Staywellfireyourdoctors Blog | Im a wellness educator and a passionate player in the Wellness Revolu

Web Name: Staywellfireyourdoctors Blog | Im a wellness educator and a passionate player in the Wellness Revolu






description:I'm a wellness educator and a passionate player in the Wellness Revolution. I also happen to be a medical doctor as well, registered to practice in the twin island Caribbean nation of Trinidad and Tobago where I've lived and trained. So my blog is meant to support your process of taking responsibility for your health and realizing that there is a lot you can do naturally to keep well. I believe there is a lot of exaggeration on both sides of the Revolution. There are the narrow minded ultra-conservatives on one hand and the enthusiastic (sometimes marketeering) disbelievers in the medical establishment on the other hand. As I navigate the battlefield my privileged role is to help you make sense of all of this and encourage you to explore and act upon what really counts. I am a mother of two beautiful children and a committed advocate of natural birth and breastfeeding so as I blog the parent in me will reflect that. Personal Development Mindset training overlaps with being empowered to manage your own health effectively so yes! we may touch on this as well. Read on and yes! I do appreciate your reading and feedback whenever you feel moved to give it!
Staywellfireyourdoctors Blog

Im a wellness educator and a passionate player in the Wellness Revolution. I also happen to be a medical doctor as well, registered to practice in the twin island Caribbean nation of Trinidad and Tobago where Ive lived and trained. So my blog is meant to support your process of taking responsibility for your health and realizing that there is a lot you can do naturally to keep well. I believe there is a lot of exaggeration on both sides of the Revolution. There are the narrow minded ultra-conservatives on one hand and the enthusiastic (sometimes marketeering) disbelievers in the medical establishment on the other hand. As I navigate the battlefield my privileged role is to help you make sense of all of this and encourage you to explore and act upon what really counts. I am a mother of two beautiful children and a committed advocate of natural birth and breastfeeding so as I blog the parent in me will reflect that. Personal Development Mindset training overlaps with being empowered to manage your own health effectively so yes! we may touch on this as well. Read on and yes! I do appreciate your reading and feedback whenever you feel moved to give it!

Home About The Blog andBlogger The Bell Jar by Syliva Plath, Exploring SevereDepression

The Bell Jar was published under a pseudonym a few weeks before its author committed suicide.

Isadora, the protagonist in Erica Jongs Fear of Flying, that much talked about novel of the feminist eras hey day, refers to Sylvia Plath, the author of The Bell Jar, with respect and awe  and mentions her sad end, almost as if it were a staged but romantic tragedy  Sylvia was found dead with her head stuck in what must have been a gas oven.

Sylvia Plath was married, had young children and had been a Fulbright scholar at Cambridge University. What did she have to be depressed about? Severe depression is not at all logical. Lesson #1.

Having read The Bell Jar and been moved by it I can now say I recommend it highly for anyone who has a friend or relative suffering from severe depression and is perplexed and frustrated by the condition.

Severe depression is not the sadness, irritability and frustration we all experience when life is not going our way. Casually, we have a bad day and we say we are depressed. In reality, severe depression is an absolute distortion of balanced thinking, not fully comprehensible by those of us blessed enough never to have experienced it. It is irrational and unless we accept that severe depression does not respond to logic, we may find our attempts to be pragmatic and supportive frustrating and futile.

As I read The Bell Jar it became apparent to me that the author did not create the details of her book from her imagination.

Nobody could possibly describe an experience of overdosing on sedatives (and the semi-conscious experience of being found and brought to hospital and there examined), so vividly, without having had first hand experience.

She was retelling her own battle with severe depression, her attempted suicides, her experiences at psychiatric hospitals as a young woman in the days of insulin treatments and ECT shock therapy (electric shocks to the brain attempting to cure various psychiatric conditions).

A quick look at her online biographies confirmed that Sylvia Plath had indeed been writing her own life story, perhaps as a catharsis, perhaps in an attempt to be instructive to those of us who will not experience the torture of depression. The Bell Jar is a work of fiction, but in the autobiographical style. The similarities in the events befalling young Esther Greenwood in the Bell Jar and Sylvia Plath herself are striking and unveiled.

As Esthers story, brilliantly written in the first person, unravelled, I remembered conversations with a friend who tried to describe what depression felt like. I remembered a relative who had been transformed from normality to a shadow, a wisp of her former self, both in body and spirit. I recalled that acute lonely pain that persons who are depressed try to express but often hide because no-one, absolutely no-one, could possibly understand it.

This is depression, as told by Sylvia Plaths Esther:

That afternoon my mother had brought me the roses.

Save them for my funeral, Id said.

My mothers face puckered, and she looked ready to cry.

But Esther, dont you remember what day it is today?


I thought it might be Saint Valentines day.

Its your birthday.

And that was when I dumped the roses in the waste-basket.

That was a silly thing for her to do, I said to Doctor Nolan.

Doctor Nolan nodded. She seemed to know what I meant.

I hate her, I said, and I waited for the blow to fall.But Doctor Nolan only smiled at me as if something had pleased her very, very much, and said, I suppose you do.

And painfully, as she is discharged from the psychiatric hospital, the asylum as it was called before the world became politically correct:

Doctor Nolan had said, quite bluntly, that a lot of people would treat me gingerly, or even avoid me, like a leper with a warning bell. My mothers face floated to mind, a pale, reproachful moon, at her last and first visit to the asylum since my twentieth birthday. A daughter in an asylum! I had done that to her. Still, she had obviously decided to forgive me.

Well take up where we left off, Esther, she had said, with her sweet, martyrs smile. Well act as if all this were a bad dream.

A bad dream.

To the person in the bell jar, blank and stopped as a dead baby, the world itself is the bad dream.

A bad dream.

I remembered everything.

[..recounts memories]

Maybe forgetfulness, like a kind snow, should numb and cover them.

But they were part of me. They were my landscape.

What I find useful about the novel is that it guides us through Esthers slide into depression in such a way that we can see, feel and experience how she begins with disinterest and boredom, how she slips into isolation and confusion, how she dissociates into someone else, into almost nothingness, how she seeks to defend herself against those trying to help her and how nothing, absolutely nothing makes any sense in the face of being totally incapacitated by her feelings.

To end I will share a little from the first chapter, which at first reading might seem unremarkable, though it foreshadows the grim slide which will follow.

Look what can happen in this country, theyd say. A girl lives in some out of-the-way town for nineteen years, so poor she cant afford a magazine, and then she gets a scholarship to college and wins a prize here and a prize there and ends up steering New York like her own private car.

Only I wasnt steering anything, not even myself. I just bumped from my hotel to work and to parties and from parties to my hotel and back to work like a numb trolley-bus. I guess I should have been excited the way most of the other girls were, but I couldnt get myself to react. I felt very still and very empty, the way the eye of a tornado must feel, moving dully along in the middle of the surrounding hullabaloo.

Sylvia Plath is gone now, but her contribution to bringing depression to light remains alive and outstanding.

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After Ramadan The Pursuit of GreatHealth

While we know the central purpose of the Ramadan fasting is developing taqwa or God Consciousness, (Sura 2, ayah 183), Muslims often ask if the Islamic fast conveys health benefits – and if so, what these benefits are.

When the digestive system receives a rest, the entire body and brain benefit from the responding change of hormones. A key example is in the reduced frequency of food leading to release of less insulin.

Is this a good thing? Well, it might surprise you to know that chronically high insulin levels are a forerunner in various disorders, most famous of them being Type II diabetes! So yes, the reduced insulin levels are beneficial!

(So let’s not offset this benefit by overeating at suhoor and iftaar!)

The extra time spent with the Quran is calming, rejuvenating to the mind and reduces stress. Today the relationship between a relaxed spirit and a greater capacity to maintain health has been demonstrated by researchers looking both at prevention and handling of illness.

So between Ramadan and the Quran are Muslims generally healthier than the average human being?

A mischievous but useful analogy would be to ask, are Muslims generally more pious than the average human being?

Even if we avoid major sins and fulfil our fard duties it takes real focus and effort to remain God conscious, to restrain our tongues from venting sarcastic, suspicious or angry words when silence would be better, to avoid acting out of pride when we have been slighted or offended, to immerse ourselves in the Quran regularly and to be sure that Allah (swt’s) direct message is guiding the steps that make up the grand construction of our short lives.

And likewise, doing our best for the physical health of body and mind is easier in theory than in practice.

As in spiritual matters we are distracted and forgetful.

One trim, youthful looking, energetic middle aged Imam, once said he would almost consider that actively safe guarding our health is fard. He clearly felt that a life of eating carelessly, excessively and with little physical exercise is just not befitting of the Muslim.

Allah (swt) tells us to eat of the good things which He has provided for us (2:172) and that he who strives is not on a rank with he who sits still. (9:19-20)

Clearly we can maximise our striving if we maintain better health, allowing us more energy and focus!

Though we live in a nation where food is abundant for most, many things get in our way of limiting our eating to “the good things.”

Greed and lack of exercise account for some of the dangerous, extra pounds we carry but the extra fat can pile on quite innocently. Consider this ironic example:

I have witnessed patients despair when they find after cutting out almost all fat from their diet (eggs, dairy, red meat, vegetable oil, avocados, nuts), their cholesterol and body weight have not come down and worse – may have increased!

Extreme diets are always counterproductive. Without fat, certain vitamins we need to maintain balance cannot be properly absorbed or utilized. Moderate amounts of fat help to provide calories and curb hunger. Without fat we find ourselves filling up on excessive amounts of bread, rice, snacks and even fruit. Most of these are refined carbohydrates (those found in processed rice, flour and sugar are dubbed bad carbs), which in excess slow down calorie burning and promote storage of food as fat instead. And too many refined carbs increase your cholesterol! What a vicious cycle! The bad carbs of course are innocent of what we accuse them. Changes in our food supply and eating habits have simply caused them to be scapegoated. After all they never asked to be produced or eaten to excess!

Most of the cholesterol in our bloodstreams (about 80%) is produced by the liver. We tend to forget this and focus instead on cholesterol intake from food. You may have noticed that many people who suffer high cholesterol do not indulge in full fat dairy, eggs or red meat on a regular basis but their cholesterol remains high.

Cutting down on refined carbs, increasing fruit and vegetable intake, including fish in our weekly diet and regular exercise will do a lot more to improve our overall health, energy and cholesterol levels than anything else. Why? Because these foods, together with exercise, stimulate our liver and fat cells to get their cholesterol production just right, whereas too many refined carbs stimulate just the opposite.

My favourite book for really giving us a great understanding of how what we eat impacts our health! Learn more at

So minimising sugar intake is a smart move. However when we choose artificial sweeteners for our drinks and desserts we are enjoying the taste of sweet without the burden of the calories. But to what end?

More recent research tells us that these sweeteners are not associated with weight loss. Worse, some are linked to weight gain! How could this be? Our bodies respond to the taste of “sweet” in anticipation of calories to come and our metabolism (the complex system by which our bodies determine how best to burn and balance energy) receives the signal to “store energy!”

Similarly low fat, low sugar “diet foods” leave the body expecting to be satisfied by real calories. So we return to the fridge, in a craving, bingeing mode, urged on by our confused bodies.

So part of our problem is that we don’t always distinguish “good food” from “bad food”, especially under all the deceptive packaging and advertising.

Three simple guidelines help us navigate a safer path amidst the food traps. One is to eat variety.

Fresh herbs contain a range of phyto-nutrients. Phyto-nutrients refers to vitamins, minerals and countless other beneficial compounds found in plants. We are at the early stages of identifying phyto-nutrients and understanding their contribution to health. Don’t wait 40 years for the details to be unravelled! Be sure to use a range of fresh and dried herbs in your meal preparation.

Some of mine. The bay leaves were from a friends garden. Of course we can grow our own herbs on our kitchen window sills. Even bay leaf trees can be grown in a pot.

Likewise, different vegetables offer different phyto-nutrients. You may love tomatoes and cucumbers but they cannot offer you the benefits of patchoi, cabbage and string beans. Ginger, garlic and carailli will have their own range of benefits and so on. Don’t bore your palate if it means undermining your health.

Many of us reject red meat in favour of chicken and fish but again variety should be our guide. Red meat is rich in certain essential minerals eg chromium and selenium. And these are two of the very minerals many of us lack today. Chromium is necessary for maintaining blood sugar balance and selenium is used to generate anti-oxidants.

Though excessive red meat consumption continues to be linked to ill health the link is much stronger for processed meats so minimising sausages, burgers and deli meats is key. Beyond that, considermoderation, rather than a complete elimination of red meat. Moderation is the second guideline.

The third is to seek out food which is fresh, minimally processed and naturally sourced.

This is where knowledge collapses in the face of busy schedules and modern living! We seem to be at the mercy of the food industry and grocery retailers. Some of us no longer have time to cook our own food, far less to research how it’s processed and what standards and practices hundreds of farms adhere to.

To return to fresh, minimally processed and naturally sourced food, thought, planning, co-operation and innovation are imperative. At best, it may take more than a decade of dedicated work and education (if enough of us start now), before healthy food becomes widely available again.

Here in the UK there are some who are working towards this very vision. One grocery chain routinely seeks to include food sourced from farms near its branches. This grocery chain includes a cookery school for their membership (customers and staff) to promote the art and joy of good cooking. Some organizations have cropped up to promote small scale local farming and even individual gardening, arguing that this is essential for long term food security and for reducing the energy burden caused by importing and other transport of food.

Perhaps some young entrepreneurs will lead the way to making fresh, minimally processed and healthier food more available in the Caribbean and elsewhere, so guideline no.3 will be simpler to follow.

While excellent nutrition is the basis of optimal health, we can never have optimal health while our bodies are starved for physical activity.

Muscles that aren’t used simply shrink and this is partly why many middle aged and elderly men and women have difficulty sitting on the ground and getting back up, even without arthritis. Shrunken muscles leave more weight to be carried by our joints, especially those of the spine, hip and knee, making injuries and arthritis more likely.

Fortunately exercise at any age will benefit our muscles. Our muscles can be redeveloped.

Wanting to lose weight motivates some of us to exercise.

For others, the wish to reduce heart attack or diabetic risk or to lower blood pressure can drive the commitment to exercise.

But those of us who don’t have these immediate or medium term goals can be quite laissez faire about keeping active.

Especially if we are young, slim and busy, exercise might take a backseat.

Consequences of this error in judgement may be just around the corner. Whether or not weight creeps on, lack of exercise leads to weakened immunity and lower energy levels. Supplements, coffee and “energy drinks” cannot do the job of the physical tune up we really need.

The term “fat skinny people” describes slim people with sedentary lifestyles (too much sitting) who therefore have low percentage muscle for their weight and height. This lifestyle places them at greater risk for the very same heart disease, diabetes, high blood pressure and cancer risk typically associated with being overweight.

When we increase our percentage muscle we immediately improve our overall metabolism. Translated: our bodies become more efficient at burning energy whether we are sleeping, exercising or working at our computers.

Regular exercise of any kind improves our muscle mass. There is no need to aim for the body builder look.

You may have heard of Metabolic Syndrome. With Westerners sitting more and gaining further weight, Metabolic Syndrome is ever more common and of grave concern, is even being diagnosed in children. Three of the following are enough to define the syndrome: high blood sugar, high triglycerides, low levels of good cholesterol, high blood pressure and waist circumference over the safe limit.

Regular exercise steers us away from metabolic syndrome. The time to get busy is always now. Have we emphasized this enough?

I had a neighbour in his seventies who went for a game of tennis every morning, weekends included.

I remember our hajj group leader being older than all of us in his hajj group but he was the most energetic too. He went swimming regularly and fasted twice a week. Being over 70 was no excuse for him.

Such fitness does not occur overnight. Like taqwa, it requires disciplined and dedicated pursuit.

For those who love physical activity, keeping up with gym, football or running 5K races might come naturally but what of the rest of us?

We too need regular activity that we enjoy. Many start off walking with friends. Soon they find that they can walk further and faster. This is indeed progress but jogging and running should only be added with the correct guidance. Poor posture, hard surfaces and the wrong shoes can lead to injuries which handicap further exercise, defeating the cause.

Gradually introduce more than one form of exercise since different types of activity work different muscle groups. One way to ensure all muscle groups are covered as well as cardio (the type of exercises that improve heart, vessel and lung capacity) is to join a gym.

Start where it’s easy and build from there. Eg start with 15 minutes of walking five days a week. With time, progress beyond aerobic exercise (eg cardio exercises walking, jogging, cycling, running, swimming), to include strengthening exercises (eg gym with weight bearing activities, yoga, pilates) and exercises that include stretching and relaxation.

Recently, a group of middle aged sisters decided to learn to swim. They simply arranged private swimming lessons with a female swim coach at one of our local pools, using burkhinis for modesty.

Consider that starting to walk for exercise at age 60 reduces Alzheimer’s risk and improving muscle strength reduces bone risk, so better a late start than none at all.

Those with medical conditions eg arthritis, heart disease, amputations and the like, can be referred by their medical professionals for professional guidance to get started.

Finally, fasting twice a week (but not two consecutive days), has been in the health news recently. Though Muslims have had this prescription for 1400 years, some medical researchers are now recommending this simple approach to help with weight loss, improve blood pressure, blood glucose and cholesterol!

Eat sensibly, exercise regularly, fast twice a week. Safeguard your health. Enough said.

Initially published in the anniversary magazine, San Fernando Jama Masjid Celebrating 100 years 1913-2013 as Health after Ramadan. Published October 2013

Re-published on this blog with minor edits and photos added.

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Im Calmer Than I used toBe

At the beginning of 2014 I said my most important health goal was to be calm. I knew I was uptight and angry enough to be impacting my health and longevity adversely. When you have chest pain or a headache after a brief spell of shouting you have been warned.

I even bought a book on stress management (which Im yet to use), as an Eid gift to myself in 2014. A year later, I do have plans to use it over August though. After all, a goal is just a dream until you pin it down with a time frame and write it down somewhere.

Anyway, despite declaring my goal to stay calm publicly, I failed spectacularly. Truth be told I was more bad tempered in 2014 than I think I have been in my whole life.

And I could see how it was affecting my relationships with my children. I wasnt setting the example I wanted them to model. And of course they were modelling the example they had.

I felt that the solution was to make time for myself, for deep breathing and focus. I included this in my affirmations on my iPhone reminders  which of course I rarely read. Of course that desperately needed 20 minutes daily of Me Time yoga was exactly what I knew I needed. Except that I never found time for the yoga and my joints are reprimanding me even as I type this.

Something else happened though.

Ive been calmer all year, all of 2015 that is. What happened?

Its hard to put my finger on it but I do believe that a critical factor was a new routine that allowed me 1 or 2 days a week away from the home front. With my mum at home with my toddler I had time weekly to attend to my driving lessons, catch up with friends and write, write, write. Im at least one third through the first draft of my first novel and most of the work has been done beginning in November of 2014.

Emotional challenges are complex. Sometimes its hard to put our finger on the one change that will make all the difference.

I didnt need 20 minutes of yoga; I needed time to be the person I believe myself to be. There was a dissonance between the person I see myself as and the woman toiling endlessly in and out of the house, almost exclusively for her family. Some women cope well with an exclusive role as care-giver and domestic engineer. Others dont.

The message here is a bit like the one I shared from Peter Bregman some months ago:

When change is needed we cant change a thousand things at once. But often there is one thing that if changed, will make a world of difference.

Try to approach health challenges like that. What is one thing that you can change which is likely to make a big difference?

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The Doula-Added Experience

At the end of pregnancy a woman’s body ushers her precious passenger into the world. Muscular contractions of the uterus soften, thin and ultimately transform the cervix often called the ‘mouth of the womb’ into an open gate through which a tiny human can pass.

Yet as eager as a woman may be to meet her new baby she may be dreading labour and birth.

Fortunately this dread can often be resolved well before birth. For many, the key to overcoming fear is to perceive labour and birth as natural processes that are made easier to work with by positive attitudes and with practical strategies.

While the attitude of every mother-to-be is a force influencing whether she faces birthing with confidence or anxiety, including a doula in her birth plans is an excellent strategy.

It may have been my midwife in 2006 who explained to me what a doula was and recommended the then-very-new doula service to me. I was excited to hear that doula support was associated with shorter labours, less medical intervention and fewer Caesareans. But what exactly is a doula?

The word ‘doula’ is derived from the Greek for ‘woman servant’ but a doula today is a trained professional, usually a woman, who provides emotional and physical support during labour and/or after pregnancy. The Doula Alliance of Trinidad and Tobago charmingly describes the doula’s role as “mothering the mother.”

My own mother had been a reassuring presence during my first labour. Her back massage and aromatherapy oils had worked wonders. She had been the unofficial doula for my first birth. But she lived abroad and my concern that she might not arrive in Trinidad in time for the birth of our second bundle of joy was a driving force behind my decision to have a doula.

And so Mags entered our birth story.

In the weeks before our baby’s birth, Mags and I got to know each other and we discussed the natural pain relief strategies she could make available.

Honestly, I was confident about being able to manage the ‘discomforts of labour.’ After all, for my first birth, I’d used certain labouring positions and visualizations from my birth preparation classes and they had worked. I was simply planning to use them again.

But in the end, somewhere in the more intense phase of labour I realised that the strategies I had used the first time round didn’t fit the experience I was going through and I had no back-up plan. However Mags did. She presented a birthing ball for me to sit on just when I needed it and later, warm compresses for my back.

She helped keep me focused at that challenging point in labour just before the actual emergence of the baby through the birth passage.

Mags was completing her training when she attended my son’s birth yet her impact was so positive I’ve been recommending having a doula (and Mags herself if she’s available), ever since.

I remember her being not just well-intentioned, as a friend, father-of-the-baby or mother might be, but also skilled and professional. Years later she holds an important place in our birth memories.

Manghanita Kempadoo was our first doula but will forever be part of a positive birth memory! We snapped this photo when she came to visit our newborn in the days following his birth.

Fast forward to 2013. A third pregnancy and another doula Zara.

This time I was preparing for a homebirth.

A few relatives asked me frankly why I should need a doula. After all, my mother and husband would be available to rub my back and I wasn’t new to the birth process. This was a reasonable question.

My answer is that a doula can identify and use more pain relief strategies than a loving family member. She comes with training, regular experience and she too comes with love. The work of a doula involves intimate work with an unknown woman at unpredictable hours for possibly days at a time. The remuneration is humble so the work is vocational, a labour of love.

Importantly too, a doula can support a labouring mum without excluding other relatives or friends. In fact meeting with my husband to discuss what he felt his involvement in the upcoming birth should be, was something Zara did very early in our relationship.

Though today’s man is often expected to be a key labour support person (once the hospital allows him to be present), and some men do embrace this opportunity, others would prefer to stand-by or be called in after the birth of their baby. Unfortunately men can feel socially pressured to be involved beyond their comfort level.

A doula can help take the pressure off baby’s father by helping him identify how he can participate at his comfort level while ensuring that mother has the support she needs.

Thanks to a few planned “chat sessions” with Zara I was better able to focus on mentally preparing for the birth. Zara made gentle suggestions which in the end I used with no regrets.

She was keen on hypnotherapy as a tool for a peaceful and natural birthing experience and so loaned me a hypnobirthing book and CD that I used in my preparations for the big day.

My birth prep stash! Including some bits on loan from Zara.

In the end, knowing that my doula could get to my house (or the hospital) in half-an-hour, that she understood and respected my birth plan and would be able to gently advocate for the written plan to be followed (should I be rendered speechless by contractions), gave me great peace of mind. A woman in labour needs to focus on her task at hand – and arguing rationally with medical personnel is hardly a distraction she can cope with effectively.

Our birthing room this time turned out to be our bedroom.

The intense phase of this labour was very brief but Zara was brilliant in helping me to keep calm and reminding me to breathe appropriately. Some people grumble that no-one needs to be reminded to breathe but I breath-hold unconsciously under stress and some people create a panic cycle by hyperventilating, so simple breathing techniques in labour can be useful.

Zara used a light feathery massage which took the “edge off” the final and most trying surges. Ironically, I had been adamant in our pregnancy discussions that light massage is irritating- but what was amazing is that she knew (intuition or experience?) exactly what I needed at moments when I had no access to words.

Overall, I sought and received peace of mind and help with natural pain relief methods from my doulas. However, what doulas offer is much broader in scope. The soothing and coaching to dissolve fear and anxiety, or encouragement provided for a particularly difficult or lengthy labour can be critical in helping a mother to persevere. I’ve had friends who found doula support priceless for labours that took place in hospital or ended in Caesarean births.

Doulas also extend their services to the period after baby’s birth, helping with breastfeeding in the critical early weeks.

Zara De Candole

Visiting on Day 12

To learn more about accessing doula support in Trinidad and Tobago do contact the Doula Alliance of Trinidad and Tobago via Facebook, call The Mamatoto Resource and Birth Centre at 621-2368 or email

Birthing and labour memories can be especially wonderful when mothers access the right preparation and support!

First published in the April-June 2014 issue of UHealth Digest, Issue 25

Photos above included for this blog but were not used in the original publication.

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The Test That Women DoesDo

Symbolic of the poor state of cervical cancer, this ribbon is made of a burst rubber band on a backdrop of a cheap paper towel!

Cancer of the cervix begins with great benevolence.

It gives us a chance to spot it long before it becomes a fully-fledged cancer.

Yet until the Pap smear becomes a routine part of our lives we are giving our chance at derailing cervical cancer early a slap in the face.

Too many of us just aren’t sure what a Pap smear is.

One perky, young UWI graduate, teaching at an all girls secondary school asked me if the Pap smear had something to do with her ovaries!

Another well-spoken woman, already at least 40, couldn’t remember the words ‘Pap smear.’ She referred to “The Test That Women Does Do,” specifically “the one” that Family Planning people do at health events.

Very simply, the Pap smear simply scrapes some cells off the cervix surface. (alliteration not intended!) In layman’s terms the cervix is known as ‘the neck of the womb’. This part of the womb is easily accessed as it hangs into the vagina so the nurse or doctor can both reach and see it once the vaginal passage is held open with a speculum under good lighting.

(A speculum is a simple flattish but rounded instrument smaller in diameter than an erect penis. For the Pap smear it’s lubricated with gel and at this point I emphasize that the speculum’s only crime is that it is often a bit cold! The dread it conjures in ladies’ minds is most unjustified!)

The cells scraped off for testing are then fixed on a slide and sent for microscopic evaluation by a cytologist or pathologist.

Though cancer cells, infections and even the presence of the human papilloma virus may be indicated when the test report is prepared, these are not the reasons you go for a Pap smear.

You go because cervical cancer develops slowly enough to be caught and arrested while the cells are still transitioning through varying degrees of dysplasia. Dysplastic cells are abnormal cells which don’t yet have the full characteristics or behavior of cancer cells.

Women who postpone their Pap smears indefinitely or who choose to believe that going every five years is okay, run the risk of missing the window of opportunity to arrest transitioning cells, long before they become frankly cancerous.

The nurse or GP will typically refer abnormal Pap smear results to a gynaecologist.

In these earlier stages, the gynaecologist advises on the right protocol for your case often based on a further more sensitive test: colposcopy.

Some mild changes that a Pap smear might reveal, especially with younger women and teenagers, are often self-reversing and need only be monitored, but always ensure that your gynaecologist gives you clear follow up advice and answers all your questions.

So now you’re saying, “Oh thank God! If I go for regular Pap smears the chance of treating and removing any unwelcome changes very early is much higher!”

So how regularly should you go? Recent US guidelines suggest that all sexually active women over 21 should have Pap smears. How often? Some practitioners will say for women under 30 every two years is enough. Others prefer that you get tested every year till you have a record of three normal consecutive smears, after which testing frequency will depend on your individualized risk.

The professional advice given considers risk factors such as chlamydia infection, the presence of HPV virus, cigarette smoking and having several partners.

Especially if you are under 30 though, the possibility of cancer seems so remote and distant that it’s easy to procrastinate and make excuses.

Remember, cancer does not happen overnight. While most women with cervical cancer are not under 30, the early changes that lead to closer evaluation and life saving removal of dyspastic tissue can be found in women still in their 20’s and early 30’s.

The risk of cancerous changes in the cervix are higher for women who smoke cigarettes, started sexual activity very young or had many partners.

But all women who are sexually active (or used to be) should reduce their risk by having routine Pap smears.

So no matter how monogamous or inexperienced you’ve been, take the precautions. Don’t equate lower risk with zero risk!

One way to overcome any fear and awkwardness is to go with a girlfriend or relative who had a positive Pap smear experience.

Once you’re relaxed and your practitioner has the basic skill required, a Pap smear is at worst, mildly uncomfortable.

On the other hand, if your practitioner is rough, rude or just makes you uncomfortable then you need to get some advice from your girlfriends about who else you can go to.

You have the right to keep a trusted friend, relative or female nurse present for your Pap smear.

If your local health centre does not offer the service every week to large numbers of clients your Member of Parliament needs to know that the government service is inadequate and putting lives at risk.

Costs of private care can be prohibitive. A visit and Pap smear can easily cost $450.00 at the gynaecologist. You may need to budget and plan for it just as you might do for school fees, a vacation or a new car.

For those on the UWI campus though, the service may be available at UWI’s Health Service Unit.

And if not, is there a good reason? Is it that campus girls are known to prefer having their pap smears done off-campus? And for the young researchers among you as well as the campus activists, has this question ever been studied?


This article was first published in The Campus Chronicles last edition. It has been edited slightly before re-publication on this blog. The Campus Chronicle was a short lived newspaper and this article was published in its last edition in November 2011.

The Campus Chronicle was published with the readership of Trinidad and Tobagos tertiary education students in mind.

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But is The HPV Vaccine theAnswer?

Is the HPV vaccine the answer to cervical cancer? It was under development when I was a medical student in 1997. I remember first hearing about it and being immediately excited about the possibilities. I had seen the misery of death by cervical cancer and I was aware of the woeful state of Trinidad and Tobagos Pap smear service so a vaccine that could do to cervical cancer what the polio vaccine did to polio certainly sounded like something to do cartwheels about.

(Pity I never learned to do cartwheels; Im too chicken now we become increasingly comfortable with our incompetencies as we grow older).

But now that the vaccine is here and routinely offered in the UK while vigorously opposed by many in the UK, is it the answer we were hoping for?

My short answer is that time will tell.

When I told my darling gynaecologist that I was dedicating myself to wellness education he said cheerily that I could include the promotion of the HPV vaccine in my work.

I gave him an appalled look. I cant recall the brief interaction that followed but hes an easy going fellow whose expert opinion I respect  yet we didnt agree on this.

Individuals, both friends and strangers, (possibly mischief makers amongst those strangers) have emailed me asking me for my view. Should they vaccinate their daughters? Are the concerns about the risks pure hysteria?

It seems likely that some of the vaccine reactions were hysterical and some of the deaths were pure co-incidence. True believers in the vaccine might want to protest that all the reactions and deaths were hysteria and co-incidence.

Let me stress two things:

1)  I am not Anti-Vaccine. My three children follow the standard vaccine schedules. I have declined receiving or giving my children the flu vaccine and the rota-virus vaccine. I simply did not accept that they were necessary. I do not give them pain killers or antibiotics that are not necessary and I do not give them vaccines that are in my humble opinion unnecessary.

2) Its rare but fatal reactions to vaccines have been known to occur, just as fatal reactions to anaesthetics and penicillin have been known to occur. Nobody says stop the use of anaesthetics or penicillin because of these unlucky deaths.

Would I vaccinate my daughter? If she were 11 now the answer is no.  But in 9 years time when she is 11, I do hope that well have enough information available for me to make a decision with confidence.

These are the questions that I hope will be answered by time and by diligent, honest research, record keeping and clinical experience. It may take more than nine years.

a) how many doses are required to achieve immunity? We were told three but more recently were told that one is enough!

b) does immunity really last more than five years?

c) are boosters needed?

d) should the vaccine be given to everyone or is it better health economics to give it to groups at higher risk?

e) were all those reported neurological reactions hysteria? Were they within the range of rare reactions that are statistically acceptable

f) does receiving the HPV vaccine make women more careless about going for Pap smears

g) how has HPV incidence changed for groups who were vaccinated?

Why am I not simply running with the vaccine, which after all, is approved by authorities such as the WHO, government health departments and leading gynaecologists?

Well honestly, after you read Dr. Ben Goldacres fact-filled Bad Pharma, you might be cautious too. In Bad Pharma, Dr.Goldacre, an Oxonian who wrote for The Guardian and works for the UKs NHS, points out that transparency, integrity and ethics are not pillars of todays pharmaceutical industry. Bad Pharma is a disturbing book and if anything, it illustrates just how vulnerable both doctors and the general population happen to be when it comes to making decisions about new drugs and vaccines. Theres misinformation and theres missing information.

The shocking inside story of how devious, corrupt and unethical the pharmaceutical industry happens to be.

Having induced a healthy scepticism into your thinking I cant help but mention a technical article I found on line. It was published in November 2010 in the Journal of Vaccines and Vaccination. Its a 7 page article available as a pdf on for readers who can make sense of the medical jargon.

The article is a Review of Gardasil (the main HPV vaccine in use in the USA). Its written by Professor of Medicine Diane M. Harper who declares her relationship with various pharmaceutical companies in the context of vaccine research. Despite this relationship, her paper is clear that expected benefits remain modest for now.

Could she be underestimating it all? Cellular biology does not always read the research papers. Time will tell.

In the long term discussion of the usefulness of the HPV vaccine, may transparency and the best health outcomes win.

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The Poor Sister of BreastCancer

This article was written in 2011 but has never been published in full before. Nearly four years later, the general message, that theres a lot of work to be done to reduce the incidence of cervical cancer, particularly in the so-called developing countries, remains relevant.


Dr. Gordon Narayansingh used his characteristic dry humour to illustrate why cervical cancer should rightly be described as the “Poor Sister of Breast Cancer.”

Dr. Narayansingh was speaking at the first Oncology Update Conference at the Hyatt last Sunday when he pointed out that this year breast cancer had a Breast Cancer Month. In previous years they had Breast Cancer Week and Breast Cancer Day. Next year, he added, might be Breast Cancer Year.

But who is running for Cervical Cancer?

The doctor, Trinidad’s only gynae-oncologist at present, made his point with statistics collected from our Cancer Registry over 1997-2006. During this time breast cancer accounted for 2960 cases of which 44 women died but cervical cancer claimed 55 lives despite only 1226 cases.

With a higher number of deaths from fewer cases, clearly cervical cancer is the more deadly of the two for us here in Trinidad and Tobago.

He supported this observation with more extensive data from Central and South America where cervical cancer accounts for vastly fewer cases but similar numbers of deaths compared to breast cancer.

While we panic about young women getting breast cancer, 15% of breast cancer cases are under 50 whereas 50% of cervical cancer cases are under age 50.

The tragedy of this is that it can be prevented. In the United States cervical cancer is the thirteenth most frequent cancer among women whereas it ranks as the No.2 most frequent in Trinidad and other less developed nations.

Why? Dr. Narayansingh explains that two-thirds of all local cases are diagnosed in an advanced stage so complete cure is less likely. This is so because only 25% of our women go for regular Pap smears.

He told a heart breaking true story of a 40 year old mother of two who went for her Pap smear only to be turned away repeatedly from the health centre because she was having “vaginal bleeding”.

The take home lesson for all of us is that all abnormal bleeding must be assessed by a doctor. This story reflects a clear deficiency in the knowledge and understanding of the workers who turned the client away. They may not have been able to do the Pap smear but she should have been assessed and treated.

Even when clients are properly channeled, due to lack of technical skills, Pap smear reports are delayed and so are follow-up investigations. We have a need for more skilled cytotechnicians to read Pap smears and gynaecologists who can perform colposcopy, an investigative procedure that may be needed after an abnormal Pap smear.

So laboratory and medical students, and those in planning and management pay attention!

Dr. Naraynsingh lamented that in the public sector, Pap smear reports can take up to three months with existing ineffeciencies. He emphasized that he was not to be accused of running a smear campaign against the system though! By stating the facts he hoped to stimulate a “Pap Smear campaign,” instead.

He estimated that in addition to regular Pap smears, we could follow the example of the developed countries and include routine vaccinations against HPV (the human papilloma virus) believed to be the underlying cause of cervical cancer.

Since most people who are sexually active will contract strains of the HPV virus during their lifetime, some of which are cancer promoting , he advocated vaccinating young girls in the 9-15 category to stimulate immunity against HPV before they become sexually active.

He said bluntly that we are a society of “hypocrites”. We say “my daughter is not going to have sex” yet our culture is one of “wining and prancing” on Carnival day.

Introducing the HPV vaccine should not be about sex but about saving lives. He felt that with bulk purchases, a rough estimate of the cost of annually vaccinating our Form One school girls would be just TT$9.6 Million, significantly lower than the cost of providing laptops at TT$35 Million.

He estimated we could save three lives per year that way.

Not one for mincing words or keeping his opinions to himself, Dr. Narayansingh couldn’t help but add that of the eight graduates of the University of the West-Indies Medical Faculty who went on to become gynae-oncologists, he was the only one serving in Trinidad.

He described the “pain” of the situation and called for a programme to encourage locals to come back to Trinidad and Tobago to serve their country, not merely in sub-specialties like gynae-oncology but across the board.

Notwithstanding word from the “developed world” that TT can now boast of being a developed country, Dr. Naraynsingh suggested that our progress in defeating cervical cancer should be a marker for true development.

Dr. Gordon Narayansingh

I agree with him and by that measure, we are not there yet.

Since the emerging youth are going to be the ones with a key role in changing this I hoped there were lots of student doctors, nurses and pharmacists in training present and internalizing the message.

The 1st Oncology Update Conference was facilitated by the Trinidad and Tobago Medical Association under the auspices of the University of the West-Indies.


The HPV vaccine was made available in the public health sector of Trinidad and Tobago the following year (2012), though its introduction was not without controversy and there remains such opposition to it. The HPV vaccine had been available to private clients who were able and willing to pay for it prior to 2012.

The Pap smear, which is an established tool in reducing the incidence of cervical cancer when used effectively in screening programmes worldwide, remains underutilised in Trinidad and Tobago. For many women, the steep cost of having the test done privately is prohibitive and the local health centres are yet to make the service widely available via a dedicated service.

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Breastfeeding With HIV, is Breast Still Best? Interview With Expert PamelaMorrison

It is 1995. HIV/AIDS is still adolescent, having burst into world consciousness less than 15 years ago. In upscale Zimbabwe a woman is newly diagnosed as HIV-positive and she is distraught. Her eight month old baby is refusing the bottle. He wants the breast but unknown to him, his mother’s breasts have just been deemed dangerous vessels capable of delivering to him a deadly virus. His mother has no way of knowing if she has already transmitted the virus to her son. Nor does she know how risky it will be to continue nursing him.

She turns to Pamela Morrison, an international board certified lactation consultant in the capital, Harare. But Pamela does not know the answers. Neither do the doctors at the Ministry of Health.

This was the heart churning encounter upon which Pamela Morrison began her quest to have the right answers about infant feeding for women who carry the HIV virus. Twenty years later Pamela continues the mission of counselling and guiding HIV positive mothers, though now with the guide of formal policy and the wisdom of decades of accumulated evidence standing behind her.

I caught up with Mrs. Morrison while she was working and waiting – waiting for the birth of her first grandson. She was not too busy to share with us.

Here in Trinidad and Tobago and the Caribbean, the idea of breastfeeding by HIV positive mums would come as a surprise to many as policy here tells these mums to avoid breastfeeding and use replacement milk formula instead. This contrasts with some resource-poor countries where formula feeding is not a safe option due to formula costs, lack of access to clean water and basic sanitation. In this scenario it is actually safer for a baby’s HIV positive mother to breastfeed her baby, even if she is not receiving anti-retroviral therapy (drugs that suppress the HIV virus, which we will call ART for short). We asked Pamela about this.

“The fact that in the absence of anti-retroviral therapy 85% of HIV-exposed breastfed babies do not become infected has always intrigued researchers. Certain factors in mothers’ milk serve to protect a baby from postpartum HIV transmission and in fact, over 2000 patents have been taken out on the components of human milk, many of which are being developed or genetically engineered as anti-AIDS drugs.”

Pamela lists off several protective components. You don’t have enough fingers to count them all. Breast milk is a living, active substance. Consider human milk oligosaccharides, an abundant component, concentrating on the surfaces of the infant’s gut. There it “serves as a decoy receptor to inhibit HIV binding, a prebiotic promoting the growth of desirable bacteria, and a probiotic to protect against HIV transmission.” Don’t we love it when the good guys win? Pamela tells more, “Then there is bile salt-stimulating lipase, a major human milk glycoprotein, which functions in milk lipid digestion and inhibits viral invasion, including HIV transfer to CD4 T cells. Lastly there have been recent press reports about a host protein called Tenascin-C in breastmilk which was found to neutralize HIV binding, and which helped to explain why the majority of HIV-exposed breastfed infants are protected against mucosal HIV-transmission.”

Yet HIV is sometimes transmitted by breast feeding, despite Mother Nature’s strategies for protecting infants. Without ART and supportive guidance from health care workers this occurs in roughly 15% of cases. By contrast, where optimal ART and health care are received by mother and infant, transmission risk is slashed below 1%, to almost zero. Independent of ART, exclusive breastfeeding makes a tremendous difference to the safety of breastfeeding for babies of HIV positive mothers. Countries with policies that encourage these mothers to breastfeed promote exclusive breastfeeding rather than mixed feeding since mixed feeding makes transmission so much more likely.

Pamela explains, “Exclusive breastfeeding means that the baby receives no other foods and liquids apart from prescribed medicines for the first six months of life. Premature introduction of other foods and liquids to the baby before age 6 months leads to disturbances of normal gastrointestinal flora,[ie the bacteria that are supposed to be in the gut and serve as a guard against harmful bacteria], exposure to dietary antigens, and inflammation resulting from infection with pathogens, all of which result in small sites of trauma and inflammation in the lining of the infants gut. When the infants compromised gut is exposed to HIV in breast milk the damage allows the virus to enter the bloodstream. Exclusive breastfeeding for six months not only reduces the risk of HIV transmission, it also reduces a childs chances of acquiring other diseases.”

In Trinidad and Tobago cultural practices include cleaning a new baby’s tongue daily with honey or among Muslims, giving the newborn a taste of something sweet, like a bit of a date that has been pre-chewed. Do such habits undermine exclusive breastfeeding?

“Indeed they do, for the reasons just described and even where concern about HIV is not a factor such cultural practices increase the risk of infection.   It might also be worth pointing out that honey is not recommended for babies under a year because of the risk of botulism. [a rare form of food poisoning that can lead to paralysis and death]. Pre-masticated [pre-chewed] food has also been shown to be a risk factor for HIV-transmission if the person feeding the child is HIV-infected.”

Pamela is currently based in the UK where formula feeding is the recommended policy for infants of HIV positive mothers. In the UK, as in Trinidad and Tobago, exclusive breastfeeding for the first six months is not a cultural norm. Indeed, far from it. So it does come as a surprise to know that the UK has guidelines for HIV positive mothers who want to breastfeed. The history that Pamela gives us may surprise even more: “It’s currently estimated that 72% of HIV-positive mothers in the UK were born in countries of high HIV prevalence where breastfeeding is the norm and where decisions about infant feeding and weaning are often made by extended family members, rather than by the mother herself. Formula-feeding identifies these mothers’ HIV-positive status to their communities within the UK. Furthermore conditions for safe formula-feeding may not be sustainable for HIV-positive mothers who are also asylum-seekers, or in detention centres. Those deported receive only enough formula for the flight home. [with their infants placed at sudden risk of under nutrition and life threatening infection] Consequently the British HIV Association (BHIVA) and the Children’s HIV Association (CHIVA) held a public consultation to take the views of health providers, mothers and others about whether the guidance prohibiting breastfeeding, should be changed and in 2010 it was.

“Current BHIVA/CHIVA pregnancy management guidelines include recommendations for combination antiretroviral therapy (known as cART) during pregnancy and the option of managed vaginal delivery for women with an undetectable* HIV viral load at term. Thanks to these interventions, mother-to-child HIV transmission is now very low, at 0.1%. The current BHIVA/CHIVA infant feeding guidelines, issued in November 2010 permit breastfeeding in a mother who really wishes to do this.

“The impact of these revisions has been profound. Now it is possible for HIV-positive mothers to discuss their wishes with their clinicians and make evidence-based decisions on which method of delivery and feeding would be safest for them. And then they can receive support to breastfeed as safely as possible if that’s the feeding method chosen.”

This is a welcome relief from the extraordinary scenarios that previous policy led to. “Because such a high percentage of HIV-positive mothers in the UK were born in Eastern or Southern Africa where breastfeeding has very important cultural and traditional significance, when these mothers are advised not to breastfeed it causes considerable stigma and distress. There have been reports of mothers hiding in their bedrooms, afraid to let family and neighbours see them bottle-feeding! Furthermore, in the past, when parents appeared to be refusing planned interventions such as bottle-feeding, it was recommended that children’s social services become involved.”

Devastatingly this meant making legally binding arrangements to “protect” the newborns by removing them from their mothers’ care. In the Caribbean formula feeding carries no stigma but carrying the HIV virus certainly does. In fact, this stigma is such that many HIV positive parents would choose the increased risk of other chronic diseases (diabetes, high blood pressure, breast cancer) to the low risk of HIV, if given the choice of how to feed their babies. So in our society formula feeding the baby of an HIV positive mum seems like the most sensible thing to do. Besides this, the other chronic diseases strike in later life and can be warded off by sensible lifestyle habits. What does Pamela say to this?

“In countries where formula-feeding is commonly practised, it would be fair to say that the culture accepts that bottle-feeding carries little risk to health, whereas the small risk of HIV transmission through breastfeeding tends to be exaggerated. As you point out, formula-feeding is not without risk, even in highly industrialized countries and almost every health outcome is improved for breastfed babies. For instance, a UK study published recently showed that exclusive and sustained breastfeeding could prevent 53% and 27% of hospitalizations due to diarrhoea and lower respiratory tract infections respectively.”

I have witnessed the tragic misery and suffering of infants dying of AIDs in the late 1990’s, before the Prevention of Mother To Child Transmission (PMTCT) programme was established, after which transmission to newborns was sharply reduced. The key tools of this programme were testing pregnant mothers, giving ART during pregnancy and labour and providing formula free of charge for their infants. No matter how we argue that breast is best and HIV is just a chronic disease, it’s a disease that can only be managed by expensive long term use of drugs that do have side effects. Isn’t the small increased risk introduced by exclusive breastfeeding too much risk in a nation where replacement formula has been made available and infant death due to infectious disease is the exception and not the rule?

Pamela is cool, rational as ever. “I think it’s difficult to oppose these arguments. As we discussed, in many industrialized countries, formula-feeding is seen as a perfectly acceptable lifestyle choice and there is the perception that a 1% risk of transmission of HIV through breastfeeding is 1% too high.   The tragedy of the HIV and infant feeding debate is that there is neither a clear benefit to one course of action nor a clear risk to another. In fact it’s quite the opposite: it’s always been a dilemma of competing risks. The best that we can hope for is that each mother can make a decision about how to feed her baby, in consultation with her doctors, who can provide her with enough background research to make an informed choice on the least likely risk to her baby in her circumstances.”

Generally, free and informed choice is the ideal we aspire to. In matters of health and safety though, public policy sometimes dictates the course of action to be urged, sometimes even enforced. The World Alliance for Breastfeeding Action (WABA) supports current the World Health Organisation’s guidelines, urging countries to have one main policy for HIV positive mums (exclusive breastfeeding or no breastfeeding). The guidelines sway counsellors away from placing the burden of choice on mothers.

Pamela says, “The World Health Organisation (WHO), says infant feeding practices should support the greatest likelihood of infant HIV-free survival. WHO believe that national or sub-national health authorities should decide whether health services will principally counsel and support HIV-positive mothers to either breastfeed and receive antiretroviral interventions or avoid all breastfeeding. The decision should be based on the socio-economic and cultural contexts of the populations served including the main causes of maternal and child under nutrition and infant and child mortality.”

Pamela adds that a colleague of hers once suggested that this “should be further tailored to the needs of particular areas – eg in areas of Trinidad and Tobago where economic conditions are such that the population resembles the poorer nations, then child survival might well be best served by a recommendation to breastfeed. Where mothers’ living conditions are more like those enjoyed by mothers in wealthy nations then the recommendation not to breastfeed might be justified. In other words, maximizing child survival will require tailoring recommendations to each mother’s unique and individual circumstances.”  

This of course sounds reasonable and logical but policy change must be guided by hard facts. An article by Anna Ramdass in the Trinidad Express of October 4th 2012 described higher than expected infant mortality statistics for Trinidad and Tobago with progress in reducing these figures lagging behind other Caribbean islands but this article reported no actual proven connections between HIV, formula feeding and death by infectious disease.

Backing away from policy discussions and returning to the sphere of personal choice, now that HIV transmission has been shown to be less than 1% when mothers with undetectable viral loads breastfeed exclusively for the first six months and wean from the breast around baby’s first year, are mothers who know this asking to breastfeed? “Yes, indeed, they are. An increasing number of mothers have become aware of the up to date research results, and seem to be putting two and two together; if – thanks to provision of current anti-retroviral therapy and knowledge about the protective effects of exclusive breastfeeding breastfeeding in the context of HIV carries such a low risk (stated to be virtually zero) then they are keen to explore with their healthcare providers whether they can safely breastfeed, and they are asking for help to do so.”

Such interest is coming not only from the UK and the African continent but from North America, Australia and from countries as resource rich as Denmark and Germany. As a lactation consultant yourself, you continue to counsel and support clients directly. What would you say is the role of the lactation professional in supporting HIV positive mothers?   “I think the role of the lactation professional is two-fold. Firstly, it is to provide information. I receive queries from HIV-positive mothers, or their breastfeeding counsellors from all over the world. They are all searching for enough information to protect individual HIV-exposed babies. Usually these mothers want to breastfeed, but healthcare providers citing out of date studies showing a high risk of transmission are warning against breastfeeding.   I feel that my role is to share with my clients the most up to date information and research that I can find so that they can discuss this fully with their own doctors. Ideally, a decision will be reached that will keep the baby safe, that the mother is happy with, and that the clinician can support. Secondly, if the decision is made for breastfeeding, then the lactation professional can work with the mother to make sure that she “manages” her own lactation in the safest possible way. In this respect, the HIV-positive mother is no different from any other mother in that she needs information about breast and nipple care, about individual variations in her milk production from day to day, and how to be reassured that her baby is getting enough breast milk. Over 99% of mothers have the capacity to exclusively breastfeed their babies, ideally for the first six months- but in the context of HIV exclusive breastfeeding is especially important and it is vital that the mother knows how to avoid and remedy common breastfeeding problems. It is not difficult to help mothers achieve this happy outcome.”

Due to the fear of stigma I can imagine an HIV positive mother seeking the support of a breastfeeding counsellor or consultant while withholding her HIV positive status. “Yes, I’ve worked with mothers who I’m almost certain knew that they were HIV-positive but would not tell me. When a mother seeks help with breastfeeding, the lactation consultant or breastfeeding counsellor is extremely privileged to be invited to share in a very intense and special time as the mother gets to know her newborn. But when a mother is being less than frank, it could have a profound impact on her baby’s health and survival. It may not be appropriate for such a mother to be encouraged to go on providing small quantities of breast milk (effectively mixed feeding) if she finds she has trouble with exclusive breastfeeding. Yet we would certainly recommend this strategy to enhance the health of the baby when the mother does not have HIV, but if she has not disclosed her status, this would absolutely be the wrong advice. I want to give individual mothers the very best information, tailored to their circumstances, that I can. I can’t do that unless she’s absolutely open with me. It’s times like this when I would like to see HIV recognized as just one more medical condition, like say diabetes, or Crohn’s disease, rather than something shameful to be hidden.

“Ideally the disclosure about positive HIV status would come at the earliest opportunity so the breastfeeding counsellor can give the mother the information which is most relevant to her and her baby, and so that we can supply references and journal articles etc. for her to share with her doctors.   We are all working for the same goal – a happy healthy mother with a happy healthy baby and it can be a very positive experience when we all work together.”

  *undetectable viral load or levels refers to extremely low levels of HIV virus in the body fluids of someone who is HIV positive. It does not mean that the person is cured and continued use of Anti-Retroviral Drugs is required to maintain these low levels.  

Pamela Morrison began her career as an international board certified lactation consultant in Harare in 1990. While in Zimbabwe, Pamela also worked as a BFHI Facilitator and Assessor, as well as serving on the Zimbabwe National Multi-Sectoral Breastfeeding Committee and the national BFHI Task Force. She has also served on the World Alliance for Breastfeeding Action (WABA) Task Forces for Children’s Nutrition Rights, and for HIV and Infant Feeding, and the ILCA Ethics Code Committee. After moving to England in 2005, she was employed until 2009 as a Consultant to WABA. She is currently the ILCA media representative on HIV and continues to do volunteer work for WABA.

This interview was first published by Fresh Start in the December 2014 issue. Here is the link to the original article:

The photograph of Mrs. Pamela Morrison does not appear in the original article. Warm thanks to Mrs. Adepeju Oyesanya, editor of Fresh Start for suggesting it and for the very generous and knowledgeable and meticulously professional Mrs. Pamela Morrison for sharing her time, experience and expertise.

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Pregnancy and Birth Across The Pond: From Trinidad toLondon

The long walk to the Women’s Health Department in the Sutton hospital was almost déjà vu. The physical building resembled that of Port-of-Spain’s General Hospital. I suspected both institutions had been designed in the same era.

In many ways, public health care in Trinidad and Tobago resembles the UK’s National Health Service (NHS). Both systems are state funded, claim to be under financial pressure and are heavily criticized by the public they serve. The NHS today is frequently in the spotlight with problems that are old thorns for Trinidad’s General Hospitals: unacceptably long waiting times at the Accident and Emergency; overcrowded wards; patients unable to access non-emergency care at their local centres; shortages of doctors; questions over expenditure by administration; client deaths linked to inadequate care.

It’s well known that the human resource element in Trinidad and Tobagos public health system has not in recent decades been able to support its clients by spoiling them for choice.

I chose private care for my first and second pregnancies in Trinidad because this allowed me the luxury of choice; which doctor or midwife to see; when to schedule appointments; which hospital to choose; what to include in my birth plan; if to have a doula; even some choice over my post-birth breakfast menu!

I wanted to avoid the unpredictability of being attended to by various strangers. Relationship building takes time but builds trust. Trust facilitates confidence and confidence makes birthing easier, on the mind, if not on the body.

For my third pregnancy I found myself living in the UK. I chose to be a client of the overburdened NHS for my third pregnancy, would I be satisfied with my options?

Well, the policy of the NHS is to encourage home births where possible since studies of UK and similar populations show that home births cost less but add no significant increased risk for “low risk pregnancies.”

Waiting to see the midwife for the first visit 12 weeks into my pregnancy, I found myself in torrents of tears after looking at the cards and photographs posted on the walls from families that had chosen home births. An emotional bomb had hit me unexpectedly. Underneath the nausea and fatigue there was a little human being under development who would, by God’s Grace, be joining us just six months into the future. Reality hit home.

The midwife loaded my answers to her numerous questions into her computer programme. The programme did its analyses, reducing the error of human misjudgements. I was deemed “low risk” and a candidate for home birthing. This, despite me being almost two years short of the big Four Zero!

I was thrilled.

The midwife who was responsible for managing home births in the area was an amazing woman. Like my obstetrician in Trinidad, she gave me all the time in the world when my questions needed to be asked and my anxieties needed to be addressed.

She emphasized my right to choose a home birth. She showed me the assessment criteria for home birth to be met towards the end of the pregnancy but expressed her conviction that the client’s right to choose should prevail. She referred to women who did not meet the criteria but whose preference for home births was respected despite contradicting medical advice; one woman was diabetic; another was giving birth for the seventh time. “We cannot refuse to come, once we have the staff,” she insisted.

Pregnancy care under the NHS offers more routine screening blood tests (including assessment of body iron stores and degree of Down Syndrome risk) and shorter waiting times than typical community health centres in Trinidad and Tobago. On the other hand, under the NHS low risk women have half the number of routine clinic visits on their schedule and perhaps because I never appeared over or under weight I was only ever weighed once.

To my surprise and horror I was expected to bring urine in a narrow glass tube supplied by the clinic, wash the tube and use it again for the duration of the pregnancy! Yes, the NHS has been under great pressure to manage its expenditure but I have to admit their system is more environmentally friendly than the use of styrotex cups!

Midway through my nine months I learned of a card for pregnant women which entitled me to free medicine and dental care for the pregnancy and first year after baby’s birth. Well off I went to the dentist, grateful for my savings of a few hundred pounds and mindful of the money previously spent because I did not know about this ‘pregnancy privilege!’  There were no doctors at the community clinics I attended so though the midwife could recommend iron, she couldn’t write a prescription and I had to wait my turn at the GP’s office again – or pay at the pharmacy.

I took the tour of the hospital’s labour ward and birthing centre. It was delightful to have the option of a water birth in a private room at a birthing centre but in the end the attractions of a homebirth won me over. In theory I could have rented my own birthing pool and had a water birth at home but the labour proceeded so efficiently when it did get going that I doubt I would have even made it into any pool.

Gentle Birth Choices by Barbara Harper, a must read if you are interested in birthing naturally and in understanding waterbirth! I really wanted a waterbirth after reading this and after being introduced to the subject at the Mamatoto birthing centre in Belmont, Trinidad. But in the toss up between the inconvenience of renting or buying and filling (then emptying and maybe selling) a pool at home, versus using the waterbirthing facilities at the hospitals birthing centre in Sutton, home birth pool free actually won! Any my early labour was so long while my active labour was so short, there would have been no time to get in and out of the pool anyway!

After the birth, our doula (labour support person), made the midwives tea and brought them fruit and chocolate wed set aside for them as refreshments. We took photos together. NHS policy emphasises the role of the midwife in helping mother and baby to get started with breastfeeding and the midwives were happy to wait for baby to have her first feed before weighing her.

She was remarkably calm. She nursed and slept and was unperturbed by the activity and conversation around her. And if it wasnt for our doula we would have had no photos of her first hour as her grandma and dad are not camera enthusiasts!

Midwives and the district health visitor made at least four visits to our home in the two weeks that followed. It was wonderful not to be roasting our newborn at the bus stop in what was a sweltering hot summer. It was comforting to know that the system actively searches out mothers at risk of postnatal depression. The home visits also seek to help and support breastfeeding and even though this was my third time with a nursling, they had some useful reminders and assurances for experienced mums too.

Despite the conscious efforts by midwives both in the UK and TT to encourage, inspire and support breastfeeding, not many women breastfeed exclusively for the first six months. In the UK new mothers are less likely to have the family support needed to facilitate sustaining breastfeeding and despite knowing that best is breast, despite baby latching on and breasts full of milk,  the sheer quanta of time required to breastfeed means that many busy mums even stay-at-home mums are defeated before they begin.

Reading about breastfeeding is a useful part of preparing for your new baby. You wont have time to do much of it once the little one arrives.

Read as much as you like but be sure to attend birth preparation classes too! Nothing replaces the insights of experienced women. Nothing replaces the sharing and caring, the camaraderie amongst pregnant women. The Birth Book by US paediatrician Dr. William Sears and his wife, registered nurse and midwife, Martha Sears.

You may have thoughts of pumping and working but dont rely on optimism or even on Gale Pryors brilliant book, Nursing Mother, Working Mother. By all means, learn what you can from books such as this one but your strategy and how best to execute it must come from women whove done it successfully, from understanding the obstacles you might face and maybe even from working with the breastfeeding counsellors and consultants whose experience and guidance can sometimes be a make or break factor.

While breastfeeding and ‘low tech birthing’ for low risk mothers with adequate antenatal care are cost effective for the national purse, in Western society freedom of choice is upheld as a sacred principle. Yet with dire predictions that nations’ health bills will be strained by ageing populations heavy laden with Alzheimers’, cancers and other chronic diseases, will a push towards natural birthing and breastfeeding be forced into policy? And isn’t policy impotent all by itself? In the UK, home births and exclusive breastfeeding remain the exception and not the norm, despite the policy support they enjoy.

For women to embrace breastfeeding and low tech birthing as gold standards to be aspired to where possible, the following would be imperative:-

Conveying the information and reassurance needed for women to embrace such options with conviction.Providing adequate and flexible maternity and paternity leaveProviding easily accessible and relevant antenatal classes for allProviding workplace support for mothers who wish to pump milk at workProviding competent and widely accessible breastfeeding support for mothers after birth.New training and retraining for a wider cadre of supporting health care workers.

This article was first published by Fresh Start, the on-line magazine of Best Start, the breastfeeding and advocacy organisation run by the very dedicated and amazing Adepeju Oyesanya. Thankyou for the privilege of publishing with Fresh Start, Adepeju.

The article was first published on page 20 of Fresh Starts May 2014 edition, link below:

The original publication did not include the photographs that are part of this post.

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Moments of Pregnancy; Love, Tears andMagic.

When a woman confirms her pregnancy, how does she feel? Elated, excited, depressed, disappointed, surprised? Or none of the above. She might just feel numb. And here friends, is where we begin.

You and your baby are unique and your first forty or so weeks together are too. Your thoughts, feelings and experiences may be nothing like what friends and relatives expect for you. As I write this I’m carrying pregnancy #3 and it certainly has not been just the same as for #1 or #2! So you don’t have to feel excited, thrilled and expectant in the first weeks or months. It’s fine if nausea and uncertainty overshadow everything in the early days. If you are miserable, find that trusted friend to talk to.

It’s possible to have an enviable “perfect pregnancy”, marked only by a change in body shape (sexier than ever as the months go by), an increase in appetite and maternity leave forms but for many women having a “normal pregnancy” there are all sorts of changes. Fatigue might hit you for six. “How could a creature the size of a kidney bean be making me so tired?” you ask. Give it a rest, mum. Baby Making is hard, detailed and technical work. So sleep when you need to. The world will continue without you. If necessary, accept help without guilt should it come your way. There’s plenty of time to return the love with kindness of your own when you are feeling better.

Interest in sex sometimes (thankfully not always), drops to an all time low in the early months. Do reassure your partner that this won’t last forever. Acknowledge and respect his feelings even if you can’t accommodate them. Remember he might be silently panicking, imagining being pushed aside, replaced by his baby. Tell him the truth: lots of women feel a resurgence of their sexiness and desire by the middle of the pregnancy. Could he just be patient and loving till then? And by then with your growing tummy, you might have to find new twists on old positions in order to make sex work for both of you!

Many mums-to-be find that nausea and vomiting resolve by mid-pregnancy if not after the first three months. However mid-pregnancy may bring with it aches and pains as the weight of your child takes a toll on stretching ligaments and back muscles. Gentle stretching exercises taught at antenatal classes, but also available on-line and in popular books like “What to Expect When You Are Expecting” go a long way towards strengthening muscles and reducing discomforts.

Sadly I was often too tired to find the time for more than a few of these exercises myself but go for it if you can!

Still, with a bit of lower back pain each time, I did make time for The Cat and it always made a positive difference! Source: Yoga for Pregnancy

Baby’s movements by mid-pregnancy increase your bonding with your little one. For some women warm feelings and positive anticipation don’t begin till the movements do. Later, baby’s movements can be felt – and sometimes even seen by baby’s daddy and siblings, making the baby more real in their minds and helping them too to begin bonding.

As pregnancy progresses women often worry if all the fat gained will ever be lost. After all, so many mothers blame their pregnancies, often their very first or only pregnancy, for fat that hangs on for several decades to come!

Here are two strategies to help you make sure your pregnancy fat is useful fat that will be lost in good time:

  #1 Eat healthy during pregnancy and afterwards. Minimize or cut out fried foods, sugar, sugary drinks and sweeteners and ensure daily intake from all food groups. Be guided by appetite, avoid delaying meals and stop when full. Weight gain should then be only what your baby needs from you during pregnancy.

And for strategy #2 breastfeeding! You may well slip back easily to your pre-pregnancy weight after just 6 months of exclusive breastfeeding! It’s true that birthing and breastfeeding are all natural.

As birth approaches, genuine fear and anxiety about birthing are not uncommon. Many women don’t feel an unwavering confidence in the ability to breastfeed. I admit to nagging doubts in my first pregnancy. After all, I have a low tolerance for pain. I would never even prick myself with a pin for a dare. How then could I endure labour? I remember hearing my first labour story at age 11. It lasted 18 hours!

As for breastfeeding, suppose I couldn’t remember the pictures in the book showing me what a correct latch-on looks like for a nursing baby? Suppose it was all too much for me? And when you hear the doubts rehearsing themselves in your head, that’s your signal to get the support you need.

For me the solution was in finding friends and midwives who built my confidence with their own experiences and knowledge. When a friend affirms, “I nursed both my daughters for two years, no regrets,” then you think, “Oh, if you did, maybe I can too.” “These women chose a completely natural childbirth,” says the midwife with a quiet confidence. And then you find yourself in a deluge of your own tears as you see them birthing, supported by midwives and then holding their newborns, on the videos and slide shows. You start to believe that maybe you are the agent to birth your baby. You stop seeing yourself as a would-be victim of a painful, unpredictable event. “In these sessions we’re going to learn how you and your birth partner can cope with the discomforts of labour. And these exercises will help your body be better prepared.” Wow! Tears fill your eyes again. This was just what you were looking for!

In addition to birth preparation classes, lactation classes are also available. Lactation classes allow you to explore breastfeeding and build your confidence with professionals who can also assist you during the first 6-8 weeks of nursing baby when new mums have the most doubts and are most likely to give up.

The first few weeks after birth are usually challenging in one way or another. Resolving as many areas of uncertainty as possible in advance of your precious arrival is a sensible investment.

Breastfeeding By Sheila Kitzinger was the first breastfeeding book I ever read. Its worth ordering on-line. I was blessed to find it in a local bookstore 12 years ago. I couldnt read it without inexplicable tears though. Almost every picture of a nursing baby and mother caused the tears to well!

Penelope Leachs amazing book Your Baby and Child, Birth to Five Years is a must read as birth approaches. It also makes a great baby shower gift. For me, the beautiful pictures provided another source of choking up on tears!

Yet there’s an emotional fortress that you build from real live human support that you can’t get on-line or even from books. Seek it out.

Perhaps in pregnancy we acquire an increased emotional sensitivity for the purpose of connecting both with other mothers and our own babies. So powerful is this sensitivity that you may find yourself feeling connected to mothers and their children everywhere. You shed tears over a mother losing her child to war half the way around the world or for a six year old you never knew personally recently diagnosed with leukaemia.

Later, in the hustle and bustle of parenting your new born, your awareness of this connectedness may fade, but in truth it is one of the most precious lessons that pregnancy teaches us. We are one species and we are connected by sadness and pain, by joy and love, by our common humanity.

This article was first written and published for Fresh Start, the e-magazine of Omo and Best Start. It appears on page 7 of Fresh Starts August 2013 issue under the title Mummy Matters. Please see the link below in which there are several other articles of interest!

I do thank Mrs. Adepeju Oyesanya for blessing me with the opportunity to share these thoughts and nuggets with my pregnant sisters everywhere. Feel free to share away. Motherhood in all its breath and depth, connects the human spirit like few other things do. We are one in our common humanity and foolish to so easily and often forget our oneness.

The above article has been expanded and edited slightly and all photos are of books from my personal library and were not part of the original publication.

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I'm a wellness educator and a passionate player in the Wellness Revolution. I also happen to be a medical doctor as well, registered to practice in the twin island Caribbean nation of Trinidad and Tobago where I've lived and trained. So my blog is meant to support your process of taking responsibility for your health and realizing that there is a lot you can do naturally to keep well. I believe there is a lot of exaggeration on both sides of the Revolution. There are the narrow minded ultra-conservatives on one hand and the enthusiastic (sometimes marketeering) disbelievers in the medical establishment on the other hand. As I navigate the battlefield my privileged role is to help you make sense of all of this and encourage you to explore and act upon what really counts. I am a mother of two beautiful children and a committed advocate of natural birth and breastfeeding so as I blog the parent in me will reflect that. Personal Development Mindset training overlaps with being empowered to manage your own health effectively so yes! we may touch on this as well. Read on and yes! I do appreciate your reading and feedback whenever you feel moved to give it!

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