I could hide under the duvet all weekend.  As anyone with children will now, sleep doesn’t happen when you have a baby!  There are other coping strategies you don’t realise you are using until they are taken away from you: time to yourself, time away from other people for instance. Having a baby means that you are permanently around another person, you are permanently responsible for something and it is something incredibly important, which if you struggle with anxiety is obviously a trigger.  You don’t get much sleep, you don’t necessarily eat that well, and life is completely and utterly different to anything you’ve experienced before, so you are totally out of your comfort zone.  Anxiety comes roaring back.

I definitely struggled with postnatal anxiety, although at that point I still didn’t know that “anxiety” as the word for the things I struggled with.  I knew I was having a hard time postnatally, I knew I was tearful and low and upset; I did the Edinburgh questionnaire and of course I came up as borderline, because I didn’t have postnatal depression, I had postnatal anxiety.  If you read my feeding story you will see that in the end it was a question of giving up breastfeeding and getting a good night’s sleep, because that’s the only coping strategy I knew. So that’s what I did, and I slept, and baby slept through from 18 weeks which was a big help.

And then I went back to work when Edward was 7 months.  And this was a problem, because work had always caused anxiety for me.  I don’t deal well with the workplace, with all the responsibilities and the constant judgement – because that’s what working life is, constantly being judged, having appraisals, doing things that your boss will then judge, that’s what it is.  Obviously as a working mum you are trying to organise a lot of things, there are still nights when you don’t get that much sleep for instance when baby is ill or teething, and I really struggled.

The stormy beach of my mental health

The stormy beach of my mental health

When Edward was 8 months old Phil and I had real problems, I was very unhappy, I had a couple of mild panic attacks at work, and we took the decision that I needed some help. We decided that I was going to give up work, even though we couldn’t afford that at the time, and I was going to have more CBT with a private therapist.  All of this had a financial implication, and we once again had to have help from our family.  I don’t know what we would have done without that.  Money is unfortunately the key. We found an incredible private therapist, Julie Ruta, who since that time has changed my life, quite frankly.  I had probably 8 months seeing her and it was just amazing.  She was the one who told me about Generalised Anxiety Disorder (GAD), we identified that that was my main area of concern, although there was some depression in there, and she taught me some brilliant things for dealing with it.  We looked very closely at so many aspects of my life, so many different ways of coping, and as I say it changed my life. When I finished with Julie I was really positive about my ability to cope.

The autumn after I finished CBT with Julie I actually had a few “tests” to go through – I had a miscarriage and I had to have surgery on my scalp.  So I had a few instances of being in hospital (I did not used to deal well with hospitals) and these things were stressful anyway, but I dealt with them very well.  It gave me hope that I was able to move forward in life using the tools that Julie had given me.  I knew this time that I needed to keep up with the CBT exercises and practice the techniques. I then fell pregnant for a third time and as you will know, my youngest son David has a congenital heart defect and the weeks surrounding his birth were very stressful.  I coped pretty well whilst we were in hospital because we got lots of attention and support, from friends, family and medical professionals.  The day David came home was one of the hardest days – I remember throwing a cup at the wall about 3 hours after he had come home because I just didn’t know how I was going to cope.  I don’t know why, looking back, I didn’t go back to see Julie then but I tried to push on through using the tools that I had.

We had a few months before David’s second operation, and my goodness that was a stressful time.  That Christmas was probably one of the worst times Phil and I have been through as a couple.  Just before David had his second op Phil and I had a couple of sessions of relationship counselling, again from a private therapist, as we needed a little bit of reassurance and a bit of assistance because we were struggling. David did remarkably well during and after his second surgery, and once he came home again as far as I was concerned we were all set to get on and enjoy life.  He doesn’t need another operation until he is 3 or 4 years old, so I just wanted to look forward and have some fun.

Beginning to build a shelter from the storm

Beginning to build a shelter from the storm

We had a holiday with friends, and when we came back David was 8 months old, the same age Edward had been when the wheels came off so to speak.  I have no idea if the timing was a factor, but the day after we returned from holiday I dropped into the deepest mental health hole I’ve ever been in.  This was depression this time, it was frightening and it was frightening for Phil. Our lovely GP came to the house and prescribed anti-depressants.  Phil took 3 weeks off work so I could just disappear into bed and recover.  So not only money this time but also Phil having sympathetic employers were a key to me getting the help I needed.  I was however able to self refer to Trafford Psychological Wellbeing Service this time around as I was pretty ill, which meant I got 6 weeks of CBT on the NHS.  It was very basic, quite different from what I had had with Julie, but it was what I needed.  It was back to the absolute basics of CBT and that’s what I needed: a reminder of the simple tools and the simple ways of coping, and it reminded me that I hadn’t been doing the exercises.  It doesn’t work if you don’t keep up with the techniques.  I went back to doing the exercises everyday until I felt ready to space them out a bit more.

I now have a relapse plan in place, a note of my red flags for when I am likely to start to struggle, and I have started to build what I call me “house of mental health”.  I saw myself as having been on a windswept beach with no shelter, buffeted by everything life threw at me, and I realised I had to build a strong house that could withstand all weathers.  So I put my tools to use and instead of trying to just “get fixed” I took it really slowly and gradually started to put myself back together.  10 months later I feel I have built a pretty good house, but I know that it will need constant maintenance.  I have so much in my toolbox though, and I know I can go back to see Julie at any time – no waiting list required.

Building my House of Mental Health

Building my House of Mental Health

I have worked hard to help myself.  I have had wonderful support from some very good friends.  I have had medication and some therapy from the NHS.  Ultimately though it has been our ability as a family to finance private therapy that has kept my life and relationship on track.  I feel incredibly lucky.  And I feel angry on behalf of all of those friends of mine who would also benefit so much from the kind of help that I have received.  Because they are priced out of the market.