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Maddie McMahon is a well respected birth and postnatal doula, and a member of our Editorial Board. This post is hers; Maddie’s clear and articulate piece reflects an increasing frustration in the commercialisation of the NHS, paying attention here to maternity services.

When an old buffalo has become decrepit and lumbering, the carrion crows start circling and the hyenas slink ever closer, waiting for any opportunity to take a bite out of the dying creature. With eyes dimming and the days of nimble feet sadly long gone, it doesn’t notice the dangers that lurk in the bushes, mistaking predatory behaviour for opportunities.

What’s more, now slower and less able, it comes last at the watering hole; left with the dregs after the younger, stronger animals have drunk their fill. Hunger and thirst drive it to acts of desperation; such is the will to live even in the most difficult of circumstances.

Our NHS is becoming that poor, failing animal; in a land of scant resources, thirsty for funding. An outlier in the herd, ready to be picked off by any passing predator, it is prey to the temptation to accept corporate interference. In a political landscape that welcomes, nay encourages, private investment and corporate partnerships, the stage is set for Greed to walk our wards and clinics.

Just like out on the plains watching the buffalos roam, it can take a while to recognise what is happening. But look more closely and you can see how corporations are slowly and surely snapping up every opportunity to make our hospitals market places.

In these cash strapped times am I being ridiculous to hold our NHS to such lofty ethical standards? After all, what’s so wrong with our healthcare system getting a bit of extra cash for some advertising? Perhaps patients could even receive some useful information in a format that is cost neutral to the NHS Trust? If I were a Chief Executive counting every penny and sweating at the sight of that big red bottom line, a salesman in a sharp suit with a briefcase of cash might look very attractive indeed.

I can’t blame the companies..

And I can’t blame the companies – this lumbering creature offers easy pickings and a massive, captive audience of patients. A marketplace of people who are particularly open to the power of advertising. It’s a Don Draper wet dream.

The insidious influence of advertising follows maternity service users throughout the whole of their pregnancy. For example, at your booking appointment you will probably be handed a folder for your handheld notes branded with Bounty logos. Bounty will stalk you for your whole pregnancy, acting as a conduit for a torrent of flyers, free samples and brand awareness material for products that aren’t always evidence-based or proven safe. Chemical-laden wipes, bathing lotions and nappies, ‘weaning foods’ that advertise infant formula by association and encourage parents to wean before 6m are most common.

The Bounty-hunting will usually culminate in a face to face encounter after the baby is born. After all, if they can get to you when the sweat of labour is hardly dry on your skin, the more likely it is that you will part with your contact details. As a doula I have witnessed Bounty reps entering birth rooms within minutes of a baby’s birth. Once a rep knocked on the door when my client was still naked, covered in blood and initiating breastfeeding. I politely asked her to go away, but the bubble of peace, love and oxytocin in the room was burst.

“I was so out of it after I gave birth and when the lady came round to take photos it was exhausting. I know I could have said no but everything was such a blur I just went along with it…At such an intimate time, I felt a bit violated when a company was trying to sell me things.” Ellie

These sales people appear to have access to all areas of the maternity wards and are often mistaken for health professionals. I spoke to one breastfeeding peer supporter who was asked to leave a woman’s room so the Bounty Rep could come in. How appropriate is this when that mother was in tears, struggling with feeding her baby?

“My baby was unwell in the NICU, I was in bed crying and this woman let herself into my room uninvited trying to sell me photos.” Mandy

It makes it look like their trusted midwives and doctors are endorsing this service

Then there are the Cord Blood Banking companies. This expensive service costs parents over £2k + yearly storage fees. Much has been written about whether banking cord blood is actually useful and there is controversy over how it can interfere with optimal cord clamping. To be honest, if my clients want to spend the money, that’s up to them. What I don’t expect is for my clients to see posters, 6 foot tall banners and flyers all over the hospital. You see, it makes it look like their trusted midwives and doctors are endorsing this service. It is easy to see why some of my clients have asked me if they “have to” bank their baby’s blood. Given that both the RCOG and the RCM have expressed concern about these businesses in the past, I am nonplussed by the way some hospitals seem to be embracing the idea.

How heartbreaking to hear a fellow doula tell me about the client who was taken into theatre crying and begging for her doula to accompany her. She was flatly refused, but then overheard the company phlebotomist being invited in to theatre to watch the birth.

I wonder how much these companies are paying the hospital to get what looks like official endorsement? Midwife and optimal cord clamping campaigner, Amanda Burleigh, told me, “The cord blood companies sometimes defer informed choice to the midwives, who are the health professionals, which absolves the company of the responsibility and also places midwives in a potentially vulnerable position…the most important thing is informed choice. If parents are given proper informed choice, and are in receipt of all the information, few will go ahead with the cord blood banking”.

How can branding and marketing materials all over a hospital facilitate informed decision making?

Next on my list of things to wonder about: TV companies paying to place CCTV cameras in examination rooms. I wonder how much it takes to get a project past an ethics committee that entails not warning patients before they enter a room that there are cameras rolling? How much does it cost to get staff to bypass normal rules of informed consent?

Nursing and Midwifery Code 21.6: cooperate with the media only when it is appropriate to do so, and then always protecting the confidentiality and dignity of people receiving treatment or care.

But you know, I can almost understand the schemes that result in hard cash in the pocket of my local maternity unit; a unit which is severely underfunded and understaffed, recovering from a period of special measures after a bad CQC inspection. If I were the boss, I’d be tempted too. What I find harder to understand are ‘cost neutral’ schemes that are supposed to provide the hospital with a useful service without any outlay. The Baby Box scheme falls into this category.

..Can double as a sleeping place for those who can’t afford cots…

So what is the Baby Box? Well that depends on where you live. The idea originated in Finland and was designed to even out social inequalities. Every mother receives a box of basic baby clothes and other items to last the first 12 months of a child’s life. The box can double as a sleeping place for those who can’t afford cots or moses baskets. The Scottish government now funds a similar scheme that provides useful items to new parents.

However, if you live in England or the US, the idea has been stolen by the new kid on the block – the Baby Box Co. This company is pretty much the next incarnation of Bounty, providing a box of marketing materials to new parents in return for watching a few videos on the website and answering some quiz questions. On the surface, it looks like a great scheme: parents get some useful antenatal education and box of freebies and the hospital provide useful products and information to users and get a little good PR.

Somewhere along the line, the box has been confused with the safe sleep campaign. Because Finland’s SIDS rates reduced massively at the same point in history as parents were receiving the box, it seems to have been credited with this achievement, despite no evidence to back it up. In fact, the public health measures being put in place at the time have been largely credited with the reduction in infant death in Finland.

Yet the hype around the Baby Box scheme seems to be mainly predicated on reducing SIDS risks and discouraging bedsharing. In fact the recently launched scheme in my town originally had a quiz question on the website equating bedsharing with sofa sharing. After complaints, this has been changed. However, there is still no mention of the fact that a baby sleeping in a box is not inherently safer than sleeping in a cot, moses basket or an appropriate shared sleep surface with the mother (ie bedsharing). Both the Lullaby Trust and The Infant Sleep Information Source have serious concerns about the Baby Box, yet hospitals around the country appear to be leaping on this scheme without due diligence and without consultation.

One mother said, “with the existing problems with Bounty invading the privacy of new mothers – advertising and using their personal details to add to databases, how much of these boxes is yet more advertising aimed at new parents who are already possibly overwhelmed and vulnerable?”

We have to tread extremely carefully here. We have mounting evidence that breastfeeding duration is extended when mothers can sleep as close as possible to their babies. I am concerned that the messages parents may be receiving through this scheme are not in direct accordance with the spirit of the Baby Friendly Hospital Initiative. In fact, UNICEF agrees that the Baby Box idea may well present difficulties for Trusts and have recently issued a statement listing potential concerns, entreating Trusts to:

Consider the claims being made about the box and how these may influence behaviour.”

All good quality SIDS research is finding that bedsharing is not a risk in itself, especially in the absence of other risk factors. Even NICE is now making the distinction between bedsharing with and without risk factors: “Sudden infant death syndrome is more likely if a parent or carer sleeps with a baby (on a bed or sofa or chair) and a parent, carer or partner smokes. It may be more likely if a parent or carer sleeps with a baby and has taken drugs, has recently drunk alcohol, or if the baby was small at birth or born early (before 37 weeks).”

Like most of these schemes, the main goal appears to be harvesting personal details to sell on to 3rd parties

If, like the Scottish version, the box was full of clothes, nappies, a baby sling and other, well, actually useful items, I could be a bit more enthusiastic about this scheme. But the version I have recently seen contains a mattress, a blanket, a sheet and a few leaflets. Like most of these schemes, the main goal appears to be harvesting personal details to sell on to 3rd parties.

On questioning the senior midwife who has championed the adoption of the boxes, she was unable to explain to me why the idea was brought in without consultation, or what the hospital was hoping to achieve with the scheme – after all, they have to make their own videos for the Baby Box website, which they could have done anyway, and uploaded them to their own website. Her argument is that this box could help the most financially deprived women, and I don’t disagree. So let’s fund it, take out the advertising, fill it with actually useful stuff and target it at the most vulnerable, needy families.

Over the years I’ve heard some utter rubbish about advertising to justify it: that it doesn’t influence behaviour (why do they spend billions then?). That it is a necessary evil in order to fund good projects (not if the marketing messages contradict the evidence and undermine public health). That it offers choice to consumers (not if those choices are not fully informed and financially out of reach to many families).

How ethical is it to market directly at people who are at particularly vulnerable points in their lives?

You know, when a midwife is asked, ‘How is this funded?’ and she replies ‘I don’t know and I don’t care’, I believe we have to stop for a second and contemplate what we want from our NHS. Should we care? What subtle and not so subtle effects does commercial influence have on our health services? How ethical is it to market directly at people who are at particularly vulnerable points in their lives? How ethical is it to force health professionals into potential conflicts of interest? And how complicated does it get when we when we mix money and morality?

Don’t get me wrong, I am completely supportive of hospitals that want to provide lots of information to families about the products and services that are available to them. Parents may be grateful to find out about hypnobirthing, doulas, sling libraries, peer support groups or lactation consultants. Many of these services can complement NHS care beautifully. I think it’s the way we provide signposts to users that matters. It is important that the NHS doesn’t endorse things by taking money or favours in return for access to patients. The regulation is already there, in the NHS guidance for trusts on accepting advertising. The statement that jumps out at me is the one that states that advertising material should not give rise to doubts about the integrity, independence or impartiality of the NHS”.

I can foresee a future where midwives are wearing branded scrubs and seen as little more than a salesforce. In a world where no-win no-fee solicitors have offices in the concourse and advertise on patient paperwork, I have to wonder where we are headed. And I have to ask: who’s standing up against the sale of our beloved NHS’s soul?

Maddie can be found on Twitter @Doulamaddie 



One Comment

  1. Pingback: My Doula Year: banging the drum for justice - The Birth Hub

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