Meet the tech evangelist who now fears for our mental health

Belinda Parmar was a passionate advocate of the digital revolution but has started keeping her familys smartphones and laptops locked away to protect her loved ones. Is she right to be so worried?

In Belinda Parmars bedroom there is a wardrobe, and inside that wardrobe there is a safe. Inside that safe is not jewellery or cash or personal documents, but devices: mobile phones, a laptop, an iPod, chargers and remote controls. Seven years ago, Parmar was the high priestess of tech empowerment. Founder of the consultancy Lady Geek, she saw it as her mission both to make tech work better for girls and women and to get more girls and women working for tech. Now she wants to talk about the damage it can cause to our mental health, to family life and to children, including her son Jedd, 11, and daughter Rocca, 10.

Parmar made her living and lived her life through these devices, so what happened to make her lock them up? Why did this tech evangelist lose her faith?

Strong women run in Parmars family. She tells me her mother raised her and her sister alone after separating from their father when Parmar was two (shes now 44 and recently separated herself), while her grandmother, who had four children, ran her own business, a recruitment firm in Mile End, east London. She grew up believing anything was possible, which is why she felt driven to start Lady Geek when she was 35, after a man in a phone shop tried to sell her a pink, sparkly phone. That was the way technology was sold and I thought: This is ridiculous. I was so angry that I went home and started a blog, she says.

The blog was called Lady Geek, and it launched a national conversation about sexism in the tech industry. Parmar left her job in advertising to turn it into a business, advising tech companies how to make their products better for women, and going into schools to encourage girls to go into the industry, for which she was awarded an OBE. For me, tech was a leveller, she says. You didnt need money, you didnt need status; it was an enabler of a more equal and more diverse society. This tiny bubble that most of us lived in had been popped and that was wonderful. That still is wonderful.

But certain aspects of her relationship with technology were not so wonderful. Id wake up and look at Twitter, she says. I had two small children, and the first thing I should have been doing was going to see the kids, but Id be looking at Twitter. She realised she was using social media for validation, to feed her ego. She began to think: If technology is an enabler, why am I just using it for things I dont like about myself?

As her children grew up, she started to be disturbed by her sons apparent compulsion to play video games. Technology takes parents out of control. I cant compete with an amazing monster, that level of dopamine. He doesnt want to eat with us, to be with us, because its not as exciting, she says. She bought a Circle, a device that allows you to manage the whole familys internet access, controlling which devices are online at which times and what they can view. My son hid it, she says. She tried to turn the wifi off, but he stood guarding it, blocking her way. She still does not know where the Circle is. In theory, she says, if youve got compliant children, this would be perfect. Perhaps that is why her combination to the safe, with his devices and hers, is 12 digits long.

Safe
Safe keeping … Parmar locks her devices in for the night. Photograph: Teri Pengilley for the Guardian

She has reason to worry. When a friends 12-year-old son showed signs of being addicted to video games, Parmar at first shrugged it off. Then he refused to go to school because he wanted to play all day, and then he spent eight weeks in a psychiatric institution. Hes 15 now. Nothings changed. He still wont go to school, she says.

Professor Mark Griffiths, a psychologist and director of the International Gaming Research Unit at Nottingham Trent University, has spent 30 years studying technological addictions; he was the first to use that phrase in 1995, to describe excessive person-machine relationships. All behaviour is on a continuum from absolutely no problems at all, he says, through to recreationally enjoying something, to excessively enjoying something, to problematic and then addictive and pathological at the far end. For someone to be genuinely addicted to technology, that technology has to be the single most important thing in their life they do it to the neglect of everything else and very few people fulfil that.

He is prolific (helped, he says, by having given up his mobile phone), publishing more than 100 papers last year alone his most recent was on Instagram addiction. But he has his doubters. There are academics wholl say this is complete nonsense, that if it doesnt involve ingestion of a psychoactive substance it cant possibly be an addiction. To that he retorts: what about gambling? What is good for me is the established bodies are catching up, he says. This year, the World Health Organization added gaming disorder to its list of mental health conditions in ICD-11, the International Classification of Diseases.

Griffiths is careful to articulate the difference between believing that technological addictions are real, and believing that they are ubiquitous. Addiction is defined not by the amount of time spent doing the activity, but by the context in which you do it. Parents tend to pathologise behaviour that isnt pathological its the technological generation gap, he says. Every week, concerned parents email him to say their daughter or son is addicted to social media, and when he asks if their children do their homework and chores, take exercise and have a wide network of friends, nearly always the answer is yes. But, they say, the kids are wasting three hours a day online. What were you doing when you were their age? Because I was watching TV for three hours a day when there were only three channels. And then there are the parents who use social media just as much as their kids, and who shouldnt be surprised when kids end up copying exactly what they are doing.

While it may be reassuring that few of us would qualify as addicts by Griffiths definition, the fashion for tech detoxes, and a recent survey that found that 75% of those aged 25 to 34 feel they use their phone too much, suggests many of us remain disturbed by our increasingly entwined relationship with technology. Richard Graham, a child and adolescent psychiatrist who runs the Tech Addiction Service at Londons private Nightingale hospital, tells me: Were psychologically cyborgs now, whether we like it or not. Were integrating these devices into our mental functioning, into our social and emotional lives. He quotes Chief Justice Roberts of the US supreme court: The proverbial visitor from Mars might conclude they were an important feature of human anatomy.

While Graham feels the addiction model has its uses, he also draws on other ways of thinking about what is going on when we cant look away from a screen. He tells me about the student who decided to wind down one evening by playing a game of League of Legends, which would take about 40 minutes; the next time he looked at the clock, it was 5.30am. To explore this, Graham turned to flow psychology, a way of understanding the process of getting into the zone around a piece of work, which can be positive but can also make you lose track of space and time. This is not escapism: A lot of gamers are thinking strategically, in a very deep way. He is also interested in the idea of hyperfocus, which some people with ADHD experience, as not so much a problem of not being able to concentrate, but of not being able to shift concentration.

He was influenced, too, by the work of Sherry Turkle, a social psychologist who has been researching the relationship between people and technology for three decades. Some of the participants in her studies, he says, were so attached to their consoles that they even found winning upsetting because it disrupts the connection with the machine. Theres a sense that they keep going because they dont want that connection to be lost. A psychoanalyst might compare this to the unconscious desire to be back in the womb, in a state of absolute connection.

For young people on the brink of or enduring the horrors of adolescence, like Belindas son, Graham feels there could be something else going on: an identity crisis, trying to find a place in the world of near-adults. For these young people, games and social media arent just fun theyre business. Whether they monetise their YouTube channel or not, this is a way to succeed, to harness digital capital and turn it into self-esteem. Griffiths suggests that screens might even be one of the reasons for the drop in youth crime over the past 25 years: More youth are spending more time in front of technology, so they havent got time to go out and commit acquisitive crime. Being very engrossing isnt necessarily bad.

These experts agree that abstinence is not the way forward: instead, we need to build what they call digital resilience, and learn to use technology in a measured, controlled way. If someone goes diving and is deeply immersed in the ocean, Graham says, you cant just bring them up quickly without significant effect. So rather than talking about digital detox, we need to think about digital decompression.

He recommends the American Academy of Pediatrics family media plan, which tells you how much sleep you need, and schedules a period of no-screen time an hour before bed, as well as clean periods in your day and clean zones in your home. I think it can really help if everyone does it together. But adults can be more slippery than young people. Theyll say: I need my phone for work, for my alarm. Unfortunately, with adolescents, anything like that smacks of hypocrisy and is incredibly damaging.

Young people can be responsive when adults change their own behaviour, he says. I had quite a nice discussion with a young man and his mother. She told me she only has a Kindle, and I replied that the later models will disrupt your sleep as much as anything else. This absolutely thrilled the adolescent, who was much more willing to change his behaviour because Id caught his mum out. And she was up for changing, too.

Parmar realises she has to set an example. I love technology, but my own behaviour has changed because Im more self-aware, she says. Hence her devices being in the safe, along with her sons. But looking around her sunlit bedroom, I see a laptop on the desk, a tablet next to her pillow. So your bedroom isnt screen-free, then, I say. She looks reflective, perhaps a little sheepish, and acknowledges that she likes to watch things on her tablet once the kids have gone to bed. Shes still figuring things out, still coming to terms with the tough decisions we all need to make if we want to be more in control of our relationship with technology.

These are the conversations Parmar wants us to have, which is why she is launching a campaign and website, TheTruthAboutTech.com (no relation to a similarly named American campaign), that will offer practical tips and a space for people to share their stories. This is my new mission. And I tell you what: dealing with my son every day, it reminds me, this is personal. This is really personal.

She also wants to hold to account the tech giants who are profiting from our over-engagement. She raises her voice: I want to say, youve got to be more responsible. You can still make billions, but you should be thinking about how can you bring all the human values we want as a society into your products. She is furious with Reed Hastings, the CEO of Netflix, who last year said the companys main competitor was not Amazon Video or YouTube, but sleep. That is disgraceful. He should be saying: My No 1 mission is to unite families in their living room around great content.

These companies, she says, are the most powerful brands in the world, more powerful than governments. Imagine if a government had said that. Theyre digital dictators, and part of this campaign is getting them to stand up and be accountable. And what does that mean? It means rethinking Snapchats streaks, which track how long users have been in daily communication, keeping them checking in for fear of losing out; it means rethinking YouTubes Up next queue, which automatically plays video after video; it means addiction ratings on video games. And thats barely scratching the surface.

How does she feel about her previous work, spreading the benefits of tech with no mention of its dangers? I think I was naive, she says. I didnt know enough. I feel good about the fact that I got more women into technology, but if I did it again, I would do it in a way that is more realistic, balancing the good and the bad.

I cant stop thinking about that safe. After all, a safe is built to protect our most precious possessions or to lock up our most dangerous weapons. It feels extraordinary that something so everyday, so anodyne as a mobile phone could have such unnerving value, such threatening power. With their influence and wealth, why would the tech giants change from digital dictators to enlightened despots?

Parmar believes commercial pressures will compel them two influential Apple shareholders are already threatening to sue the company for not limiting screen time. Graham proposes a darker alternative: We could edge towards the equivalent of a parasite that drains its host so much that it kills itself, along with the host. He doesnt mean that these technology companies and their products will actually kill us, of course. But if its this relentless, the so-called attention economy will fall down, because well all be too exhausted.

Build your digital resilience

Four tips from addiction expert Richard Graham.

1 Be united as a family. Use the American Academy of Pediatrics family media plan but remember: The whole family needs to buy into this.

2 Plan activities outside the home. Go to the cinema, for example. Its a shared experience, and theres a narrative to stoke the imagination.

3 Vary your digital diet. People get stuck in very simple diets of media consumption, using the same platforms, games and messaging apps. Using different platforms is important its about moving between them and having a sense of ease of being able to do something, then stop and move on.

4 Live healthily. Sleep enough, eat well, drink enough water and do some physical activity every day.

Read more: https://www.theguardian.com/technology/2018/mar/15/meet-the-tech-evangelist-who-now-fears-for-our-mental-health

It’s not just in the genes: the foods that can help and harm your brain

Our diet has a huge effect on our brain and our mental wellbeing, even protecting against dementia. So, what should be on the menu?

It’s not just in the genes: the foods that can help and harm your brain

Our diet has a huge effect on our brain and our mental wellbeing, even protecting against dementia. So, what should be on the menu?

Read more: https://www.theguardian.com/lifeandstyle/2018/feb/12/its-not-just-in-the-genes-the-foods-that-can-help-and-harm-your-brain

My life in sex: Its a thrice-weekly session with a dilator

The cervical cancer survivor

My life in sex: Its a thrice-weekly session with a dilator

The cervical cancer survivor

Read more: https://www.theguardian.com/lifeandstyle/2018/feb/16/my-life-in-sex-cervical-cancer-survivor-vaginal-dilator

How to feed your gut

Want a healthy gut? Reach for the kimchi, sauerkraut, artichokes, coffee and chocolate. But watch out one category of food will make your microbes wither

Magical microbes how to feed your gut

Magical microbes how to feed your gut

Want a healthy gut? Reach for the kimchi, sauerkraut, artichokes, coffee and chocolate. But watch out one category of food will make your microbes wither

Read more: https://www.theguardian.com/lifeandstyle/2018/jan/29/magical-microbes-how-to-feed-your-gut

I just want to cut it off: the weight-loss patients who no longer fit their skin

Bariatric surgery is a highly cost-effective way to lose life-changing amounts of weight but the NHS rarely removes the excess skin that is left behind. Desperate patients are now crowdfunding their operations while struggling with anxiety, depression and identity issues

When Haze Atkin passed the 32kg (5st) mark on her weight-loss programme, something strange began happening to her skin. First it grew softer. Then it grew emptier. By the time she had shed her 64th kilo, her body had shrunk so much that her loose skin needed to be folded into her clothes. Now, when Haze sits, a hovercraft of skin skirts her seat. When she takes a bath, her spare skin floats. In bed, her husband Chris accidentally rests an elbow on it; he cant always be sure where Haze ends. The edges of her have become mistakable.

To her childrens delight, Haze can wobble her skin and make it talk like a puppet. Sometimes her daughter holds out her hands like a set of scales and Haze places her stomach skin on them. She thinks it weighs a stone. It has become oddly plastic, so that Haze can gather it in her hands and stretch and shake it, fold and mould it. But the one thing she can never do with her skin is forget it.

Like many people with excess skin, Haze lost a lot of weight after bariatric surgery. In the 10 months after her gastric bypass an operation the NHS has come to see as highly cost-effective she shrank from 149kg (23.5st) to 70kg (11st). She met all her targets. Her surgeons called her a model patient. And yet, just when Haze should have felt she had achieved her goal, her skin held her back. The scales said she had reached the end of her journey, but the mirror told a different story.

Haze is one of the 9,325 UK patients who in 2013 underwent bariatric surgery on the NHS, according to statistics held by NHS Digital. The same year, NHS England reported that the price of keyhole bariatric surgery for diabetes patients with a BMI of 35, for instance, is recoverable in just 26 months. According to projections from the Department of Health, the cost to society and the economy of people being overweight and obese could increase to almost 50bn in 2050, so it is easy to see why bariatric procedures make financial sense. But is the surgery causing a different kind of health crisis? Is such massive weight loss MWL, as healthcare professionals call it solving one problem only to create a new one, a generation of weight-loss survivors tormented by anxiety and depression because they no longer fit their skin?

Haze has a simple message to the NHS. You dont just leave people half-done. Finish it.

The NHS does perform some skin removal operations. But the only mention of skin removal in all Nices recommendations is that a multidisciplinary bariatric team provide information on, or access to, plastic surgery (such as apronectomy) when appropriate (an apronectomy is a mini tummy tuck to remove the apron of skin that hangs over the pubic area). This provision varies hugely by region. In theory, a patient needs to show that skin removal surgery is a health rather than a cosmetic intervention.

In practice, the local clinical commissioning groups, which commission NHS healthcare, rarely approve such applications which is why crowdfunding websites are full of people who have lost massive amounts of weight and are desperate to remove their skin, even if it means posting explicit, naked or near-naked photographs that play to a sort of pornography of excess skin. Hazes page has raised 332 of the 6,600 she needs for surgery. She applied to the NHS she suffers from skin infections, anxiety and depression, and believes the extra weight exacerbates her fibromyalgia (she is registered disabled). But she was rejected.

Lisa
Lisa Riley, who had skin surgery. Photograph: Ken McKay/ITV/Rex/Shutterstock

So each week for the past four years she and Chris have laid aside 20 every spare penny towards the cost of the fleur de lis abdominoplasty on which Haze has set her heart. This double incision runs vertically and horizontally, and was part of the suite of operations carried out on the actor and TV presenter Lisa Riley in her documentary Lisa Rileys Baggy Body Club. The fleur de lis leaves a wound so severe that Rob Winterton, the cosmetic surgeon who performed it on Riley, says it is comparable to a 20 or 30% burn.

But for Haze, the surgery is the only way out of an unbearable predicament. At 30, she finds her skin so invasive, so mentally hard to deal with, every day I just want to cut it off myself. It invades my thoughts, my feelings, all the time. Every time I get dressed.

If you catch yourself in the mirror, Chris interjects. If I touch you wrong. If I roll on you. If I see you getting dressed.

Hazes skin is always on her mind which is not, of course, where skin is meant to be. Her daily life has evolved to make dozens of minute accommodations. She must wash carefully, lying down and stretching her skin out in order to clean and dry it thoroughly. Where the skin is folded, bacteria grows, she says. Dressing is a military operation. Everything is tucked away. And her relationship, the way she and Chris interact, has changed too.

Haze has gone from one kind of person to another, and the speed of her transformation has caught both her and Chris by surprise. You went from having a plus-size, curvy, full wife which you never had a problem with to suddenly this petite woman with hanging sacks of skin, Haze says to Chris, who is seated at her side. And it really threw you.

It was trying to remember who she is, Chris replies. Not mentally but physically. Its like, are you sure its you?

The pair have been married for 13 years. But the surgery, so hyper-efficient and cost-effective, has not given their emotions, their instincts, their bodies, time to adjust. Ill get there in the end, Chris says. Its because the process is so quick. Very shocking.

They had a small amount of savings, which Haze spent on a breast augmentation to save my sanity because she was so depressed by her new paper bag breasts. Even so, in their most intimate moments, Hazes skin still comes between them. If Im on top and I lean forward, she says, my stomach gets there first. She turns to Chris. You literally hold it back, she says, putting her hands at her narrow waist to demonstrate. To try and make you feel better, he nods, and they reach for each others hands.

Two further years of saving lie between Haze and Chris Atkin and the promised land of an operation so extensive that Winterton says it puts two and a half feet of scar on a patient. Providing, of course, that inflation does not outstrip them. But Paul Watling, 34, from Manchester, has barely a week to wait. Like Haze, he was rejected for the operation on the NHS after months of psycho-evaluation. He was trying to get along with his skin, to live with it, until last summer when he picked up a friend from hospital after body lift surgery.

The sight of his friend in his new skin made Paul see himself with unexpected clarity. At lunch with his mother and his girlfriend, Charlotte, I turned around and said: I need it. I just felt the time had come to put this part of my life to bed.

We are talking in a breakout area of Manchester Metropolitan University where Paul works as a night-time duty manager for halls of residence. While students amble down the corridor, Pauls voice quickens. This is it! Something that has been a negative aspect of my life for all my life is banished for ever.

Paul
Paul Watling: I feel great. But I dont look it. I look awful. Photograph: Christopher Thomond for the Guardian

The negative aspect of Pauls life began as a child with a tendency to overeat. At 22, he weighed 191kg (30st). He was offered a gastric bypass after doctors discovered a lung tumour (he was too fat to operate on) and this was in 2005 was promised that his excess skin would be removed on the NHS. However, by the time his weight had stabilised, he was turned down for the skin surgery. Depressed by what he saw in the mirror, the nipples that sagged far below his chest, the reams of spare stomach and undereye sacks that made him look permanently tired, Paul began to eat and drink heavily.

I thought: If Im going to look this bad, I may as well fill it out and just be the fat guy again, he says.

Over the next 10 years his weight rose as he ate to fill up his skin; a gastric bypass is only a tool to help with weight loss, and depends on adjustments to diet and exercise to work. While his stomach expanded, Paul kept telling himself: Im nowhere near as bad as I was. Then, last Christmas, he woke up after a binge and needed the bathroom. Looking down at the toilet bowl, he realised he couldnt see what he was doing; his stomach was too large. I thought, thats not normal. I dont remember that.

He was staying at a friends house, and his friends bathroom contained a set of scales, something Paul hadnt seen in a long time. He stepped on. I was like: Wow! This is insane! The scales said he weighed 162kg (25.5st). He found his friend in the kitchen. I took my shirt off and said: Take a photo. And I could see, in that photo, the 21-year-old me. I said: This has to stop.

He researched nutrition and exercise plans and began to adjust his diet and lift weights. After 11 months, in an entirely self-directed effort, he had lost 64kg (10st).

I feel better than I have ever felt in my life, Paul says. I feel great. But I dont look it. I look awful. While we talk, Pauls right arm disappears beneath the table to shield his stomach from passersby.

Im happier now with the way people treat me and it is a world of difference. But when I was bigger, I was happier with the way I looked. I was just a fat guy. Thats all I was. Yeah, people take the piss and are cruel but its there for everyone to see. This, he says, looking down to where he can feel his skin pulling over his belt line, is a hidden shame. Even the fat guys in the gym hang around in the dressing room. But Im ashamed. I sneak into the family room and lock the door.

Paul is troubled not only by his skin but also by the fact that it troubles him. Its a constant internal struggle for me. Why are you spending 10 grand on this? Its just appearance. Come on! You can rise above this. Of course, how you look shouldnt matter, he says, but it does matter, because of the experiences you had when you were younger, the years of verbal and physical abuse. He is a heavy metal fanand has always identified as an outsider, found comfort in it. But his skin has made him feel more privately misplaced, estranged in a way that is unfamiliar he has become an outsider in his own body.

I know I should be proud of my excess skin. It should be a battle scar But the flip side, which is the stronger side that always wins, is: Look at the state of you, youre gross, youre disgusting, you cant let anyone see you I dont want to fit in with society, I want to fit in with myself.

Paul is right that not everyone with excess skin feels as he does. Krystina Wright, 31, from Grendon in Warwickshire, lost 44kg (7st) with the help of Slimming World, and has a pouch at her stomach.

She knows she has undergone a transformation, and that her skin tells the story of it. Last year she was shortlisted for Slimming Worlds woman of the year. Out dress shopping, she stood in the fitting room in her underwear, and her mum remarked, You can see youve lost weight. But I never see that in the mirror, Krystina says. When Im walking, [the skin] around my legs is obviously looser than somebody who hasnt lost weight but I just ignore it. Im so happy with my journey that everything negative about my old self doesnt seem to matter.

Even in her contentment, however, Krystina still associates the experience of being fat with an old self, and it is this sense of disjuncture between an old self and a new self, a fat self and a thin self, that challenges people who have lost a transformative amount of weight.

Skin is a boundary between ourselves and the outside world. But for Haze Atkin, her skin, in its looseness, provides an untrue border; her skin seems to stop beyond her true edges. Instead, she strongly demarcates the line between old and new selves. When she was fat, she was Hayley. Two years ago, after weight loss, she changed her name legally. Its weird to see pictures of me before, she says. You cant I cant tie those two people together.

Im very proud of Hayley. But thats not me. Theres a real separation. She picks up her stomach. The thing thats hanging on is this. Hayleys skin.

Elna Baker can relate to Hazes divided self. The American writer and performer, 35, has documented her weight loss and skin removal surgery in blogs and podcasts such as This American Life. Between losing weight (nearly 50kg/8st) and losing the skin, she lived in the same sort of limbo as Haze she thinks of it now as a transitional place between fat and this idea of thin.

Elna
Elna Baker: I feel like Im wearing a disguise. Photograph: PR

But Baker also says she has travelled further along the timeline I dont know how to explain it. But theres, like, a core thing that youre still running from, she says, speaking on the phone from New York. And not to sound ungrateful for the means and the experience of getting to transform, but I also feel its more complicated than I expected, because its about identity and gender and worth. The thing that still saddens me is that I lived too long in the world as a fat woman to forget the way the world exists when youre fat. So now I feel like Im wearing a disguise, which allows me not to have to experience on a daily basis judgment, shame and hatred. But I also have all this muscle memory of that. So I sometimes feel confused like Im still experiencing a side-effect of a thing I no longer am.

Baker had implants to return her breasts to their former size, a body lift, a thigh lift and a circumferential body lift a cut around the circumference of the body. The scar draws a line between her top half and bottom half and has left her feeling, literally, a little divided.

Despite complications afterwards that meant that she had to pack her wounds with gauze, pushing wads into the holes left by burst stitches as if she were stuffing a soft toy, Baker is glad that she had the operations. But she has spent the past year using therapy, meditation and self-help to address the boundary between old Elna and new Elna. She hopes the division is an illusion and it is possible to reach into the depths of me and meet the person [I was] and integrate it.

Haze, meanwhile, hopes for the opposite, that surgery will not only make her proud of her body but sever her from the past. And Paul, only a week away from his operation, sometimes has to quiet the small voice that asks: What if I go through this and Im still not happy? He reminds himself: Ive set this up in my mind. This is closure of a lifetime of not being happy in my body.

All he, and Haze and anyone, really want is to be comfortable in their own skin.

Read more: https://www.theguardian.com/lifeandstyle/2018/jan/02/i-want-to-cut-it-off-weight-loss-patients-excess-skin

Dont listen to Gwyneth Paltrow: keep your coffee well away from your rectum | Jen Gunter

The colonic irrigation and coffee enemas promoted on Paltrows website Goop are not merely unnecessary, they are potentially dangerous, writes obstetrician and gynaecologist Dr Jen Gunter

It seems January is Gwyneth Paltrows go-to month for promoting potentially dangerous things that should not go in or near an orifice. January 2015 brought us vagina steaming, January 2017 was jade eggs, and here we are in the early days of January 2018 and Goop.com is hawking coffee enemas and promoting colonic irrigation.

I suspect that GP and her pals at Goop.com believe people are especially vulnerable to buying quasi-medical items in the New Year as they have just released their latest detox and wellness guide complete with a multitude of products to help get you nowhere.

colon
Ha ha, go deep. Nice play on words for a dangerous yet ineffective therapy. An advertisement on Goop.com.

One offers to help if youre looking to go deep on many levels. Ha ha, go deep. Nice play on words for a dangerous yet ineffective therapy. Goop.com is not selling a coffee machine, it is selling a coffee enema-making machine. That, my friends, is a messed-up way to make money. I know the people at Goop will either ignore the inquiries from reporters or release a statement saying the article is a conversation not a promotion and that they included the advice of a board-certified doctor, Dr Alejandro Junger, but any time you lend someone else your platform their ideas are now your ideas. That is why I never let anyone write guest posts for my blog. And lets be real, if you are selling the hardware to shoot coffee up your ass then you are promoting it as a therapy especially as Goop actually called the $135 coffee enema-making machine Dr Jungers pick. I mean come on.

The interview with Junger is filled with information that is unsupported both by the medical literature and by human anatomy and physiology. There is no data to suggest that a colonic helps with the elimination of the waste that is transiting the colon on its way out. That is what bowel movements do. There are no toxins to be cleansed or irrigated. That is fake medicine. A 2011 review on colonics concluded that doctors should advise patients that colon cleansing has no proven benefits and many adverse effects.

The idea that colonics are used in conjunction with a cleanse is beyond ridiculous. Junger tells us via Goop that a cleanse creates some kind of extra sticky mucus that blocks elimination of what needs to be disposed of (I will admit that hurt my brain more than a little). Dr Junger says this cleanse residue is a mucoid plaque, basically some kind of adherent, cleanse-induced super-glue that needs a colonic for removal. He supports this assertion not with published research, but by telling Goops readers to Google mucoid plaque.

No really. That is what he said. Google it. So I did. This is what came up first:

Mucoid plaque (or mucoid cap or rope) is a pseudoscientific term used by some alternative medicine advocates to describe what is claimed to be a combination of allegedly harmful mucus-like material and food residue that they say coats the gastrointestinal tract of most people.

Apparently, the term mucoid plaque was coined by Richard Anderson, who is a naturopath, not a gastroenterologist, so not a doctor who actually looks inside the colon. I looked mucoid plaques up in PubMed. Guess what? Nothing colon-related. There is not one study or even case-report describing this phenomenon. Apparently only doctors who sell cleanses and colonics can see them. I am fairly confident that if some gastroenterologist (actual colon doctor) found some crazy mucus that looked like drool from the alien queen that she or he would have taken pictures and written about it or discussed it at a conference.

If we needed cleanses to live and thus colonics to manage this alien-like mucous residue created by cleanses, how did we ever evolve? Wouldnt we have died out from these mysterious toxins? Wouldnt our rectums be different? Wouldnt we have invented irrigation tubing before the wheel? So many questions.

There is only a side mention in the Goop post of two of the many complications seen with colonics: colon perforation and damage to gastrointestinal bacteria. And as for coffee enemas? While Dr Kelly Brogan, Paltrows Aids-denialist doctor gal pal who is speaking at In Goop Health later this month, is also a huge fan, there is no data to suggest that coffee offers any benefit via the rectal route but there are plenty of reports of coffee enema-induced rectal burns.

So here are the facts. No one needs a cleanse. Ever. There are no waste products left behind in the colon that need removing just because or after a cleanse. If a cleanse did leave gross, adherent hunks of weird mucus then that would be a sign that the cleanse was damaging the colon. You know what creates excess, weird mucous? Irritation and inflammation.

There are serious risks to colonics such as bowel perforation, damaging the intestinal bacteria, abdominal pain, vomiting, electrolyte abnormalities and renal failure. There are also reports of serious infections, air embolisms, colitis, and rectal perforation. If you go to a spa and the equipment is not sterilised, infections can be transmitted via the tubing.

Coffee enemas and colonics offer no health benefit. The biology used to support these therapies is unsound and there can be very real complications. Keep the coffee out of your rectum and in your cup. It is only meant to access your colon from the top.

Dr Jen Gunter is an obstetrician, gynaecologist and pain medicine physician. This piece originally ran on Jen Gunters blog

Read more: https://www.theguardian.com/commentisfree/2018/jan/09/gwyneth-paltrow-goop-coffee-enema-colonic-irrigation

It tears every part of your life away: the truth about male infertility

Men are facing a fertility crisis, so why is most practical and emotional support offered to couples struggling to conceive aimed at women?

James and Davina DSouza met and fell in love in their early 20s. They got married five years later, and three years afterwards had saved enough to buy a family home in a quiet cul-de-sac in London. Then, when Davina was 29 and James 33, they started trying for a baby.

I knew that the moment we bought a home, wed start a family, Davina tells me in their living room, beside shelves crammed with framed photos of nieces, nephews, cousins and siblings. My parents live down the road, and if I needed help to raise a child, my mum would be here.

We thought about all of that stuff, James adds. The job, the future, the house, the home: we make things happen.

But after a year of trying, nothing had happened. Davina went to their GP, who referred her for the kind of invasive tests that have become the norm for women who experience problems conceiving: she had an internal, transvaginal scan to check her womb for fibroids, and an HSG test, where dye was pushed into her fallopian tubes to see if they were blocked. Everything looked normal.

It was only then that anyone suggested testing James. He had his semen analysed, and was told that only 1% of his sperm were formed normally. Still, it only takes one, the consultant said. She told them not to worry and to carry on trying. Two years after Davina came off the pill, James was tested again. This time, he had no normally formed sperm at all.

My first thought was, Oh, its my fault, James says, quietly. He stares at the coffee table through his thick-framed glasses. I felt helpless. No one was talking about this stuff. Youd go online and there was no male conversation. Id Google problems having a baby or fertility issues, and the websites that came up were all pink. Id post in a forum and women would respond on behalf of their husbands. There was nothing for men.

Though he may have felt it, James is not alone. Across the western world, men are facing a fertility crisis. A landmark study by the Hebrew University of Jerusalem, published in July, showed that among men from Europe, North America and Australia, sperm counts have declined by almost 60% in less than 40 years. Fertility specialists have described it as the most robust study of its kind (the researchers came to their conclusions after reviewing 185 previous studies involving 43,000 men from across the globe) and the findings are stark. Such a significant decline in male reproductive health over a relatively short period in such a specific population suggests theres something in the way we live now that means its much harder for men to become fathers than a generation ago.

***

Until recently, the focus of both fertility experts and research scientists has been overwhelmingly on womens bodies, while male reproductive health has been almost ignored. For decades, the average age of both fathers and mothers has been increasing, but its women who have felt the pressure of balancing the need to invest in their careers with the so-called timebomb of their own declining fertility. They have been encouraged to put family first and to change their lifestyles if they want to become mothers, at the same time as male fertility appears to have fallen off a cliff.

Davina says the consultant gynaecologist who was treating her and James had no hesitation about next steps. She said, Jamess sperm results are in, and we think you should go for IVF. That was it. The NHS didnt have any other options for us. Indeed, the NHS couldnt even fund any IVF in their area at that time, so they had to scrape the money together to go private. They spent more than 12,000 on two rounds of IVF, and were finally offered a third round on the NHS this year. But after nearly seven years of trying for a baby, they are still childless.

IVF takes a huge physical, hormonal and emotional toll on a woman, James tells me. Sometimes I felt totally powerless, ineffective. I questioned my masculinity, my sense of myself as a man, through those rounds of IVF. During consultations, James felt the conversations were always directed at Davina. I felt like I had to say, Im here. Id deliberately ask a question to make my presence felt.

On their first round of IVF, someone at the clinic recommended James take a vitamin supplement. It was the first time lifestyle factors had been mentioned. That was when I realised, maybe there is something I can do, he says between slurps of his own blend of bulletproof coffee (made with grass-fed butter, coconut oil and egg yolk). James, head of sixth form at a local school, is a fan of self-help books. Hes been on a high-fat, low-carbohydrate ketogenic diet for months and says its done him good: hes slim and spry, but says he wasnt always this way. Hes wearing a digital fitness tracker. But as someone who rarely drinks, has never smoked and doesnt ride a bike, there were few lifestyle changes he could make, beyond taking colder showers and wearing looser underwear. Still, his sperm quality has improved.

At the moment, the couples fertility problems are unexplained. They decided against adoption when social workers said theyd have to use contraception during the process, because it wouldnt be fair on an adopted child to move into a home with a new baby, and they arent prepared to stop trying just yet.

Weve talked about when were going to call it a day, James says.

Davina glances at him with wet eyes. It makes me sad to think well be putting a cap on it.

But it regularly comes up, he says. We did actually say at the end of this year well stop. Ive been asking, Why do we want to have children? Weve decided it isnt going to define us.

There is treatment for male infertility, but its certainly not in the fertility clinic, says Sheryl Homa, scientific director of Andrology Solutions, the only clinic licensed by the Human Fertilisation & Embryology Authority to focus purely on male reproductive health in the UK. Men are channelled from their GP with a semen analysis and sent straight to a gynaecologist in an IVF clinic. But gynaecologists are interested in the female reproductive tract.

A former clinical embryologist, Homa once led IVF laboratories in both the private and public sectors. I was quite horrified by the lack of investigation and appropriate management of male infertility, she says, so I decided to start my own clinic specifically to focus on male fertility diagnosis and investigation. Male reproductive health is being assessed through semen analysis, which she argues has a very poor correlation with fertility. Instead of having their detailed medical history taken and a full physical examination, men are being given a cup and asked to produce a sample.

Homa says the leading cause of male infertility (around 40%) is varicocele (a clump of varicose veins in the testes). It can be determined from a physical exam, and can certainly be ruled out by an ultrasound scan. All women get ultrasound scans; why arent men getting them?

Varicoceles can be repaired by fairly simple surgery under local or general anaesthetic, leading to a significant improvement in a couples chances of successful natural or assisted conception. But many are going undiagnosed. The NHS is carrying out far too many IVF treatments when they could be saving money by doing proper investigations in men.

Homa says there is also some evidence linking silent infections those with no symptoms, such as chlamydia in men with delayed conception and an increased risk of miscarriage. But if a man is judged by his semen sample alone, there would be no way of addressing these hidden concerns.

Apart from saving the NHS money, there are important medical reasons why men should be thoroughly examined, Homa argues. Semen parameters are a marker of underlying systemic illness: they might have diabetes, they might have kidney disease, they might have cardiac problems. It could be something much more serious thats contributing to the problem.

As for the possible reasons for falling sperm counts across the west, Homa mentions all the chemicals and pesticides that we are exposed to in our environment, as well as smoking, rising levels of obesity and increasingly sedentary lifestyles. But at the moment, ideas such as these including hormones in the water and BPA in plastics that might mimic the effect of oestrogen inside the body are just theories that make intuitive sense. In the absence of widespread research over time, no one can pinpoint exactly which factor or combination of factors is making the difference.

In the 10 years her clinic has been operating, Homa has seen demand for her services steadily rise. She says she gets the fallout from men whove been sent by their GP for multiple rounds of fertility treatments that fail, when IVF should be the last resort. But at the moment, National Institute for Health and Care Excellence (Nice) guidelines give GPs no option but to refer men with fertility problems to IVF clinics. If theres a female problem, the GP will refer them to a gynaecology clinic. If theres a male problem, they need to be referring to a consultant urologist who deals with male infertility. But its just not happening.

Gareth
Gareth Down and his wife, Natalie, went through 10 rounds of IVF before their son, Reece, was born. Photograph: Harry Borden for the Guardian

In some ways, Gareth Down and his wife, Natalie, were lucky: they knew from the start that their problems conceiving were probably down to Gareth, because he had had surgery to remove benign lumps on his testes as a teenager, and always feared they might interfere with his chances of becoming a father. But after 10 cycles of IVF that cost them tens of thousands of pounds, and several miscarriages, lucky doesnt feel like the right word.

I always wanted kids, says Gareth, 31. My mum was a childminder, and I was brought up looking after kids, so from as young as I can remember, weve had a house full of them. He and Natalie started trying for a baby six months before their wedding in 2010, and went to the GP a year later, when nothing had happened. Gareth was referred to a urologist, who confirmed that the surgery hed had as a teen had affected his sperm production, and that he had azoospermia: a zero sperm count.

The Downs were determined to have children, but trying almost broke them. It invades every part of your life, Gareth says. On a personal level, you have to confront the fact that you might not have a family. It affects you financially, as you try and save to fund the treatment. We had family fallouts because we couldnt see newborn nieces and nephews we just couldnt be around babies. We changed jobs because time off with certain employers was difficult. I had quite a customer-facing job at one point, and when they were telling me about their problems, I was thinking, You aint got problems. He pauses. I dont think there was any part of who we were that we held on to by the end. It tears just about every part of your life away.

Gareth has just put his 16-month-old son, Reece, to bed while Natalie is still at work. Reece was conceived with donor sperm, on their 10th round of IVF, when Natalie had had enough of the heartache of fertility treatment and was convinced they should give up. After going through so much to have him, their first feeling when Reece was finally born was not joy, but disbelief. It was surreal, says Gareth. I dont think either of us could accept it was real and going to last. Wed had so many ups and downs that we couldnt believe nothing bad was going to happen. We kept checking the cot to see if he was still there. It was weeks before we realised he was not going to be taken away from us.

It was during their final attempt to have a baby that Gareth set up his closed, men-only Facebook group, Mens Fertility Support. Over the years, Natalie had found a lot of comfort online, from forums and support pages to Facebook groups, and was surrounded by an international community of women going through the same experience. Gareth had tried to contribute in the same places, but never stuck around long. There were no other men there to relate to what you were saying, or make you feel you could say what you meant and that it wouldnt be taken the wrong way by an audience that vastly outnumbered you.

The 300 or so members of his group are a diverse mix of men, mostly from the UK. Some are just beginning to have problems with conception, others went through it decades ago; some never had a happy ending and are there to share their experiences that a life beyond trying to have a family is possible. Many members say its the only place they can be totally honest: the belief that the ability to father children is a marker of masculinity has left many unwilling to talk about their issues anywhere else.

We do get women wanting to join, Gareth tells me with a smile, but we want a degree of privacy. Its about having freedom to talk, to say, yes, those [IVF] hormones really do screw her up and its really tough. You need to be able to vent somewhere without causing offence to anyone you know.

Everyone Gareth and Natalie told about their problems conceiving assumed the issue must be hers. Every step of the way it was, Poor Nat whats going on with her? But he hopes that men are starting to seek help. If it was any other part of your body that wasnt working properly, youd seek advice. Slowly, those barriers are beginning to come down a bit.

He wonders whether the new figures on declining sperm counts could have been coloured by this growth in awareness: fertility treatments are more in demand than ever, so more men are having their fertility investigated. Are we just testing more, looking into things more? he asks. If you had fertility problems 40 years ago, you wouldnt have wanted to confront it or had anywhere to go with it.

Dr Xiao-Ping Zhai, the fertility specialist behind the Zhai Clinic, agrees. We never really tested men in the past, and if you use the word decline, you have to have something to compare it to. In the past, people probably had problems, didnt want to say they had problems, and didnt have children. Even though the Hebrew University of Jerusalem study is the best piece of research weve had so far, she points out, the data from 40 years ago is still very thin.

Trained both in western and traditional Chinese medicine, Zhai has a unique perspective on fertility treatment and, since she opened her Harley Street clinic more than 20 years ago, claims shes had a great deal of success in helping couples conceive even though many patients come to her out of desperation rather than faith in traditional medicine. Its mainly women who call to make the appointments. Eighty per cent of the time, the partner doesnt even want to come along. They dont think they have a problem.

Rather than look at sperm counts, Zhai takes a full health MOT of all her patients, using diagnostics from Chinese medicine to find out which part of the body needs to be addressed: You find that a lot of people have something that cant be discovered on a scan or through mechanical investigation what wed call a functional problem. Zhai offers a range of treatments according to the patients specific constitution, including acupuncture, herbal supplements and advice on lifestyle changes and diet. None of this is cheap: an initial consultation costs 250, and a four-week course of bespoke herbal supplements can cost up to 350.

But IVF treatment on Harley Street costs even more, and Zhai says many of her patients arrive in the consulting room having already spent lots of money. Its to do with the culture here: in the UK, if a man has a problem, then the woman needs IVF. IVF clinics can offer only what they specialise in.

In 2014, Zhai launched a national campaign to end the stigma attached to male infertility and improve the treatment choices offered to men. She called for a full parliamentary debate on male fertility issues, and on health secretary Jeremy Hunt to work with doctors to improve practice and treatment pathways for men within the NHS. But there has been no debate and no change in NHS strategy. There are too few options for infertile patients, Zhai says. It will take a long, long time to overcome this culture.

Gary
The doctor who rang with Gary Parsons sperm count results simply said it was game over. Photograph: Harry Borden for the Guardian

Gary and Kim Parsons went to their GP two years after Kim stopped taking the pill, when there was still no sign of pregnancy. She went through all the regular tests blood tests and then more invasive examinations and everything came back A-OK, says Gary, 36, from his home in Burnham-on-Sea. Then it was my turn. Like James, Gary had no physical examination and was asked only to produce a sample to check his sperm count. That came back as a big fat zero. There was nothing to count.

When the doctor rang to deliver the results, he said it was game over. Gary blinks in disbelief when he tells me this. I really didnt need any encouragement to feel more down about things, so that was an unfortunate turn of phrase. Gary thinks this may have been because it was a conversation between men. That extreme, direct way of communicating might have been the only way he thought he could get me to understand that this is not something where I could drink a kale smoothie and everything would be OK.

Still, thats what Gary tried, at first. Or, rather, he turned to vitamin supplements and a high-protein diet in the hope they could help. Im a vegetarian, so for a second I thought, Oh no, Im one of these anaemic, lentil-based stereotypes. But, ultimately, he knew this probably wouldnt help because his count wasnt low it was zero. There was nothing to improve. Thats the thing Ive found hardest. Most problems Ive had in my life Ive overcome with either bloody-mindedness or effort, and thats not this, he says, shaking his head. Thats not this.

Garys infertility remains unexplained. The next step is for him to have a testicular sperm extraction procedure, to find out if hes producing sperm that are being blocked, which could potentially be extracted for use in assisted conception. Three years after they started trying for a baby, this will be the first time he will be examined beyond blood tests and semen samples.

Without Gareth Downs Facebook group, it would have been hard to find someone to talk to. Gary is a counsellor, and when he looked at who was registered with the British Infertility Counselling Association, the professional body for fertility counsellors in the UK, he found that the 46 registered practitioners were all women. Emotional support provision for men is glaring in its absence, he says. Its just a case of, On your bike, son. Get on with it.

The way that men are treated as the secondary partner in infertility treatment could have worrying consequences, he says. All the paperwork goes through the female. Everything is done through my wife. In meetings, its been very rare that Ive even been able to get any eye contact from a consultant so far. It occurred to me that, should my wife leave me, I would have no mechanism for resolving this, or getting any questions answered, and that would have an impact in terms of maybe meeting someone new, or even knowing if Im able to be a parent one day.

Edinburgh University professor Richard Sharpe, an expert in sperm count and male fertility, believes the University of Jerusalem studys findings should be taken very seriously. If something is having that big an effect something in our environment, diet, lifestyle, and we dont know what it is what else might it be doing to us? We think of sperm counts as a fairly crude barometer of overall male health. Its a warning shot across our bows.

Sharpe has been specialising in male infertility for 25 years, but even he can offer only general hypotheses about what could have made sperm counts fall by 60% in little over a generation. He thinks diet and lifestyle are much more likely to be contributory factors than environmental chemicals such as pesticides, plastics and hormones in the water, because the evidence that they could induce such striking effects at low levels of exposure is unconvincing. But our understanding of the normal process of sperm production is very poor, completely superficial, he says. Its a much more complex process to understand than the menstrual cycle, and we havent done enough research.

There is a chance that women might ultimately be behind the sudden drop in sperm count, Sharpe believes. His work has looked at the link between rates of maternal smoking and the use of painkillers during pregnancy, and the reduced sperm counts of sons in adulthood. A baby boys testes are formed during the first trimester, when many women dont know theyre pregnant, and the period immediately after their formation is critical for the production of testosterone. What we are seeing now could be the expression of a generational problem: the fact that, since the 1970s, women are more likely than ever to smoke and take over-the-counter painkillers.

But, again, the evidence isnt strong enough. There are four studies that all show a significant association between maternal smoking and reduction in sperm counts in male offspring, so its plausible, he says, but it cant explain the 60% fall, because not so many women smoke and smoke heavily. A longitudinal study, over 20 years, would be needed to demonstrate the effects of maternal lifestyle on male fertility, but long-term research projects are inherently difficult to get funding for, unless public bodies think the issue is critically important. Male fertility is not considered a high-priority issue, partly because theres this perception that its a problem solved by assisted reproduction. Thats not treatment of the underlying issue behind male infertility. Its simply ignoring it.

We may be sleepwalking into a future where we become increasingly dependent on assisted reproduction, Sharpe argues, without fully understanding the long-term consequences of the technologies were relying upon. Researchers have already demonstrated in animals that its possible to make sperm out of other kinds of cell. People are going to do this in humans not in the UK, initially, but they will somewhere in the world. Those techniques are going to be applied in the fertility clinic, but we dont have the knowledge to do it in a truly informed way, to know that its all safe, that there are no consequences.

Whatever the reasons for our underinvestment in male fertility lack of funding and research, male pride or the overemphasis on women in fertility treatment it has huge implications for both men and women. Were flying blind to a large extent, and so far weve been ridiculously lucky, Sharpe says. Its a perfect storm, at every level.

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Read more: https://www.theguardian.com/lifeandstyle/2017/nov/18/tears-every-part-life-truth-male-infertility-ivf

Reality shrivels. This is your life now: 88 days trapped in bed to save a pregnancy

The long read: Months before she was due to give birth, disaster struck for Katherine Heiny. Doctors ordered her to lie on her side in bed and not move and gave her a 1% chance of carrying her baby to term

When I was five years old, my parents decided they could no longer watch the nightly news. Or rather, they could no longer watch it if I was in earshot. The coverage of the attack at the Munich Olympics had caused me to have such an intense fear of being killed by gorillas that I couldnt sleep. No matter how many times my parents explained the difference between terrorist guerrillas and primate gorillas and that there were no gorillas in Michigan anyway I remained sleepless with worry late into the night for weeks. My parents eventually gave up and subscribed to the afternoon paper as well as the morning one.

The problem is not just that I am a champion worrier. Its that I court worry I seek it out, I invite it into my home, never remembering how hard it is too dislodge it from its comfortable chair by the fire. I watch true-crime documentaries when Im alone. I Google photos of black widow spider bites. I know the statistics about paracetamol overdoses. I have memorised the beaches with dangerous riptides. I have installed a carbon monoxide detector in every house I have ever lived in. And when I got pregnant with my first child, I bought What to Expect When Youre Expecting and the chapter titled What Can Go Wrong was the one I read first.

Retained placenta; umbilical cord prolapse; foetal arrhythmia; toxoplasmosis; preeclampsia; placental abruption; gestational diabetes; cytomegalovirus: I read about all of them, and learned the warning signs. Perhaps to other women, these complications remain obscure, shadowy threats during pregnancy, but to me they were hard, clear, immediate dangers. When my obstetrician told me that mine was a perfectly normal pregnancy, the very first thing I said was: Are you sure?

And yet I was surprised when disaster struck. The things you worry about arent supposed to happen thats what worry does. Its a preventative. And my disaster happened quickly, without fanfare or drama. One second, I was a nice, normal, happy pregnant married woman of 32, walking across my bedroom to my desk while my husband made lunch downstairs. And then the warm fluid gushed out of me, soaking my clothing and leaving a little wet spot on the pale green carpet.

I yanked down my jeans and pants, expecting blood, but there was only wetness. I knew it was very likely that my waters had broken, but I was barely 26 weeks pregnant. It didnt seem possible. I stepped out of my clothes and went to the top of the stairs to call my husband. He stood on the landing with his hands all sticky from making hamburgers, and I told him what had happened. We discussed it for a surprisingly long time. Was it really so bad? How much fluid? Maybe a cup? Was there blood? Was the baby still kicking? Should I call my doctor? Yes, we decided.

I wrapped a towel around my waist and called my obstetrician. He was a man in his late 50s with a perpetual hangdog expression, and for this reason, my husband and I called him Doggie B. I loved Doggie B. Nothing ever surprised him, nothing ever alarmed him. I could not picture him giving me bad news, and because I could not imagine it, I felt it wouldnt happen.

I want you to meet me at the hospital, Doggie B said. Go to the maternity ward. And I want you at Georgetown Hospital where they have the neonatal unit.

I put on fresh pants and jeans and my husband and I drove to the hospital. It was 29 January 2000, and an ice storm was just beginning. Something happened to me on the way to the hospital: my mind split in two. One half was convinced that that this trip was unnecessary, that, of course, my water hadnt broken, that I was just fine. The other half was just as sure my waters had broken and that I would almost certainly go into labour and give birth to a baby too young to live. The two halves of my mind rotated inside my head like the lights of a lighthouse, the worried part flashing and then disappearing, replaced by the calm one.


At the hospital, a doctor who looked just like Andie MacDowell performed a pelvic exam and took vaginal swabs. A nitrate test was done on one of the swabs for the presence of amniotic fluid. (Its presence would have meant membranes containing the baby had ruptured three months prematurely and would most likely cause me to go, disastrously, into labour.) The other swab was for sent off to the lab to check for the presence of arborisation, otherwise known as ferning, because amniotic fluid produces a delicate, leafy pattern under the microscope. Both tests were negative, although they were running a repeat just in case. I began to feel a little ridiculous.

The Andie MacDowell doctor told us that there was no evidence that I was leaking amniotic fluid, but that they were going to admit me, she said, on the strength of my story.

The strength of my story! I was appalled. Im a writer of course I told a strong story. Maybe I didnt need to be here, I told my husband, as nurses wheeled my gurney into a private room. Maybe I should just tell an equally strong story about how nothing was wrong and go home.

The doctor came back. I just saw the ferns, she said. You have definitely ruptured. Well try to delay labour as long as possible.

Three months? I asked.

Yes, thats the hope, she said.

I wouldnt have been so scared if it werent for the look on her face.

Dom
Illustration: Dom Mckenzie

Nurses came into my room and began to bustle around me while the doctor explained that my condition was called preterm premature rupture of membranes, or pPROM. The two most dangerous (and most common) complications of pPROM are extreme pre-term birth and chorioamnionitis, a bacterial infection of the foetal membranes. Both are devastating for the foetus. I reached for my husbands hand.

The nurses put me in Trendelenburg, meaning my hospital bed was tilted so that my head was 20 degrees lower than my feet. (I thought it was some long German word that meant head below feet on the side of a mountain.) A nurse wrapped a foetal monitor to my belly with a thick strap, explaining that it could be read from the nurses station, and they would know immediately if I began having contractions. Another nurse slid a pair of puffy compression leggings on to my legs. They inflated and deflated every other minute with a whooshing sound. It was like having Darth Vader breathing at my bedside. I was told to lie on my side in order not to put pressure on my vena cava, which would lower the babys oxygen supply. Yet another nurse poked a needle into my arm to start a line for intravenous antibiotics.

The doctor gave me a shot of steroids to help develop the babys lungs, in case the baby would shortly be needing those lungs to breathe. Arent steroids counter-indicated in pregnancy? I asked.

Yes, but its more dangerous to go without, she said.

Doggie B called the hospital to stay that he couldnt make it in because of the ice storm. In his absence, the doctor ordered the nurses to give me a shot of terbutaline, a medication that can delay preterm labour for up to 48 hours.

Please, I begged. I dont want any more shots. Im not in labour. This could be so bad for the baby.

From the moment I learned I was pregnant, I had divided the world into things that were OK for the baby, and things that were bad for the baby. The first group included rice, poached chicken and yoga, The second group included alcohol, secondhand smoke, deli meat, smoked seafood, raw eggs, soft cheese, pt, caffeine, unwashed vegetables, diet soda, eggnog, x-rays, aspirin, ibuprofen, antihistamines, nasal decongestants, cough syrup, librium, valium, sleeping pills, castor oil, vitamin A supplements, paint fumes, insect repellent, acupuncture, cats, hair dye, altitude, saunas, reptiles, tick bites, microwaves, electric blankets, rollercoasters, bikini waxes, stiletto heels, hot dogs and tap water. I trusted no one but myself and Doggie B to categorise items, and certainly not a doctor I had met 10 minutes before.

They gave me the terbutaline anyway. It made me dizzy and cold, though it makes most people hot. They piled more blankets on top of me. My hands shook uncontrollably.

The neonatologist came to talk to us. He had thick glasses and he talked in percentages. It was clear that he was not interested in offering comfort; he was there to convey information. He told us that for babies born at 26 weeks, the survival rate is 50%. Of the surviving half, one-third had major disabilities, and are likely to be dependent on caregivers for ever. It was common for them to have breathing problems, cardiac disorders, brain bleeds, cerebral palsy. Brain damage, deafness, blindness. Another third had more moderate disabilities: spastic muscles, significant hearing loss, impaired vision without blindness. The final third (the best we could hope for, apparently) had milder learning disabilities, anemia and digestive complications.

I watched him dispassionately, not really listening. He was so stereotypically nerdy that I couldnt get over it. Why was he telling us all this scary shit anyway? I wasnt going to go into labour. The baby wasnt going to be born yet. Why couldnt anyone understand that?


The first night was longer than I would have believed possible. Visiting hours ended and the nurses chased my husband out. He drove home on streets that crackled and shifted with ice. I was not allowed to stand, or even sit. I was served a dinner that I was too nervous to eat. And I learned about bedpans. Peeing into something the size and shape of a casserole dish while lying in bed with your head angled toward the floor is messy and awkward.

But that is not the worst thing about bedpans. The worst thing is the other people involved. Having to ask someone to bring you a bedpan, having to make conversation with that person while you use it, having to apologise because your aim is a little off and now theres a wet spot on the sheets, having to ask that person to wipe you, having to ask her to wipe you again because you still feel damp and sticky, having to thank the person, and you do really thank her, you are so grateful, its just that two hours ago you were an upright person with a little dignity, and now youre not.

The hospital lowered the lights in the hall, just like on a transatlantic flight. Nurses went by on squeaky shoes. I lay on my side and gripped the metal railing of my bed. The lighthouse in my mind revolved, and for one instant the room was flooded with cold, bright, white fear for the baby. Then it was gone. Certainty that the baby would not be born early stole over me, and I gathered that certainty close. I lay awake and watched the sleet falling outside my window. It occurred to me that I could not see the ground.

Doggie B came to see me the next day.

Can you believe this? I said to him. Me, your most paranoid patient!

He didnt bother to deny that I was his most paranoid patient. When he spoke, his voice was mild and unconcerned. He said that I would remain on bed rest, and unless infection forced us to act sooner, he would deliver the baby at 33 weeks, when the greatest risk was over.

I didnt want to have the baby at 33 weeks. I wanted to have the baby at 40 weeks, like everyone else. I knew the risks. But I had also been told the risks of preterm infection: a baby born with brain damage, cardiac defects, limb abnormalities, microcephaly, hydrocephalus, paralysis, bone lesions, eye lesions or possibly no live baby at all. I refused to weigh the risks; I would simply not go into labour, nor would I develop an infection. That was all there was to it.

I frowned at Doggie B. Why 33 weeks? Why not go to May 10? That was my due date.

He shrugged. OK, May 10.

He was a much better liar than the Andie MacDowell doctor.

After Doggie B left, the nerdy neonatology doctor came to my room again. He wanted me to go down to the neonatal intensive care unit (NICU). You need to see what a preemie looks like, he said, pushing his glasses up his nose. You need to prepare yourself.

The Andie MacDowell doctor was there, too. A three-pound baby takes some getting used to, she said. You dont want to see one for the first time in the delivery room.

To both of them, I turned a deaf ear and a sullen face. I was not going into labour. I was not going to go to the NICU and no one could make me. Conversation was cut short when another nurse came in and told me that my monitor had showed slight disturbances, and gave me another shot of terbutaline.

I cant believe terbutaline makes you cold, this nurse said as she took blankets from the blanket-warmer and I shivered beneath them. Out in the hall I heard her say to someone: That one is so contrary.

I could see remotely that all these doctors and nurses knew something I didnt. I found out much later that what they knew were the odds. Fifty per cent of women with pPROM go into labour within 48 hours, and 95% deliver within one week of rupture. Four of the remaining 5% deliver within two weeks. One percent of women with pPROM experience spontaneous resealment of the membranes and go on to carry the baby to term.

One per cent.


Do you knit or crochet? one of the nurses asked me early on. Lots of bed rest patients find that helps them pass the time. No, I read and I write, I answered, pretentiously. And untruthfully, because I have always watched a great deal of TV.

I couldnt write because I couldnt sit up. I also couldnt write because if I focused too much on my situation, the lighthouse in my mind would revolve and the worried, scared part of me would rush out, gibbering with alarm, baying, screaming, howling that the baby was going to be born too soon, the baby was coming now, the baby was going to die. How could I write with that going on?

I had a headache from being in Trendelenburg. I couldnt remember what it was like to look someone in the eye, so long had I now spent gazing up at everyone from thigh-level. When I ate, it was one wobbly, precarious forkful at time. After a while, I just gave up and if I couldnt eat it with my fingers, I didnt eat at all. I drank through a straw, until everything tasted the same: like the plastic of the straws.

I couldnt write, so instead I read. Constantly. Ceaselessly. I had to hold the book open in front of me sideways, like someone gripping a large steering wheel. My husband brought me books and I stacked them on my overbed table, and as I read each book, I held the next book in my free hand, with my finger marking the start of the first chapter so that as soon I finished one book, I could immediately start another. I must have read dozens of books while I was in hospital, and I can only remember one of them.

Only one book held my interest. I told my husband exactly where to find it on the bookshelf near my desk and he brought it to me: Steven Callahans Adrift, a memoir of the 76 days in 1982 during which Callahan had survived in an inflatable life raft after his sailboat sank. I had fallen in love with the book when it was first published, in 1986. It seems like a strange choice of reading for a teenage girl, especially one as studious and non-athletic and seasickness-prone as I was. But I have always been drawn to survival stories: they dovetail nicely with my chronic fear of disasters.

Callahan spent more than two months in a rubber raft in the middle of the Atlantic, spearing fish to eat raw, using solar stills to distil water, and making endless, desperate makeshift repairs to his patched and leaking vessel. I had read Adrift many times over the years, but now I read it again, and was inspired by his suffering and ingenuity in a new way. I was in a hospital bed where nurses brought me meals three times a day, and I slept in a bed on clean sheets and was in no danger of drowning. I could do this. I could.


You dont sleep in hospital. You cant sleep. Too many people coming and going. A nurse comes every four hours to check your vitals: temperature, pulse rate, blood pressure, babys heartbeat. Another nurse comes in every two hours to make sure you are doing your kick-counts. Meals come three times a day, plus a night-time snack for pregnant women, which means four times someone comes into your room to deliver a meal, and four more times someone comes back to collect the tray. A nurse comes every time you need to use the bedpan. An orderly comes every morning to take you for an ultrasound. Your obstetrician comes by every day to check on you, and you dont want to miss his visit, because he is the only one who tells you what you want to hear no, theres no sign of infection; yes, Im sure youll carry to term. The hospital chaplain stops by once a day. She was a mousy woman with a perpetually scared expression. Its not a good look on a hospital chaplain.

So thats more than 30 people coming to your room and interrupting your sleep. And then theres the physical part of it. If you are confined to bed, after you lie on your side for a few days, it begins to feel as if your hip sockets are lined with metal shavings, as if the sheets are covered with shattered glass. Before long, red, rough, scaly patches the size of saucers appear on your hips and your shoulders the beginnings of bedsores. The compression leggings chafe your thighs.

You forget how to sleep. The line between waking and sleeping used to be as clear and sharp as the line down the middle of a road, but after two weeks, that line has blurred and is almost invisible. You stagger back and forth across it like a shambling drunk, until there is no more sleeping and waking; there is just this dim, dull, soupy consciousness. Your reality shrivels down into one long, hazy, beige-tiled tunnel. You used to worry, but it has gone beyond that now. Worry used to be inside you, but now you are inside it. Worry is a dome that has descended over you and trapped you. This is your life now. This is your world.

Every day about 10am, an orderly arrived with a gurney and I carefully scooted on to it and then the orderly pushed the gurney through the hospital halls to the prenatal department.

Two weeks had gone by, and I hadnt gone into labour. This seemed to surprise everyone but me and Doggie B, who began, cautiously, to speak of resealment. The nerdy doctor came by and gave me a whole bunch of new statistics about what the babys chances were at 28 weeks, at 30 weeks. He didnt go beyond 30 weeks, though. They removed my IV. Everyone talked about something called BP as though they were speaking of the Rapture. (Bathroom Privileges.) The atmosphere in my room became positively springlike, despite the snow outside.

Doggie B said the first step would be for me to get up and take a shower. A shower! Nothing could have been more tempting. He gave me a date. Now it was something to look forward to. I had my husband bring in a bottle of my favourite shampoo and a bar of coconut soap. The day finally came. A nurse removed my circulation leggings. I sat up slowly and swung my feet to the floor. The nurse took my arm and helped me to stand. I stood there, swaying. Amniotic fluid poured out of me and splashed to the floor. The nurse let go of my arm in surprise. I lay back down and turned my face to the wall.

It took me a while to regain my strange equilibrium, especially considering that the doctors now suspected I had been leaking continuously since the first rupture. Rupture of the membranes is considered prolonged (and therefore dangerous) when more than 24 hours passes between the rupture and the onset of labour. My waters had broken more than 300 hours ago. The risk of sepsis was very high.

Katherine
Katherine Heiny. Photograph: Leila Barbaro

But still, two days maybe three and the stubbornly optimistic side of my personality fought its way to the forefront and re-planted its battle flag. The Andie McDowell doctor wrote in my chart: Patient needs to understand that resealment is highly unlikely at this time and that preterm birth is almost a certainty. Yeah, well, thats what she thought. This baby was not coming early. I simply wouldnt allow it.

Another week in bed went by. Every once in a while, they had me stand up, and every time I leaked amniotic fluid. But still I didnt go into labour. Nor did I have a fever or abdominal pain, the two greatest indicators of infection. Life as I now knew it went on.

After I had been on bed rest in the hospital for 25 days, there came a time when I stood up and no fluid gushed out of me to splatter on the floor. The nurse and I looked at each other in amazement. Go take a shower, quick! she said. Ill change the sheets on your bed.

It was not the slow, luxurious shower I had dreamed of, but I can tell you this: it was pretty fucking nice. They didnt allow me out of bed again that day, but I was finally taken out of Trendelenburg. I stood up the next day and again there was no leak. I took another shower.

When Doggie B came to see me next, I was sitting in a chair to greet him, radiant, both my pride and my belly enormous.

I had done it. I had resealed. I was in the 1%.


Doggie B wanted to send me home. I fought him. I had been in the hospital for almost a month at this point, and I was pretty much institutionalised. Go home? Without the foetal monitor? With no nurses to listen for the babys heartbeat every four hours? No daily ultrasound? Uh-uh. He was crazy if he thought I could handle that much responsibility. I told him that I needed to be in the hospital near the NICU. I pointed to my chart where it said Severe Risk Pregnancy in big scary letters. Doggie B stood firm. He discharged me and my husband drove me home.

Steven Callahan writes of seeing the first food after his rescue a cake of chipped coconut topped with a dot of red sugar and how he looked at it in wonder and thought: Red! That was exactly how I felt when I saw my house again. Green! Blue! Lilac! My hospital room had been unrelentingly beige.

I was still on almost total bed rest, allowed up for 15 minutes twice a day. A shower in the morning and dinner at night. Out of the hospital, the lighthouse in my mind revolved faster and faster, unchecked by the nurses reassurance. I counted constantly how often the baby kicked, and took my temperature five times a day. The amniotic sac had resealed, but the rupture had been extremely prolonged, greatly increasing the chances of an infection reaching the baby. Even feeling the babys movements could not quell my worry. Doggie Bs receptionist learned to put me straight through to him when I called.

Time ground slowly by. My husband brought me breakfast in the morning before he left for work. Our housekeeper brought me lunch. My husband brought me dinner and we ate at the card table he had set up in the corner of our bedroom. Then I crawled back into bed and worried until I fell asleep, woke up, and started another day. That was my routine, and I never varied from it. I dont mean I never varied from it significantly; I mean I never varied from it at all.

Thirty-one weeks. Thirty-two weeks. Thirty-three. Still I didnt go into labour. I lay in bed and stroked my abdomen with my fingertips. Thirty-four weeks. Thirty-five. March ended and April began. A blizzard of cherry blossoms replaced the snow outside my bedroom window. Thirty-six weeks. Thirty-seven weeks. I no longer watched TV or pretended to read books. I knew nothing but my belly and the endless waiting. Time had softened and stretched like taffy, pulling itself into long, gooey ribbons. Thirty-eight weeks. Thirty-nine. I was certain that the baby would be born on 21 April, the same day Steven Callahan was rescued. But 21 April came and went. And then one day I got up to take my morning shower and felt the slightest trickle of fluid run down my leg. My waters had broken for the last time.


Our son was born 12 hours later at Sibley Hospital in Washington DC. We named him Angus. And so my life changed again in another minute, another second. The two halves of my mind fused back together. I went from severe-risk pregnancy to healthy new mother. I was totally unprepared. For so long the goal had been to stay pregnant I had almost forgotten that a baby was the end result. I knew nothing about newborns, nothing about breastfeeding or burping or vaccinations. The nurses had to show me everything. One them said, in a careful voice: Ive heard about you, I think. I could tell that whatever she had heard was, at best, a mixed review. Didnt you rupture very early and do a lot of bed rest over at Georgetown?

I felt a stubborn thump of pride. Thirty days at Georgetown. Eighty-eight days altogether.

Wow, she said. I bet you never want to see a hospital again.

I didnt know how to tell her that almost the opposite was true. It wasnt just that I knew about hospitals now, and knew I could survive a long stay in one. I was a different person from the one who had been admitted all those weeks and months ago: a tried person, a changed person. Very few experiences transform your view of the world and yourself, but bed rest did that for me. I had beaten nearly unthinkable odds. All the things I have always meant to fix about myself but had never got around to my stubbornness, my hypochondria, my inflexible nature had turned out not to need fixing. Had, in fact, turned out to be survival skills.

Twenty-four hours went by, and I cried because I never wanted Angus to get any older. The impossible had happened: time had speeded up.

Six months later, I arranged to speak to Steven Callahan by phone. I told him how much his book had meant to me, how much he had inspired me. We discovered that we had both been obsessed with numbers, with calculating and re-calculating the days of our progress. I told him that my ordeal had altered me in some fundamental way, that sometimes I even missed the mind-bending, terrifying force of it. He agreed.

Sometimes I feel a loss, he said, in terms of the fact that few if any experiences I will ever have again can equal the intensity and importance of that one. You try to mine the precious elements of the experience, but they slip away from you, and thats another loss. You try to appreciate this enormous gift youve been given, but eventually you just get on with it.

The precious elements of my experience were fading, too. I took my bathroom privileges for granted now. I slept on my back again. I went for walks. I worried about traffic jams and deadlines and love handles, just like a normal person. I got on with it.

Angus is 17 now, taller than me, taller than my husband. He has the beginnings of a moustache and a voice as deep as James Earl Joness. He knows how to do laundry, and make spaghetti. He can take the Metro by himself, and he learned to drive this summer. Its possible he watches porn on the internet. (Its extremely possible.) I have new fears and worries, about teenagers. The bright, icy terror of the hospital is behind me, but it has taken a long time.

One day, when Angus was about three years old, I cleaned out a closet and unexpectedly found the plastic water pitcher that had been by my hospital bed. In an instant, the lighthouse in my head revolved, and everything went white and cold. I was certain that the baby was in danger so certain that I had to run to the bathroom and vomit. I dont know why this surprised me, or why I thought I would be different, immune to the after-effects of my ordeal. All survivors have scars.

Main illustration by Dom McKenzie

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Read more: https://www.theguardian.com/lifeandstyle/2017/oct/24/88-days-trapped-in-bed-to-save-a-pregnancy-bed-rest

‘A third of people get major surgery to be born’: why are C-sections routine in the US?

Caesareans have transformed from life-saving intervention into risky procedure performed for one in three births and often geography is the deciding factor

Carmen Walker didnt realize how bad things had gotten until she heard her doctors voice from across the operating room: Im going to try to save her uterus.

Walker had delivered her first child by caesarean section, so when she became pregnant a second time, doctors didnt think twice before scheduling another. And then another and another. Now, giving birth to her sixth child, she was experiencing the consequences: placenta accreta, a condition which is linked to multiple C-sections and can result in fatal bleeding.

Caesarean sections have saved the lives of millions of infants who might have otherwise been killed or permanently injured during difficult births. But in the US, the rate of caesareans has increased so much over the decades that the surgery has been transformed from a life-saving intervention into a procedure performed as a matter of course during one in three US births.

In 2015, the latest year for which the Centers for Disease Control has data, the share of births by C-section was 32%. The World Health Organization has suggested that the rate should not be higher than 10% – 15%, while other experts have suggested it should not be higher than 19%. The last time the USs rate was that low was during the 1970s.

Carmen
Carmen Walker and her sixth child, Olivia. Photograph: Carmen Walker

We are quite worried when the C-section rate goes above 30%, as it is in the United States, said Dr Flavia Bustreo, the assistant director general for family, womens and childrens health at the World Health Organization. It becomes routine but it is still a major surgery. That carries a long-term effect on maternal health.

A C-section rate of 10% to 15% is natural, she said. Above 15%, you dont have additional benefits, and you have the risks, and you have the unnecessary health costs.

A third of people get major surgery to be born, said Dr Neel Shah, a practicing OB-GYN and an assistant professor at the Harvard School of Medicine who works on ways to reduce avoidable C-sections. Many of the mothers in that equation were having a low-risk birth, he added that is, there were few or no medical indications that a C-section was necessary.

That is hundreds of thousands of women every year who get surgery they never need in the first place. Thats crazy. We can do much better than that.

The caesarean rate in the US has shot up by roughly 50% since the 1990s

The associated risks are serious. For the mother, they carry the potential for deadly bleeding, a lengthy recovery, organ damage and permanent injury. Compared with women having a vaginal birth, those having a C-section for the first time have 3.1 times greater risk of blood transfusions, a 5.7 times greater risk of an unplanned hysterectomy and a six times greater risk of being admitted into intensive care.

The rate of C-sections is now well beyond what is medically justifiable to save the lives of infants, experts say.

As C-section rates in the US have gone up, there has been no accompanying rise in infant survival rates. In the case of low-risk mothers, theres not a lot of evidence of improved outcomes, said Eugene Declercq, a professor at the Boston University School of Health who studies caesareans. Its just not there.

Women having a first-time caesarean in the US face a greater risk of dangerous pregnancy complications than women giving birth vaginally

In fact, some experts believe this rise in caesareans is one of the many intertwining factors contributing to crisis rates of maternal mortality, or death, and morbidity defined as significant injury related to a pregnancy.

Its certainly one of the downstream consequences of performing avoidable C-sections, said Jill Arnold, who runs a website that tracks individual hospitals C-section rates, and works as a consultant to Consumer Reports. Its connected to seeing more women bleed out, or have near misses.

Placenta accreta, for example, the condition that nearly killed Walker, is roughly 600 times more common today than it was in the 1950s, an increase scientists have linked to the rise in C-sections.

A 2007 analysis of more than two million birth outcomes in Canada found that women with low-risk pregnancies were three times more likely to die or be seriously injured if they had a C-section rather than a vaginal delivery. The findings helped move the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to put out a joint call in 2014 for reducing avoidable C-sections.

For most pregnancies, which are low-risk, caesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery, the groups said.

In the US, the rate of maternal deaths per 100,000 live births is 26.4, and it has been rising since 2000. Just about every other western country has seen a decline in maternal death rates since 2000, and the next closest western country, the UK, has a mortality rate of 9.2 per 100,000 live births.

It is very, very clear to me the connection between the number of C-sections and mortality and morbidity, said Dr Shah.

Whats not so clear is whether c-sections are whats causing maternal mortality rates in the US to rise. Declercq, who notes he is no fan of unnecessary C-sections, says the bigger drivers of maternal mortality probably include factors like the opioid crisis and the fact that many new mothers are dropped fromMedicaid, the government-run health program, shortly after they give birth.

Just addressing the C-section rate alone wont reduce the maternal mortality rate. Other developed countries have C-section rates that are as high as the United States. A 2012 international comparison found that the C-section rate was 21.8% in Norway and 24.4% in the UK but 31.7% in Germany and 26.2% in Canada.

But those countries also have medical teams that are better at recognizing and treating life-threatening pregnancy complications, investigations have found, and experts note they do not face factors like poor access to maternity care.

Why is the C-section rate rising?

The factors that drove up the rates of C-sections are numerous and difficult to untangle. Women who are older, heavier or have certain health conditions can be more likely to need a C-section to deliver a healthy baby.

But changes in the US population dont completely explain the increase seen since the 1970s. One factor is that doctors recommend C-sections when they believe the fetus is showing signs of distress, but many hospitals have a culture or use technologies that send a physicians better-safe-than-sorry instincts into overdrive.

Fetal heart monitoring strips, which produce a steady stream of information about a fetuss vital signs, are a prime example, said Declercq, because they furnish physicians with a torrent of information including, inevitably, false positives to scrutinize for signs of trouble. The rise in C-sections since the early 1970s closely tracks the introduction and widespread adoption of fetal heart monitors.

Then theres the fact that C-sections dont look like a public health disaster to those up close and personal with them.

I didnt realize this was a problem until you zoom way out, said Dr Shah. Theyre so common they look fine. And people are usually fine. They had their babies and they love their babies. Even people who had a stressful birth experience tend to look back fondly.

Many doctors and hospitals are in the dark about the rate at which they perform C-sections for low-risk births, because none of the government agencies or accreditors who oversee hospitals require the figures to be public. Arnold said she once heard of a hospital CEO crying the first time she learned her hospitals figures.

Pilot programs have found that, just as in Arkansas, the simple act of disclosing the numbers can cause hospitals to reduce their rates.

Many hospitals have a long way to go. Healthy People 2020, a federal initiative to improve US health outcomes and Leapfrog, a nonprofit that lobbies hospitals to release various health metrics as a way to improve overall care, deems a hospital to meet acceptable standards if C-sections account for no more than 23.9% of births.

In 2016, 55% of hospitals who voluntarily reported data to Leapfrog had a C-section rate that was higher than 23.9%, or 730 hospitals out of more than 1,300. At 223, or nearly 17%, more than one in three births takes place via C-section.

Honestly, it should be lower, Arnold said, referring to the 23.9% threshold. Even hospitals with high-risk patients, every hospital should be able to hit that number.

C-section rates by hospital

Geographical disparities

And yet, in the US, a womans odds of undergoing this risky operation are completely untethered from whether or not her circumstances require it.

A womans greatest risk factor for having a C-section is what hospital she chooses. Looking at a map, its normal for one hospital to have double the caesarean rate of a neighboring hospital located less than a mile away and serving the same community. Other times, geography equals destiny. The south in particular contains whole communities served only by hospitals where the caesarean rate is 33% or greater.

Walkers story illustrates the point. Her first caesarean was necessary, she says. She was in labor for 36 hours, but she never dilated enough to deliver vaginally.

But by the time she was pregnant with her second child, she lived in Mississippi, a state that had a C-section rate of 36.8% in 2014 and where scarcely any OB-GYNs are willing to attempt a vaginal delivery after a woman has already had a C-section. Her lack of options, she says, locked her into a succession of increasingly risky operations.

Walker wound up lucky. Although she spent three days on high-risk watch in the hospital and would still be undergoing a painful recovery months later, her doctor stopped the hemorrhage. The blood loss meant she remembers little about the initial aftermath, but she remembers being unable to stand up under her own power.

Her complications could have been far more severe. Placenta accreta patients account for 38% of caesarean-related hysterectomies, and up to 7% of women with placenta accreta die.

Read more: https://www.theguardian.com/lifeandstyle/2017/oct/04/one-in-three-us-births-happen-by-c-section-caesarean-births

The shorter your sleep, the shorter your life: the new sleep science

Leading neuroscientist Matthew Walker on why sleep deprivation is increasing our risk of cancer, heart attack and Alzheimers and what you can do about it

Matthew Walker has learned to dread the question What do you do? At parties, it signals the end of his evening; thereafter, his new acquaintance will inevitably cling to him like ivy. On an aeroplane, it usually means that while everyone else watches movies or reads a thriller, he will find himself running an hours-long salon for the benefit of passengers and crew alike. Ive begun to lie, he says. Seriously. I just tell people Im a dolphin trainer. Its better for everyone.

Walker is a sleep scientist. To be specific, he is the director of the Center for Human Sleep Science at the University of California, Berkeley, a research institute whose goal possibly unachievable is to understand everything about sleeps impact on us, from birth to death, in sickness and health. No wonder, then, that people long for his counsel. As the line between work and leisure grows ever more blurred, rare is the person who doesnt worry about their sleep. But even as we contemplate the shadows beneath our eyes, most of us dont know the half of it and perhaps this is the real reason he has stopped telling strangers how he makes his living. When Walker talks about sleep he cant, in all conscience, limit himself to whispering comforting nothings about camomile tea and warm baths. Its his conviction that we are in the midst of a catastrophic sleep-loss epidemic, the consequences of which are far graver than any of us could imagine. This situation, he believes, is only likely to change if government gets involved.

Walker has spent the last four and a half years writing Why We Sleep, a complex but urgent book that examines the effects of this epidemic close up, the idea being that once people know of the powerful links between sleep loss and, among other things, Alzheimers disease, cancer, diabetes, obesity and poor mental health, they will try harder to get the recommended eight hours a night (sleep deprivation, amazing as this may sound to Donald Trump types, constitutes anything less than seven hours). But, in the end, the individual can achieve only so much. Walker wants major institutions and law-makers to take up his ideas, too. No aspect of our biology is left unscathed by sleep deprivation, he says. It sinks down into every possible nook and cranny. And yet no one is doing anything about it. Things have to change: in the workplace and our communities, our homes and families. But when did you ever see an NHS poster urging sleep on people? When did a doctor prescribe, not sleeping pills, but sleep itself? It needs to be prioritised, even incentivised. Sleep loss costs the UK economy over 30bn a year in lost revenue, or 2% of GDP. I could double the NHS budget if only they would institute policies to mandate or powerfully encourage sleep.

Why, exactly, are we so sleep-deprived? What has happened over the course of the last 75 years? In 1942, less than 8% of the population was trying to survive on six hours or less sleep a night; in 2017, almost one in two people is. The reasons are seemingly obvious. First, we electrified the night, Walker says. Light is a profound degrader of our sleep. Second, there is the issue of work: not only the porous borders between when you start and finish, but longer commuter times, too. No one wants to give up time with their family or entertainment, so they give up sleep instead. And anxiety plays a part. Were a lonelier, more depressed society. Alcohol and caffeine are more widely available. All these are the enemies of sleep.

But Walker believes, too, that in the developed world sleep is strongly associated with weakness, even shame. We have stigmatised sleep with the label of laziness. We want to seem busy, and one way we express that is by proclaiming how little sleep were getting. Its a badge of honour. When I give lectures, people will wait behind until there is no one around and then tell me quietly: I seem to be one of those people who need eight or nine hours sleep. Its embarrassing to say it in public. They would rather wait 45 minutes for the confessional. Theyre convinced that theyre abnormal, and why wouldnt they be? We chastise people for sleeping what are, after all, only sufficient amounts. We think of them as slothful. No one would look at an infant baby asleep, and say What a lazy baby! We know sleeping is non-negotiable for a baby. But that notion is quickly abandoned [as we grow up]. Humans are the only species that deliberately deprive themselves of sleep for no apparent reason. In case youre wondering, the number of people who can survive on five hours of sleep or less without any impairment, expressed as a percent of the population and rounded to a whole number, is zero.

The world of sleep science is still relatively small. But it is growing exponentially, thanks both to demand (the multifarious and growing pressures caused by the epidemic) and to new technology (such as electrical and magnetic brain stimulators), which enables researchers to have what Walker describes as VIP access to the sleeping brain. Walker, who is 44 and was born in Liverpool, has been in the field for more than 20 years, having published his first research paper at the age of just 21. I would love to tell you that I was fascinated by conscious states from childhood, he says. But in truth, it was accidental. He started out studying for a medical degree in Nottingham. But having discovered that doctoring wasnt for him he was more enthralled by questions than by answers he switched to neuroscience, and after graduation, began a PhD in neurophysiology supported by the Medical Research Council. It was while working on this that he stumbled into the realm of sleep.

Matthew
Matthew Walker photographed in his sleep lab. Photograph: Saroyan Humphrey for the Observer

I was looking at the brainwave patterns of people with different forms of dementia, but I was failing miserably at finding any difference between them, he recalls now. One night, however, he read a scientific paper that changed everything. It described which parts of the brain were being attacked by these different types of dementia: Some were attacking parts of the brain that had to do with controlled sleep, while other types left those sleep centres unaffected. I realised my mistake. I had been measuring the brainwave activity of my patients while they were awake, when I should have been doing so while they were asleep. Over the next six months, Walker taught himself how to set up a sleep laboratory and, sure enough, the recordings he made in it subsequently spoke loudly of a clear difference between patients. Sleep, it seemed, could be a new early diagnostic litmus test for different subtypes of dementia.

After this, sleep became his obsession. Only then did I ask: what is this thing called sleep, and what does it do? I was always curious, annoyingly so, but when I started to read about sleep, I would look up and hours would have gone by. No one could answer the simple question: why do we sleep? That seemed to me to be the greatest scientific mystery. I was going to attack it, and I was going to do that in two years. But I was naive. I didnt realise that some of the greatest scientific minds had been trying to do the same thing for their entire careers. That was two decades ago, and Im still cracking away. After gaining his doctorate, he moved to the US. Formerly a professor of psychiatry at Harvard Medical School, he is now professor of neuroscience and psychology at the University of California.

Does his obsession extend to the bedroom? Does he take his own advice when it comes to sleep? Yes. I give myself a non-negotiable eight-hour sleep opportunity every night, and I keep very regular hours: if there is one thing I tell people, its to go to bed and to wake up at the same time every day, no matter what. I take my sleep incredibly seriously because I have seen the evidence. Once you know that after just one night of only four or five hours sleep, your natural killer cells the ones that attack the cancer cells that appear in your body every day drop by 70%, or that a lack of sleep is linked to cancer of the bowel, prostate and breast, or even just that the World Health Organisation has classed any form of night-time shift work as a probable carcinogen, how could you do anything else?

There is, however, a sting in the tale. Should his eyelids fail to close, Walker admits that he can be a touch Woody Allen-neurotic. When, for instance, he came to London over the summer, he found himself jet-lagged and wide awake in his hotel room at two oclock in the morning. His problem then, as always in these situations, was that he knew too much. His brain began to race. I thought: my orexin isnt being turned off, the sensory gate of my thalamus is wedged open, my dorsolateral prefrontal cortex wont shut down, and my melatonin surge wont happen for another seven hours. What did he do? In the end, it seems, even world experts in sleep act just like the rest of us when struck by the curse of insomnia. He turned on a light and read for a while.

Will Why We Sleep have the impact its author hopes? Im not sure: the science bits, it must be said, require some concentration. But what I can tell you is that it had a powerful effect on me. After reading it, I was absolutely determined to go to bed earlier a regime to which I am sticking determinedly. In a way, I was prepared for this. I first encountered Walker some months ago, when he spoke at an event at Somerset House in London, and he struck me then as both passionate and convincing (our later interview takes place via Skype from the basement of his sleep centre, a spot which, with its bedrooms off a long corridor, apparently resembles the ward of a private hospital). But in another way, it was unexpected. I am mostly immune to health advice. Inside my head, there is always a voice that says just enjoy life while it lasts.

The evidence Walker presents, however, is enough to send anyone early to bed. Its no kind of choice at all. Without sleep, there is low energy and disease. With sleep, there is vitality and health. More than 20 large scale epidemiological studies all report the same clear relationship: the shorter your sleep, the shorter your life. To take just one example, adults aged 45 years or older who sleep less than six hours a night are 200% more likely to have a heart attack or stroke in their lifetime, as compared with those sleeping seven or eight hours a night (part of the reason for this has to do with blood pressure: even just one night of modest sleep reduction will speed the rate of a persons heart, hour upon hour, and significantly increase their blood pressure).

A lack of sleep also appears to hijack the bodys effective control of blood sugar, the cells of the sleep-deprived appearing, in experiments, to become less responsive to insulin, and thus to cause a prediabetic state of hyperglycaemia. When your sleep becomes short, moreover, you are susceptible to weight gain. Among the reasons for this are the fact that inadequate sleep decreases levels of the satiety-signalling hormone, leptin, and increases levels of the hunger-signalling hormone, ghrelin. Im not going to say that the obesity crisis is caused by the sleep-loss epidemic alone, says Walker. Its not. However, processed food and sedentary lifestyles do not adequately explain its rise. Something is missing. Its now clear that sleep is that third ingredient. Tiredness, of course, also affects motivation.

Sleep has a powerful effect on the immune system, which is why, when we have flu, our first instinct is to go to bed: our body is trying to sleep itself well. Reduce sleep even for a single night, and your resilience is drastically reduced. If you are tired, you are more likely to catch a cold. The well-rested also respond better to the flu vaccine. As Walker has already said, more gravely, studies show that short sleep can affect our cancer-fighting immune cells. A number of epidemiological studies have reported that night-time shift work and the disruption to circadian sleep and rhythms that it causes increase the odds of developing cancers including breast, prostate, endometrium and colon.

Getting too little sleep across the adult lifespan will significantly raise your risk of developing Alzheimers disease. The reasons for this are difficult to summarise, but in essence it has to do with the amyloid deposits (a toxin protein) that accumulate in the brains of those suffering from the disease, killing the surrounding cells. During deep sleep, such deposits are effectively cleaned from the brain. What occurs in an Alzheimers patient is a kind of vicious circle. Without sufficient sleep, these plaques build up, especially in the brains deep-sleep-generating regions, attacking and degrading them. The loss of deep sleep caused by this assault therefore lessens our ability to remove them from the brain at night. More amyloid, less deep sleep; less deep sleep, more amyloid, and so on. (In his book, Walker notes unscientifically that he has always found it curious that Margaret Thatcher and Ronald Reagan, both of whom were vocal about how little sleep they needed, both went on to develop the disease; it is, moreover, a myth that older adults need less sleep.) Away from dementia, sleep aids our ability to make new memories, and restores our capacity for learning.

And then there is sleeps effect on mental health. When your mother told you that everything would look better in the morning, she was wise. Walkers book includes a long section on dreams (which, says Walker, contrary to Dr Freud, cannot be analysed). Here he details the various ways in which the dream state connects to creativity. He also suggests that dreaming is a soothing balm. If we sleep to remember (see above), then we also sleep to forget. Deep sleep the part when we begin to dream is a therapeutic state during which we cast off the emotional charge of our experiences, making them easier to bear. Sleep, or a lack of it, also affects our mood more generally. Brain scans carried out by Walker revealed a 60% amplification in the reactivity of the amygdala a key spot for triggering anger and rage in those who were sleep-deprived. In children, sleeplessness has been linked to aggression and bullying; in adolescents, to suicidal thoughts. Insufficient sleep is also associated with relapse in addiction disorders. A prevailing view in psychiatry is that mental disorders cause sleep disruption. But Walker believes it is, in fact, a two-way street. Regulated sleep can improve the health of, for instance, those with bipolar disorder.

Ive mentioned deep sleep in this (too brief) summary several times. What is it, exactly? We sleep in 90-minute cycles, and its only towards the end of each one of these that we go into deep sleep. Each cycle comprises two kinds of sleep. First, there is NREM sleep (non-rapid eye movement sleep); this is then followed by REM (rapid eye movement) sleep. When Walker talks about these cycles, which still have their mysteries, his voice changes. He sounds bewitched, almost dazed.

During NREM sleep, your brain goes into this incredible synchronised pattern of rhythmic chanting, he says. Theres a remarkable unity across the surface of the brain, like a deep, slow mantra. Researchers were once fooled that this state was similar to a coma. But nothing could be further from the truth. Vast amounts of memory processing is going on. To produce these brainwaves, hundreds of thousands of cells all sing together, and then go silent, and on and on. Meanwhile, your body settles into this lovely low state of energy, the best blood-pressure medicine you could ever hope for. REM sleep, on the other hand, is sometimes known as paradoxical sleep, because the brain patterns are identical to when youre awake. Its an incredibly active brain state. Your heart and nervous system go through spurts of activity: were still not exactly sure why.

Does the 90-minute cycle mean that so-called power naps are worthless? They can take the edge off basic sleepiness. But you need 90 minutes to get to deep sleep, and one cycle isnt enough to do all the work. You need four or five cycles to get all the benefit. Is it possible to have too much sleep? This is unclear. There is no good evidence at the moment. But I do think 14 hours is too much. Too much water can kill you, and too much food, and I think ultimately the same will prove to be true for sleep. How is it possible to tell if a person is sleep-deprived? Walker thinks we should trust our instincts. Those who would sleep on if their alarm clock was turned off are simply not getting enough. Ditto those who need caffeine in the afternoon to stay awake. I see it all the time, he says. I get on a flight at 10am when people should be at peak alert, and I look around, and half of the plane has immediately fallen asleep.

So what can the individual do? First, they should avoid pulling all-nighters, at their desks or on the dancefloor. After being awake for 19 hours, youre as cognitively impaired as someone who is drunk. Second, they should start thinking about sleep as a kind of work, like going to the gym (with the key difference that it is both free and, if youre me, enjoyable). People use alarms to wake up, Walker says. So why dont we have a bedtime alarm to tell us weve got half an hour, that we should start cycling down? We should start thinking of midnight more in terms of its original meaning: as the middle of the night. Schools should consider later starts for students; such delays correlate with improved IQs. Companies should think about rewarding sleep. Productivity will rise, and motivation, creativity and even levels of honesty will be improved. Sleep can be measured using tracking devices, and some far-sighted companies in the US already give employees time off if they clock enough of it. Sleeping pills, by the way, are to be avoided. Among other things, they can have a deleterious effect on memory.

Those who are focused on so-called clean sleep are determined to outlaw mobiles and computers from the bedroom and quite right, too, given the effect of LED-emitting devices on melatonin, the sleep-inducing hormone. Ultimately, though, Walker believes that technology will be sleeps saviour. There is going to be a revolution in the quantified self in industrial nations, he says. We will know everything about our bodies from one day to the next in high fidelity. That will be a seismic shift, and we will then start to develop methods by which we can amplify different components of human sleep, and do that from the bedside. Sleep will come to be seen as a preventive medicine.

What questions does Walker still most want to answer? For a while, he is quiet. Its so difficult, he says, with a sigh. There are so many. I would still like to know where we go, psychologically and physiologically, when we dream. Dreaming is the second state of human consciousness, and we have only scratched the surface so far. But I would also like to find out when sleep emerged. I like to posit a ridiculous theory, which is: perhaps sleep did not evolve. Perhaps it was the thing from which wakefulness emerged. He laughs. If I could have some kind of medical Tardis and go back in time to look at that, well, I would sleep better at night.

Why We Sleep: The New Science of Sleep and Dreamsby Matthew Walker is published by Allen Lane (20). To order a copy for 17 go toguardianbookshop.com or call 0330 333 6846. Free UK p&p over 10, online orders only. Phone orders min p&p of 1.99

Sleep in numbers

Two-thirds of adults in developed nations fail to obtain the nightly eight hours of sleep recommended by the World Health Organisation.

An adult sleeping only 6.75 hours a night would be predicted to live only to their early 60s without medical intervention.

A 2013 study reported that men who slept too little had a sperm count 29% lower than those who regularly get a full and restful nights sleep.

If you drive a car when you have had less than five hours sleep, you are 4.3 times more likely to be involved in a crash. If you drive having had four hours, you are 11.5 times more likely to be involved in an accident.

A hot bath aids sleep not because it makes you warm, but because your dilated blood vessels radiate inner heat, and your core body temperature drops. To successfully initiate sleep, your core temperature needs to drop about 1C.

The time taken to reach physical exhaustion by athletes who obtain anything less than eight hours of sleep, and especially less than six hours, drops by 10-30%.

There are now more than 100 diagnosed sleep disorders, of which insomnia is the mostcommon.

Morning types, who prefer to awake at or around dawn, make up about 40% of the population. Evening types, who prefer to go to bed late and wake up late, account for about 30%. The remaining 30% lie somewhere in between.

Read more: https://www.theguardian.com/lifeandstyle/2017/sep/24/why-lack-of-sleep-health-worst-enemy-matthew-walker-why-we-sleep