You know those glossy pages in the Sunday paper supplements that tell you what’s going up and down in terms of style?
Well every time I open them I am more and more surprised not to see bacteria featuring in there, given how fashionable our prokaryotic colleagues have become of late.
At first I wondered if I was just hyper-aware of anything that mentioned bacteria because I happened to be studying and writing about some of them. And of course because the much-anticipated Microbirth (2014) film had received lots of attention among midwives.
But I have come to believe that they are actually trending within the midwifery and obstetric worlds.
Furthermore, I think their trendiness could be rather beneficial, and I will explain why I am hoping that the current popularity of bacteria might have a part to play in improving care for women and babies.
How are bacteria portrayed?
May I ask you to think back to your first memories of bacteria being mentioned, perhaps by your parents or teachers? Were they mentioned in a positive or negative light? As benign, helpful and/or harmful organisms? As cells to be feared, celebrated and/or wondered at? Did you get the impression that bacteria were a relatively homogenous group of organisms which could be judged (for good or bad) as such, or did you get a sense of their complexity and variety and the fact that the same bacteria could have different effects in different circumstances? What were bugs called in your house, and what pictures and emotions does that term evoke in you now?
I ask because the things that we learn as children – and, of course, the things we pass on when it is our turn – can have a powerful impact on the way we view and relate to ideas, theories or, I guess, classes of biological organisms. With the exception of a particularly fun and enthusiastic biology teacher who loved to point out the extraordinary value of flies, bacteria and other non-cuddly organisms, my early memories of references to bacteria were almost all based on their potential to harm me. Not that this was overemphasised though, and it certainly never stopped me from spending half my childhood making mud pies, for I am one of those lucky people who grew up in the years before the risk management paradigm took hold, but I don’t recall encountering the notion that bacteria could also be helpful to me until much later. These days, children may be more likely to meet ‘good’ bacteria early on – perhaps in the form of a smiling, happy, child-targeted yogurt pot – although, somewhat paradoxically, they are perhaps also likely to be more familiar with an array of antibacterial cleaning products, both for them and their home.
Does it matter?
I am going to propose that it is vital to ask how, as a culture, we view and portray a group of organisms as essential to our survival as we now know bacteria are. It also seems important to consider how we are experiencing the massive shift in our understanding of these organisms and their relationship with us. It is far too early on in this shift to even think about pre-empting where our knowledge will take us, but I have hope that the insights coming out of areas such as the microbiome project (Turnbaugh et al 2007) will lead to a genuine re-thinking of our knowledge.
If you haven’t yet read a lot about this area, though, or if you keep seeing references to it and thinking you need to look into it more, Reed and Johnson-Cash (2014) have written an excellent overview of emerging knowledge about the human microbiome and the way in which this relates to pregnancy, birth and early mothering, which I highly recommend.
Exploring theories of health and disease
Until recently, Western culture has been very focused on the ‘bacteria-as-bad’ school of thought. Mainstream science and medicine teach Louis Pasteur’s germ theory, and we have learned to value (and thus buy) products and techniques that help protect our bodies from baddies perhaps more than about the ways in which we can proactively support our bodies – and the bacteria which live with us – to help themselves. Many of these ways, out of interest and by contrast, cost very little.
The work of Louis Pasteur is pivotal in the development of modern medical thinking, and yet the thinking of others who offered different but equally interesting viewpoints – with Antoine Béchamp being one example – has been largely ignored. Béchamp, in case you haven’t heard of him, proposed that the health of the terrain – or body – was just as or even more important in the spread of disease as the existence of germs, bugs, naughty bacteria or whatever term you want to use. He and his followers claimed that it is better to maintain a healthy body through good nutrition and habits, as this then deprives harmful bacteria of an environment in which to proliferate.
I don’t know whether, under what circumstances, or to what extent Béchamp’s theories are true. I do know that many people reject his theories out of hand, and that sepsis is a serious issue. But because of the limitations and ramifications of the germ-theory based approach, concerns about antibiotic resistance, side effects and the fact that antibiotics kill healthy strains of bacteria as well as those associated with disease, and because that it is possible to explore a theory for interesting facets without necessarily having to swallow it whole or reject it outright, I think other ideas are worth exploring.
Hope on the horizon
So my first thread of hope relates to the way in which our growing knowledge about bacteria is enabling us to move beyond the one-track, often negative way in which we have come to view these microorganisms that live on us, in us and around us. We are beginning to understand that our relationship with them is not simple or easily packaged up. We are starting to see the complexity of our relationships with bacteria, and that we may need to reconsider what we thought we knew.
Why do we need to re-think?
I am certainly not suggesting that we throw the proverbial baby out with the bathwater (not least because bathing our babies is another area that we need to reconsider), and I want to acknowledge the importance of appropriately detecting and responding to sepsis, as highlighted in the latest MBRRACE-UK report (Knight et al 2014). Pasteur’s achievements were incredible, and we should be grateful to him every time we sip a glass of wine, let alone when we use an antibiotic that is truly warranted. But we don’t have to throw out or devalue his work in order to reconsider elements of it or think about the issues in a more nuanced way. We will soon need a different approach to the current trend of giving incredible volumes of antibiotics to large numbers of people, which is unsustainable in the long term because of antibiotic resistance.
There are many reasons for re-thinking, including that it may help us to get back on track as far as giving effective care is concerned. In Reed and Johnson-Cash’s (2014) overview of emerging knowledge about the human microbiome and the way in which this relates to pregnancy, birth and early mothering, they point to the theory that stress can affect our gut microbiota and ask whether antenatal care should focus on reassurance and relaxation rather than clinical testing and discussion of risk. How many other areas of care could we improve if we could go back to the drawing board?
The GBS example
The prevention of group B strep (GBS) disease is one example of an area in which I believe that a re-think might help us drastically improve the care we offer. Here, we have a situation where a particular kind of bacteria is known to live within about a fifth of people (although testing is not especially accurate, so this figure may not be either) and it causes no harm in the vast majority of situations. It gets passed to about half of the babies born to women who carry it, and most of them experience no ill consequences, but now and again it causes huge and potentially fatal problems for a baby (Wickham 2014). Often, these babies are already compromised, for instance because they have been born preterm, but this is not always the case, so there is no straightforward linear explanation here.
As current methods of screening and treatment require lots of healthy women and babies to be exposed to antibiotics, there is ongoing discussion about whether we could come up with a better response to this problem, with one proposed solution being a vaccine (Schrag and Verani 2013). Yet vaccination also has limitations and side effects, including that it may negatively impact on a woman and baby’s microbiome. To my mind, one of the main reasons that we should also be considering other options is that a vaccine would have to be offered to every woman, too. In an age where we can do almost everything bar make a cup of tea from the comfort of our smartphones (and I expect an app for that will be available soon), can we really not find a way to determine which individual women and babies are at risk – and why – rather than only being able to offer sledgehammer-level treatments to the entire population?
The clues in the question
There are a couple of really tantalising clues which may serve as starting points. One is that, although the currently available research studies are not of premium quality (Wickham 2014), there is a bit of a trend in the studies looking at the various possible treatments for GBS, which include chlorhexidine douching and water birth as well as antibiotics. They show that it is relatively easy to reduce colonisation with GBS bacteria but that this doesn’t necessarily lead to a reduction in GBS disease. This might not be the case if we did better research studies, but even the possibility that the presence of GBS is only one of the factors needed for GBS disease to occur may be worth exploring. It might come to nothing, but we’ll never know if we don’t try.
Another avenue for exploration is that we know from the experiences of women whose babies have had GBS disease that some of these women have low levels of antibodies to a certain type of GBS bacteria. Why not look at that, and ask deeper questions about the terrain, or the way in which our bodies relate to the bacteria that live within us? As I recently wrote, “as long as there is a possibility that GBS disease has multiple causes, or is caused by something else in the presence of GBS bacteria then the best thing that we can do for our current and future babies is to keep our minds open to other possibilities” (Wickham 2014).
I don’t know what these other possibilities are. I accept that the roads I’ve described may not be the exact ones that we need and that we may have to go down lots of cul de sacs before we find a better pathway than we currently have, but I think we owe it to women and babies to keep exploring. And it’s precisely because I think that we should keep exploring that I am so delighted about the focus on bacteria. Because, in my book, anything that helps us re-evaluate and re-think what we think we know is a jolly good thing indeed.
Knight M, Kenyon S, Brocklehurst P et al (2014). Saving lives, improving mothers’ care. Lessons learned to inform future maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009-2012, Oxford: NPEU.
Microbirth (2014) Directed by Toni Harman and Alex Wakeford [Film]. UK: Alto Films.
Reed R and Johnson-Cash J (2014). The human microbiome: considerations for pregnancy, birth and early mothering. Available at: http://tinyurl.com/oo6usbh.
Schrag SJ and Verani JR (2013). ‘Intrapartum antibiotic prophylaxis for the prevention of perinatal group B streptococcal disease: experience in the United States and implications for a potential group B streptococcal vaccine’. Vaccine, 31(Suppl 4): D20-26.
Turnbaugh PJ, Ley RE and Hamady M (2007). The human microbiome project. Nature 449:804–10.
Wickham S (2014). Group B Strep explained, Now updated!
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