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Dying and its aftermath

January 24, 2018

Two poems by Elizabeth Jennings

In the early 1960’s, Jennings made a number of suicide attempts and spent time in and out of mental hospitals. She wrote For a Woman with a Fatal Illness, part of the masterpiece Sequence in Hospital (1963), during this period. Absence is from  an earlier collection A Sense of the World (1958).

For a Woman with a Fatal Illness

The verdict has been given and you lie quietly
Beyond hope, hate, revenge, even self-pity.

You accept gratefully the gifts – flowers, fruit –
Clumsily offered now that your visitors too

Know you must certainly die in a matter of months,
They are dumb now, reduced only to gestures,

Helpless before your news, perhaps hating
You because you are the cause of their unease.

I, too, watching from my temporary corner,
Feel impotent and wish for something violent –

Whether as sympathy only, I am not sure –
But something at least to break the terrible tension.

Death has no right to come so quietly.



I visited the place where we last met.
Nothing was changed, the gardens were well-tended,
The fountains sprayed their usual steady jet;
There was no sign that anything had ended
And nothing to instruct me to forget.

The thoughtless birds that shook out of the trees,
Singing an ecstasy I could not share,
Played cunning in my thoughts. Surely in these
Pleasures there could not be a pain to bear
Or any discord shake the level breeze.

It was because the place was just the same
That made your absence seem a savage force,
For under all the gentleness there came
An earthquake tremor: Fountain, birds and grass
Were shaken by my thinking of your name.



Cerclage pessaries

January 7, 2018

Do they make sense?

The cervix is a tube of fibrous tissue with an important job, to hold the baby in for nine months. If it fails the pregnancy ends in miscarriage or preterm birth.

Here’s how the cervix opens. The muscular upper part of the uterus contracts, effacing (shortening) the tube and then stretching the cervix passively over the baby’s head.


The cerclage pessary is a plastic device inserted in the vagina in such a way that it encircles that part of the cervix which protrudes into the vagina (picture below). The idea is that it can prevent miscarriage or premature birth by holding the cervix closed.  Trials have had mixed results (click here), but today I want to ask; is the idea even plausible?

Look at the pictures again, and get your head around the process of effacement.  How could a pessary lying loosely round that part of the cervix which protrudes into the vagina hold the cervix closed? The cervix can’t dilate until it has effaced.  But effacement pulls the cervix out of the pessary. The idea is impossible.

Even if the pessary exerted some pressure on the cervix it would not be able to do so on the very ones that most need it – those where the effacement/shortening has already started, or where the cervix was already shortened by previous surgery such as cone biopsy.

And don’t forget the pessary is a foreign body kept in the vagina for may weeks, sometime months. Infection is a well recognised cause of preterm birth. How did the idea that the cerclage pessary might work ever get traction?

Jim Thornton

Never Your Own

October 31, 2017

by Ferron

I discovered Ferron via the dark comedy One Mississipi on Amazon Prime. Tig Notaro, who among other indignities has recently undergone a double mastectomy for cancer, gets stood up by her new hot date at a Ferron concert. Emily Nussbaum in the New Yorker (click here) described the scene as “what may be the most lesbian plot ever on television”.  I’m no judge of that, but Tig, alone in the crowd, as Ferron sings Aint Life a Brook was a bit of a moment.

Never Your Own is from Ferron’s 2009 album Boulder.


Could the album cover image be a reference to her fellow Canadian, Leonard Cohen? No. It’s from this song, about holding back those troublesome thoughts about the fate that’s coming down the line – to us all.


What you dream in the morning, may you dream at night
May your love light be so bright it diminish the darkness
that comes without warning
And in no particular way
and threatens to blow you away.

You can pray to a flower or a bird on the line,
What’s clear in the mirror twists with cheap evening wine
Still, those sweet running creek beds seem
to show up on time
And keep you from blowing away

I wish I could tell you all the pain’s in your head
That it all would be better if you’d just do what they said
But if the voice that is talking is never your own
Then who’s going to tell you that you finally come home.

Me, I’ve run with the big boys and I’ve lain in their dirt
It’s the same sorry story and we all have been hurt
by the Truth that we carry and the truth that flies by
And the distance between them is the sweet by and by

We’re born to a body that is destined to die
And we wail at that moment ‘til we learn to say ‘why’
Is it me, am I the only one who suffers this way
that’s when the glorified game goes to play

In the wind there’s a story, in the trees there’s a song
In a friend’s touch there’s so much,
makes you want to live longer
And do a little something that might soften the blow
With your arms wrapped together you say baby I know…

Loire canoeing – Nevers to Chateauneuf

October 21, 2017

A beautiful section. At normal water levels the flow is excellent; 135 km took us (middle-aged paddlers) seven days. But the river is not to be trifled with. Although most rapids are easy, and the channel easy to find, there are a couple of problems for an open canoe. We launched below Nevers bridge’s tricky step, but the similar step at La Charité is more difficult to avoid. The natural portage right is the wrong bank for the island campsite, and repair work (May 2017) makes a carry over the bridge unattractive. We shot the third arch from the right, but took on a lot of water and only just avoided a capsize.

My other worry, the nuclear plants at Belleville (click here) and Dampierre (click here), proved easier than expected. Both easy portages, albeit the latter invisible from the canoe until you’re almost on the weir.

This stretch passes the china factories of Gien, and some magnificent canal engineering at Briare. Apart from Sully the chateaux are set well back, but the river touches many vineyards; the famous Pouilly and Sancerre, and the less famous Coteaux du Giennois. The Canal latéral à la Loire has followed the left bank from Digoin and continues to do so till crossing at Briare.

Between March and June terns and grebes migrate from Africa to nest on the islands. It’s fine to use the shingle banks for access, few birds nest there, but canoeists are asked to avoid landing on the islands during this period.


0 km – Nevers-sur-Loire. Camping left bank (click here), upstream of the bridge (1832). A few yards from the campsite, the Nevers branch of the canal latéral ends in a marina.

Tricky step below bridge. Launch downstream or shoot right (click here).



Is this tower on the right bank 50 meters below the bridge a toll house?

200 metres – Nevers Railway bridge (1946)

7 km – River Allier joins left. With similar length and flow to the main river, some argue that the Loire is a tributary of the Allier! The junction is rather a disappointment. The picture below right is the view upstream from the mouth of the Allier.


8 km –  Iles-de-Marzy Main channel left.

13.5 km – Fourchambault Givry bridge  Givry left. Fourchambault right. The “Camping de la Loire” campsite right above the bridge (click here) closed in 2016 and was still closed in May 2017.


Broken weir right immediately after the bridge. Pass left.

14 km – Canal du Givry joins left. A branch of the canal lateral


Immediately after the Canal du Givry river lock, is a broken weir left, with an attractive gap for white water enthusiasts. The main channel right is easier.

21 km – Marseilles-les-Aubigny left The canal du Briare, running along the left bank, is close here.

28 km – La Marche right


29 km – Weir left. Stay right for the beautiful old bridge at La Charite, the oldest crossing of the Loire.

31 km – N151 La Charité bridge. New bridge (1951) over left channel.  Old bridge (original 1520. This one 1731) right. Currently May 2017 under extensive repair.  La Charité right.

The Abbey was an important stop on the Camino de Santiago pilgrimage route from Scandinavia and Germany. Shoot 3rd arch from right. If you manage not to fall in, ferry glide across to shingle bank on the island for access to the campsite.

charite-new-bridge   charite-sur-loire-grand-pont     

Camping (click here) on the island downstream of the bridges. Nice site with good facilities but rather too securely fenced for my taste! No access to the campsite from the left (new bridge) channel.


37 km – Chateau Mouron right

45 km – Pouilly-sur-Loire bridge (1902) P-s-L right. The vineyards right behind the town mostly grow sauvignon blanc for Pouilly-Fumé. A minority grow the chasselas grape for the slightly inferior Pouilly-sur-Loire wine. (Click here for more)

 pouilly-sur-loireview-from-bridge   pouilly-fume-chateaux-de-tracy

Camping de Malaga right bank about 0.5 km below the bridge. More a holiday park than campsite.

Soon the unmistakable outline of Sancerre hill comes into view.


55 km – Saint-Thibault-sur-Loire bridge


55.5 km – Junction canal left The river lock is no longer working and the junction canal is now a marina. Followed immediately on left bank by Flower Camping Les Portes de Sancerre (click here)

60 km – Port Aubry railway bridge (1893)

63 km – Cosne-Cours-sur-Loire suspension bridge (1959) Camping left bank just upstream of the bridge (click here) Lovely site.

75 km – Belleville nuclear power station left The beautiful cooling towers, among the largest ever built, return most of the water it uses to the river (more here)


76 km – Pont de Neuvy-sur-Loire (1984) Portage the weir under the bridge right (more here).


82 km – Bonny-sur-Loire suspension bridge (1902) Bonny-s-L right. Beaulieu-sur-Loire left

86 km – Ousson-sur-Loire right  Broken weir left. Main channel right.


87 km – Mantelot lock left Prior to the opening of the Briare aqueduct, boats coming from the south on the Canal Lateral a Loire crossed the river here to reach the Canal de Briare at Combles lock on the other bank.

chatillon-lock-mantelot chattelot-eclusemantelot-w580

A long jetty left, the Levee d’L’Escargot extends as far as the bridge and guided barges towards the safety of Combles lock.

88 km – Chatillon-sur-Loire bridge (1951) Land right for campsite (click here) and parking. Left for the village.


Don’t worry that landing left will leave you on the island. A spiral ramp gives access to the bridge.


Just below the bridge, Combles lock gates right, connect to the original canal de Briare.

91 km – Aqueduct de Briare (1896)  Briare right

briare-aqueduct briare-aqueduct2 briare-aqueduct3

92 km – Briare canal lock right No longer in much use since the aqueduct opened. But looks like it still functions

briare-canal-loire-lock2 briare-loire-lock

The vineyards on the low hills to the right are the Coteaux de Giennois, the tiniest Loire appellation.

The red and white wines are collector’s pieces, the ‘insider’s alternative’ to Sancerre and Pouilly-Fumé (Hugh Johnson), much cheaper than Sancerre, and rather good, but few ever leave France. The winery Domaine Poupat in Briare (click here) is the place to buy them.

98 km – Gien D951 bridge (1980)


99 km – Gien old bridge (1734). Gien right. Home of Gien china (click here)

gien-bridge gien-bridge2    

Camping Gien left bank 200 metres downstream of bridge (Click here)

100 km – Railway bridge (1893)


106 km – Weir. Inflow channel to Dampierre nuclear power plant right. Portage/line down left end of the weir. More details here


117 km – Sully-sur-Loire road bridge (1986). Chateau de Sully left.  The map marks a campsite left a few hundred metres upstream of the bridge, but I think it may have closed. All I could find was a large RV park.


Followed by rail bridge. S-s-L left. Saint-Pere-sur-Loire right


Land right just below the railway bridge for a tiny campsite with no facilities associated with a canoe hire company.


Or 100 metres further on for the Camping Le Jardin de Sully (click here) with all facilities.


Saint Benoit-sur-Loire right.  Camping Le Port right.  (click here)

Sigloy left. Village not visible from the river but you can hire traditional Loire boat trips from here. (Click here)


132km Chateauneuf sur Loir bridge.  C-s-L right.  Camping La Maltournee left 300 metres upstream of the bridge. (Click here)


Next year Chateauneuf to Tours!

Jim Thornton

“Larkin with Women” in Eskdale

September 7, 2017

Who was “the one”?


Scene one. The poet, wrestling with the final verse of An Arundel Tomb, calls out to Monica: “Heraldic, two syllables, with oomph!” Fans in the audience bite their fists, and partners kick shins; it’s a play not a pantomime. But Monica comes up with “blazon” and smiles contentedly when she reads the soon to be famous final line “What will survive of us is love”. 

Scene two. The librarian hides his dirty magazine stash from his secretary. No-nonsense Betty turns a blind eye until a letter from the vice squad arrives – he’s been rumbled.  Larkin panics but Betty forces him to take a call from his fellow porn connoisseur, Bob Conquest. It’s a set-up!

And so it goes. Readers of the letters and biographies will know most of the stories; the hedgehog and the mower, Mrs Thatcher and Deceptions, jazz, drinking, and – three women.

Monica Jones, his intellectual equal, has stuck with him ever since Larkin’s best friend Kingsley Amis drew on her as the model for uptight Margaret Beale in Lucky Jim; she must love him to stay around after that. Betty Mackereth knows all his secrets, including that Monica takes precedence, but loves him all the same. Repressed Maeve Brennan, bowled over by a published poet, waits 15 years to go all the way; of course she loves him.

Ben Brown’s Larkin with Women tells the story of his 30-year entanglement with the trio. It’s been revived many times and this summer came to the village hall in the North Yorkshire hamlet of Glaisdale. One wonders how such a place can support even a summer season of professional theatre, but every year it does; Larkin easily sold out thirty shows. We, drawn by Larkin, had come up from Nottingham. Two ladies sitting next to us had come from Whitby. Conversation: “Not much of a looker.” “Miserable too.” “What did they see in him?” “I guess there are no ugly poets.”

We had popped in before the show to look around the empty theatre, and one of the scene shifters had told us its story. Esk Valley Theatre has been running ten years – Willy Russell’s Educating Rita last year – with minimal subsidy but much local volunteering.  The company bring their own seating and put on one production annually. They have some connection with Scarborough where Alan Ayckbourn tries out most of his plays; Larkin with Women was first performed there in 1999, and Ayckbourn himself had turned up in the audience the previous night.

And the play? The women were all brilliant, but I was disappointed in the Larkin character. Jonathan Pembroke occasionally showed a clunking lack of empathy, almost playing him as somewhere “on the spectrum”. The Freudian slip of admiring Monica’s “maeve” sheets was OK, but the laugh he got when denying that he’d had sex with Maeve, by gratuitously adding “not by choice”, grated. Larkin was selfish but, judging by the poems, few people were more empathic. Perhaps it’s difficult to differentiate selfishness and lack of empathy in a few lines.  

There were plenty of jokes. Waving a newspaper article about a woman who shrieked and vomited at a Ted Hughes poetry reading, he mutters: “I never felt like shrieking!” Tussling with Maeve he comes out with: “Marriage is a wonderful thing for other people, like going to the stake.”

But there was also much Larkin melancholy. Although death came late to his fourth woman, his mother, cancer comes to Larkin a good bit earlier. He asks Betty to give Monica a lift to the hospital. Maeve gives him her bible. The women meet by the death bed, each wanting to be told she is “the one”. Larkin withholds that comfort, although he does admit to loving Monica. Nor will he pretend to the faith he does not hold.

But we the audience have had time to read An Arundel Tomb more carefully than Monica did that day. To get to know the layers of ambiguity he got into that final line.

Time has transfigured them into
Untruth. The stone finality
They hardly meant has come to be
Their final blazon, and to prove
Our almost-instinct almost true:
What will survive of us is love.

The pun in the play’s title was misplaced. All Larkin’s women were “the one”.

Jim Thornton

“Success for All” literacy programmes

July 15, 2017

The Education Endowment Foundation trial results were negative

Is the Foundation spinning it as positive?

Success for All is a commercial education programme (click here) which claims to improve literacy in primary schools. Teachers are shown how to provide effective phonics teaching and provided with structured lesson plans. Heads and managers get help with ability grouping and with encouraging parental involvement.

Sounds good, but does it really make a worthwhile difference? The Education Endowment Foundation (EEF) has just published a randomised trial testing the programme’s effectiveness. loves randomised trials of educational innovations, but criticised an earlier Foundation trial (click here), for playing down its predefined primary and secondary endpoints, which had shown no benefit, and claiming that the treatment had worked on the basis of new, possibly data driven, endpoints. Let’s look at the Success for All trial (click here for the full report or Success_for_All_Evaluation_Report).

It was a cluster randomised trial comparing 27 intervention schools (874 pupils) with 27 controls (893 pupils). That’s 54 schools and 1767 pupils in total. Randomisation details are not given in the main report but, according to the revised protocol, schools were “allocated in pairs based on a ranking of Key Stage 2 results”. The planned sample size (50 schools, 1250 pupils) was exceeded, and the trial had 80% power at conventional levels of statistical significance (5%) to detect a difference of 0.2 of a standard deviation in mean test scores. This would convert to about three months attainment difference. Educationalists generally label such an effect size as at the border between “small” and “medium”. The researchers presumably judged it as the minimum worthwhile difference for a relatively expensive intervention like this. That seems reasonable, although I confess I’m not qualified to judge. The intervention took place in two waves, June 2013-14 and 14-15, with results collected during the intervention (end of reception class) and at project completion (end of year one class), so the final results were in by August 2016.

The trial was retrospectively registered (click here) in June 2016, and the two versions of the protocol on the EEF website (click here) are dated Feb and August 2016. Nevertheless the analysis didn’t happen till November 2016, so this late registration may not matter.

The primary outcome on the registry and both protocols was the same, the six components of the Woodcock Reading Mastery Test score (high is good), three measured at end of reception and three at year one. Six primary endpoints are too many, but the authors eventually compared just the total Woodcock scores, so only two primary endpoints. Seven intervention schools gave up on the programme, but fortunately all but one of them collected outcome data so they were included in the primary “analysis by intention to treat”.  Schools and pupils were well balanced at trial entry (table 5), but 214 children (12% of the original sample) missed the reception class assessment, and by the year one point 430 children (24%) were lost to follow-up.


The raw mean end of year one scores in the intervention schools were 82 v 78 controls (Table 6) but the standard deviation was huge (about 57 points) so the four point difference amounted to a tiny effect size of only 0.07 SD (95% CI -0.03 to 0.18, P=0.14). The effect size on the mean Woodcock score at the end of reception (trial midpoint) was even smaller 0.04 SD (95% CI -0.06 to 0.14 P=0.42).

In summary the main trial result was negative. These effects are too small to be educationally meaningful, they could easily have occurred by chance, and even if real, they would be too small to justify either the cost or the teachers’ time and effort.

The authors also looked at a phonics score at the trial end (not pre-specified) and adjusted for different combinations of baseline variables, but the effect sizes were smaller and the nominal P values larger. Curiously, although they had planned to test the Woodcock subscales, they decided not to do so “to avoid multiple testing”.  The raw sub-scale scores differed little (Table 7).

Subgroup analyses

No subgroup analyses are mentioned on the trial registry, but the original protocol planned “exploratory analysis [… e.g.] boys/girls, ethnicity, children of different abilities at baseline, high/low implementation schools”.  In the revised protocol they added “the main analysis will be repeated on a subsample […] eligible for free school meals”.

The free school meal subgroup analysis was negative at the end of the trial; effect size 0.12 SD (95% CI -0.10, 0.34, P = 0.23) but nominally significant at the midpoint reception class; effect size 0.22 SD (95% CI 0.01, 0.44, P = 0.03). This intermediate benefit would be worthwhile if real, although presumably not worth much if it disappeared a year later.

The secondary analysis by baseline attainment showed no differences, and the other secondary analyses by gender or ethnicity appear to have been quietly (and wisely) forgotten.

This left a secondary analysis excluding the seven intervention schools who gave up on the programme. Removing those schools, which were so disorganised that they couldn’t follow through on a two year literacy project, from the intervention group but not from controls, introduces bias in favour of the intervention. Even so the effect size was tiny, and of borderline statistical significance, 0.10 SD (95% CI -0.01, 0.22, P=0.05).

The programme cost £46,000 per school in the first year (about £169 per pupil) which fell steeply in subsequent years, so that over three years the cost per pupil per year was estimated at £62. The cost of the recipient school’s own staff training time was excluded from this figure.

Here are the Foundation evaluators’ conclusions together with my comments. Note an effect size of 0.07 is equivalent to one months progress.

“Children who took part in Success for All (SfA) made 1 additional month’s progress, on average, after two years compared to children in other schools. [We] are moderately confident that this difference was due to SfA.”

My interpretation. Depends what you mean by “moderately confident”. I’m moderately confident that the intervention is ineffective. The trial hasn’t ruled out a tiny beneficial effect size, but the observed difference could well have occurred by chance. The trial has not ruled out a small harmful effect either. No-one would licence a new drug on the basis of such a result.

“Children eligible for free school meals (FSM) made 2 additional months’ progress after two years, compared to FSM children in control schools. The smaller number of FSM pupils in the trial limits the security of this result, though combined with other findings in the report it provides some evidence that SfA does improve literacy ability for children eligible for free school meals.”

My interpretation. No they didn’t. The 2 months additional progress (total 3 months) comes from the effect size 0.22 SD P=0.03 for the interim score at the end of reception. Not only was this a secondary endpoint, albeit pre-specified, but the apparent effect faded by year one (effect size 0.12 SD. 95% CI -0.10 to 0.34. P = 0.23).

The remainder of the Foundation’s summary points are bland but positive, e.g “Schools that successfully delivered SfA were enthusiastic and valued the programme.”

The trial authors know the results were negative. The full report contains this sentence:

“The only other trials were based in the US and reported a positive effect of the programme, achieving effect sizes in the region of 0.15-0.30. The current trial has been unable to replicate these effects in an English context.”

But a visitor to the Foundation’s website would struggle to find it among the positive spin.

Perhaps it’s churlish to criticise. Randomised trials of educational innovations are few and far between, and I certainly don’t want to discourage them. But if negative trials are spun as positive, disinterested parties will soon disbelieve their results, as they currently do most non-randomised education research. That would be a pity.

This trial cost £1.4M. It was well designed and conducted. The result was negative. It should be reported as such.

Jim Thornton

Birth underwater

July 7, 2017

Charkovsky, Odent and Leboyer


For millennia, women lucky enough to live near suitable springs or tropical seas, have sat in warm water to ease their labour pains. But they mostly got out for the birth. This makes sense. Humans are land mammals; as the uterus empties, placental oxygen transfer falls and the baby needs to breathe quickly. Drowning, or short of that, inhaling hypotonic or infected water are both possible. The first doctor to advise a woman to actually give birth underwater was taking a risk.

He was also a charlatan. In the 1960’s a self-publicising Russian healer, Igor Charkovsky – he had a doctorate in yoga but no medical training – began to popularise birth underwater. Some say his original idea was to protect the baby from the shock of emerging from the fluid filled womb into gravity, but it seems he also wanted to toughen babies and mothers up. He advocated birth in icy water, and a technique he called baby yoga, tossing the baby in the air, swinging it by its legs and immersing it under water (click here or here). Sensitive Westerners may find parts hard to watch. At 29 minutes in the second clip, while onlookers stand around in the snow wearing fur hats, a few weeks old naked screaming baby is swung about by his legs a few times and then dunked repeatedly in a freezing pond.

His disciples, of which a few remain, film themselves giving birth in warm tropical seas with soft music accompaniment, and blather on about birthing with dolphins (click here). The sea is big, and dolphins swim in it, so I guess they’re right about that.

But sensible supporters of natural birth, like the late Sheila Kitzinger, condemned Charkovsky’s methods, the authorities caught up with him, and soon he was forced to flee Russia. He ended up in the US, where he was accused of sexually assaulting his adult female disciples (click here).

The next pioneer was more reputable.  Michel Odent, a French surgeon, who also ran the maternity unit in Pithiviers, a small town south of Paris, was a disciple of Frederick Leboyer, who in a famous 1975 book, Birth Without Violence, had advocated labouring (not birthing) in warm water with soft lights and music in the birth room. Odent put Leboyer’s principles into practice in Pithivers, and installed deep and roomy birth pools. Most women got out for the birth but a few didn’t, and by 1983 he had collected 100 cases where the mother had birthed underwater (Odent Lancet 1983). One baby had breathing difficulties and another died suddenly some weeks later. Neither, according to Odent, related to the birth underwater.

Odent left Pithiviers two years later, moved to London, and founded the Primal Health Research Centre to promote his ideas (click here for the Primal Health Research Database and here for a related website Wombecology).  So far as I can see he published no more original research on waterbirth, although he continued to advocate it. Instead he produced reviews and opinion pieces, and about 15 books on various aspects of childbirth, and became one of the fathers of the natural childbirth movement. Some of his ideas are a bit nutty, but few would argue with his general efforts to promote a calm environment for childbirth.  Even I have to admit to a scintilla of sympathy for his “Two sets of commandments for obstetricians” (J Med Ethics 1985 click here).

Leboyer meanwhile, who died last month, also continued to advocate tranquillity in the birth room, and lived to see many of his ideas enter mainstream practice. He continued to encourage warm baths during the long hours of labour, but to the end of his life argued that birth underwater was dangerous: “Waterbirth is completely wrong. To give birth, you need to be on dry land.” (click here).

I think we can all agree that Charkovsky was a dangerous child abuser and con artist.  But what about Odent and Leboyer?  Who was right about birth underwater?

I’m with Leboyer. For humans, birth underwater is a treatment like amniotomy, or oxytocin. It may have benefits, but it also has risks, and should only be offered outside well conducted trials if there is good evidence that the benefits outweigh the harms. There is no such evidence yet (click here for the Cochrane review).

Enthusiasts often rightly point to other interventions in obstetrics, such as the two above, for which the evidence base even now is relatively weak, but which are in widespread use.  Why discourage water birth but not those two?

Answer; we should discourage them too. They are both overused. Amniotomy and oxytocin should be limited to situations where the mother wants labour speeded up, there is evidence to support that (click here and here), and is prepared to take the risk of unintended side effects.

Labouring in a warm bath should be encouraged; it’s a useful method of pain relief. But women should be advised either to get out for the actual birth or for the bath to be drained. A few Odent disciples may want to give birth underwater, and take the risks. I guess they should be free to do so, but there’s no need to encourage them. Gently point them to Frederick Leboyer and Birth Without Violence instead.

Jim Thornton

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