Scans and Caesarians cost money and lead to more work: Better to risk a dead baby
Right up until the day she gave birth, Niki Cunningham was told she could expect to have a perfectly healthy baby.
Though a routine scan at 12 weeks found her placenta was lying low in her womb — and might block the birth canal — by her 20-week check-up she was told it no longer posed a problem as her womb had enlarged.
When Niki, 29, a financial adviser from Budleigh Salterton, Devon, suffered bleeding at 32 and 34 weeks, she was sent home from hospital, the cause undiagnosed, and told not to worry.
‘It is heartbreaking to discover all it would have taken was an extra two minutes to check and Harry would be here with me now,’ said Niki Cunningham
‘It is heartbreaking to discover all it would have taken was an extra two minutes to check and Harry would be here with me now,’ said Niki Cunningham
So when she went into labour in June, three weeks before her due date, Niki had no reason to expect anything but a happy outcome.
But half an hour after her waters broke, her baby’s heart rate dramatically dipped and Niki suffered heavy blood loss, prompting doctors to perform an emergency Caesarean.
It was already too late. The moment her son Harry was born, weighing 6lb, it was clear he was critically ill.
‘I couldn’t move because I was paralysed by the epidural. ‘All I could do was look at the concerned faces of the medical staff and beg them to tell me what they meant when they said he was “extremely poorly”.’
As the medical team fought to resuscitate Harry, a doctor explained that the baby had suffered major blood loss because the umbilical cord — the lifeline that carries blood, nutrients and oxygen from the mother’s placenta — had torn.
For the next 24 hours, Niki could only watch helplessly as her son underwent six transfusions to try to save his life.
The next day, Harry was handed to Niki and her husband Jamie to hold for the first — and last — time as his life ebbed away.
Niki was discharged from the Royal Devon & Exeter Hospital the same day.
She refused to believe Harry’s death was ‘just one of those things’. She researched on the internet and discovered her case was not as rare as she’d been led to believe.
Her pregnancy had been complicated by vasa praevia, where the blood vessels of the placenta grow abnormally and rupture, resulting in the infant starting to bleed to death.
Far from being unusual, this condition is conservatively estimated to affect more than one baby in the UK every day.
Worse still, Niki discovered vasa praevia can be diagnosed easily during pregnancy — leading obstetricians say almost every baby affected could be saved if delivered by a planned Caesarean before labour starts.
Furthermore, the technology to scan for the problem is available at almost no extra cost to the NHS.
In vasa praevia, either the umbilical cord does not grow into the middle of the placenta as it should, but attaches around the edge of the placenta, leaving the blood vessels exposed; or the placenta develops in two parts and the blood vessels grow to connect these parts, sometimes over the entrance of the birth canal.
In both cases, this leaves the blood vessels at risk of rupture as the baby is born.
In an estimated six out of ten births affected by vasa praevia, the baby dies of blood loss — those who survive may suffer conditions such as cerebral palsy as a result of being starved of blood and oxygen.
The latest guidelines by the Royal College of Obstetricians and Gynaecologists, published last year, say the condition could affect one in 2,000 pregnancies — but adds it may be ‘under-reported’.
A study by the Showa University School of Medicine in Japan puts the figure as high as one in every 350 pregnancies — which would mean it affects 2,800 babies a year in Britain.
One of the main reasons it’s believed to be underestimated is because many neonatal deaths are put down to unspecified haemorrhaging.
Furthermore, in a third of stillbirths the cause of death is never established, according to SANDS, the neonatal death charity.
Women who have had a previous Caesarean or any type of uterine surgery are more at risk because scarring can make it more difficult for the placenta to get the nourishment it needs, and it grows abnormally.
Most in danger of vasa praevia are women who have conceived by IVF — the rate of pregnancies affected could be one in 300.
This is probably because the embryo is artificially implanted lower down the womb than with a natural conception.
The technology to test for vasa praevia is available on all modern ultrasound machines, through Doppler colour scanning.
Sonographers switch it on when they want to look at the speed and direction of blood flow, often if a baby is small.
But leading experts say the same technique can and should be used to check routinely how the umbilical cord attaches to the placenta and to check for blood vessels over the entrance to the birth canal.
Indeed, Niki underwent Doppler scanning at 20 weeks, but it was not used to check how Harry was attached to the placenta because this is not part of NHS guidelines.
As Niki says: ‘It is staggering, and heartbreaking, to discover all it would have taken was an extra two minutes to check and Harry would be here with me now.’
In order to raise awareness of this, Niki has decided the picture of her son’s final moments should be published.
Yet in its last review four years ago, the National Screening Committee — the body that draws up scanning guidance for the NHS — decided there was not enough evidence to justify adding vasa praevia to the list of conditions mothers are scanned for, even for those in high-risk groups, and it would cause mothers too much anxiety to know more about it.
The Royal College of Obstetricians and Gynaecologists fears vasa praevia may be wrongly diagnosed in around 15 per cent of cases.
This would lead to unnecessary anxiety for mothers-to-be who would end up having Caesareans they don’t need.
However, one of the world’s leading experts in antenatal care, Professor Kypros Nicolaides, of King’s College, London, says that while vasa praevia is still thought of as a ‘rare condition’, ‘it is more common than Down’s syndrome — which accounts for one in 600 pregnancies. ‘Down’s is no longer thought of as rare and is screened for by the NHS.
‘There is a fear in the NHS that mothers will need to be hospitalised for the weeks leading up to birth. Vasa praevia is not generally a problem until labour.
‘And this can be avoided with a Caesarean. Screening will prevent infant deaths and disabilities.’
As with Niki Cunningham, for Daren and Natalie Samat, from Great Missenden, Buckinghamshire, the diagnosis came too late.
Natalie underwent four years of fertility treatment before she became pregnant using IVF. The couple were not informed of the risks.
Even when Natalie, 41, a former lawyer, suffered frequent bleeds — often a symptom of vasa praevia as the vessels start to stretch — and underwent 18 ultrasound scans to look for the cause, vasa praevia was not suspected.
Their baby, Henry, died soon after his birth in 2005. The couple were told what had happened was rare.
Daren, a criminal barrister and spokesperson for the charity UK Vasa Praevia, says: ‘One of the objections to adding it to the national screening programme is that telling women about this condition would cause them unnecessary anxiety. ‘But I don’t know a mother who would not rather know about this, so they at least have the opportunity to manage that risk.’
A small number of NHS units are using their Doppler scanning machines to check for vasa praevia. Private antenatal clinics also offer checks for between £130 and £180.
West Middlesex University Hospital has been scanning all pregnant women for the condition for the past three years. Elizabeth Daly-Jones, advanced ultrasound practitioner at the hospital, says: ‘If we take the time to screen, 97 per cent of these babies will survive.’
Niki Cunningham, who has a son, William, two, and hopes to conceive again, says: ‘I just can’t understand why at one of my scans, for example, they spent ages checking to see what sex Harry was. ‘That time could have been spent diagnosing a condition that took his life. ‘As quickly as I said hello to my son, I had to say goodbye.
‘I don’t want anyone else to go through this — for the sake of an extra two minutes on a scan, no one else would have to.’
Mother-to-be lost baby after staff at midwife-led birthing centre neglected her
Ill baby froze to death
A couple slammed the NHS after losing their tiny daughter just six hours after she was born, claiming she should have had better treatment. Kate Seren Stanton-Davies died on March 1, 2009, after suffering from a rare pregnancy condition in which blood leaks from the foetus into the mother.
Her mother Rhiannon Davies, 38, a technical writer from Ludlow, Shrops., suffered complications in the last month of her pregnancy which lead to a series of hospital trips and tests.
Just two hours after being born at Ludlow Community Hospital, tiny Kate suffered a collapse and was flown by the West Midlands Air Ambulance to Birmingham Heartlands Hospital where she died at 4.05pm the same day.
On Friday, an inquest jury at South Shropshire Coroners’ Court unanimously concluded that the baby would have survived if she had been delivered elsewhere, and the decision by clinicians to treat Mrs Davies’ pregnancy as low risk contributed to Kate’s death.
Mrs Davies and her husband Mr Stanton, who got married in December last year, described the care given to Kate as ‘a complete and utter catastrophe’, and say everything which could have gone wrong did.
Speaking after the inquest, Mrs Davies said: ‘Lessons must be learned and change implemented to ensure no other family has to endure what we have been through.
‘Throughout my pregnancy and Kate’s birth we, as a family, have been let down by the various organisations within the NHS. ‘Knowing what we know now I would never have consented to have given birth at Ludlow maternity unit.
‘We have grave concerns about the quality of midwifery care that Kate received after her birth. ‘Following the inquest we now know that she was left alone in a cold cot in a hypothermic state with signs of respiratory distress by a midwife who was meant to be caring for her. ‘That image haunts us.’
Mr Stanton, a professional photographer, told The Sunday Times: ‘The hospital trust were, and are responsible for the death of our daughter.
‘The questions we have been battling to get answered for three years and eight months have finally been answered by a unanimous jury verdict.’
After the inquest, Cathy Smith, head of midwifery and deputy centre chief for the women and children’s centre at The Shrewsbury and Telford Hospital NHS Trust, said: ‘We will now be taking the time to reflect on the jury’s findings.’
Ian Cohen, of Goodmans Law, the family’s solicitor, told the newspaper: ‘Lessons must be learnt, but it is of critical importance that mothers-to-be are fully informed and give full and informed consent.’
House of Lords threat to derail plans for secret courts
Ministers are heading for defeat today over plans to create secret courts that have been denounced as an affront to justice.
Labour, Lib Dem and crossbench peers are expected to unite in the House of Lords to water down the proposals and give greater powers to judges to resist demands from ministers to hold sensitive cases in private.
Senior Labour sources revealed last night they will work with Lib Dem rebels when the Justice and Security Bill reaches its report stage in the Lords today.
They will back an amendment giving judges the right to ignore government demands for secret justice if it is in the public interest.
A second amendment would demand that secret courts could only be used as a very last resort.
If those measures are not passed, Labour will vote to strip all references to such ‘closed material proceedings’ from the Bill – potentially killing the plans stone dead.
The Government faces the prospect of defeat in the Lords both today and on Wednesday.
Sources close to Ken Clarke, the minister without portfolio who has piloted the plans, hinted there could be further concessions, saying: ‘We want to hear what people have to say this week.’
The Daily Mail has led criticism of plans to allow secret courts, under which civil cases would be conducted entirely in private. Ministers claim they need to hold some cases behind closed doors so that judges can hear evidence on intelligence matters.
The Government has paid millions of pounds to terror suspects who accuse it of complicity in torture and rendition, after ministers said it was impossible to defend such claims without releasing secret material.
Critics argued the Bill will help ministers cover up abuses by the security services.
Shami Chakrabarti, of human rights group Liberty, said: ‘This odious Bill turns British civil courts into Soviet-style secret commissions.’
Amnesty International said: ‘The Bill seems designed to allow the Government to throw a cloak of secrecy over wrongdoing.’
Daily Mail’s campaign against secret courts
A spokesman for Labour leader Ed Miliband said: ‘We don’t think there are nearly enough safeguards in the Bill.’
Mr Clarke last night told the Mail that, currently, the ‘finest, wisest judges in the world’ were barred from taking into account some evidence at the heart of important civil cases because of the problems with releasing secret material.
Defending his proposals, he added: ‘I have ensured that under the Bill a closed material procedure could only be used to hear evidence which a judge has found is genuinely national security sensitive. ‘They will never be available in inquests or criminal trials.’ [Hah!]
Poll shows little support in Britain for state regulation of the press
Rules governing the press must be more stringently enforced, according to a poll released ahead of the publication of the Leveson report – but the public do not believe any new legislation is required.
Almost three quarters of those polled (71 per cent) said that the main focus in stopping bad practice in the media should be tougher application of existing laws, with only 24 per cent saying new legislation and regulations were necessary.
The survey comes as Lord Justice Leveson is preparing to publish the results of his inquiry into press standards, which was sparked by the phone hacking scandal at the News of the World.
The judge is expected to call for an overhaul in the way newspapers are regulated, with some campaigners urging him to advocate a system of state regulation, which they say would ensure the industry abides by high standards of journalism and of ethics.
However, others have warned that such a system – even if “light touch” – will lead to politicians and the powerful being able to prevent publication of material embarrassing to them. Rather, they argue that abuses, such as those exposed at the News of the World, can be, and should have been, tackled by existing laws.
The new poll was carried out by the Free Speech Network, an organisation set up to by the publishers of several newspapers, including The Sunday Telegraph, to make the case against state regulation. It has called for “independent self regulation”, enforced by a non-statutory body that would rely on civil law contracts, have investigative powers and the ability to fine publishers up to £1 million.
Bob Satchwell, chairman of the Society of Editors – which is a member of the network – said: “The British people are clear that they want a free press and free speech. We agree. This is why the industry supports a new system, independent of both government and the newspaper industry to ensure the highest standards in the press without undermining its capacity to hold people such as politicians to account.
“We have established a free press in this country over 300 years – we don’t want to reverse this trend. It would send a terrible signal to emerging democracies around the world if this were to end. How can we encourage the freedom of the press and free speech abroad, if we are threatening it at home?”
The study examined public opinion on a wide range of issues raised by the Leveson inquiry.
It appeared to show little appetite for statutory regulation, or greater controls on press practices and widespread support for a free press.
Nine out of ten respondents (91 per cent) said people should be free to say and write whatever they think on matters of public debate, as long as they do not make false statements that damage people’s reputations.
A similar proportion (94 per cent) said that apart from already illegal practices such as phone hacking, computer hacking and making payments to public officials, there was no need to outlaw or regulate additional press practices. Almost two thirds (64 per cent) said they were proud that the UK was regarded as a model of press freedom and freedom of speech.
The public were also asked for their opinions about cases of investigative journalism which sometimes involves the obtaining and publishing of confidential information. They were given two examples – the Telegraph’s exposé of MPs’ expenses, as well as the hacking of phones by the News of the World.
Sixty two per cent believed editors should be able to make a judgement as to whether such methods are in the public interest and that this should be taken into account if any legal action is taken against them. By contrast, 31 per cent thought that journalists obtaining such information should always be prosecuted.
In a further argument against state intervention in the press, half of respondents thought a new system of regulation should be introduced within a year, while 28 per cent wanted it in force within four months.
Opponents of state regulation claim it would take longer than a year to implement such an option, whereas an enhanced form of self regulation could be put in place more swiftly.
The issue of press regulation also ranked low in a list of issues that the public thought their MPs should be concerning themselves with.
Presented with a list of 20 topics, from unemployment and the economy to foreign affairs and illegal drugs, the issue of press regulation was ranked as the second least important. The only subject that people thought their MPs should find less pressing was constitutional reform. Just one in 200 (0.5 per cent) thought regulation of the press should be the top priority for politicians.
The phone hacking scandal also ranked behind allegations of a BBC cover-up of Jimmy Savile’s sex attacks on children, and accusations of police and public officials being paid by journalists, in terms of the issues which most concerned people.
Fifty five per cent ranked the BBC scandal the most concerning, followed by 32 per cent for alleged corrupt payments and just 13 per cent for the phone hacking controversy.
That scandal started with accusations that the mobile phone of Milly Dowler, the murder victim, had been hacked into by the News of the World and messages deleted. However, the subsequent Leveson inquiry has looked into not only wider press practices, but also the conduct of police and politicians.
More than half of those questioned (55 per cent), said the biggest failure the phone hacking scandal had uncovered was journalists not adhering to their own codes of practice, while just under a third (31 per cent) said it was the police not adequately investigating wrongdoing in the press and 14 per cent said it was the politicians for not doing enough to regulate the press.
One of the key issues facing Lord Leveson has been the extent to which any new system of regulation should cover just newspapers and their websites, or whether it should also apply to bloggers and even individuals writing on websites such as Twitter.
The issue was highlighted last week when a number of individuals, including George Monbiot, a Guardian journalist, and Sally Bercow, the wife of the Commons Speaker, used their Twitter feeds to wrongly suggest that Lord McAlpine, the former Conservative Party treasurer, was a paedophile.
When asked who should be covered by a new, tougher system of regulation, 41 per cent said it should apply to bloggers and Twitter users, as well as newspaper journalists. By contrast, 35 per cent said it should only cover newspaper journalists.
The poll also showed support for the argument that a new regulatory system which applies only to newspapers and their websites, will be flawed because there will be no controls over other websites.
More than half of those questioned (55 per cent) said they would turn to the internet to find out about a particular story, if they knew that it was not being published by newspapers because it contravened new laws.
The same proportion (55 per cent) said they would access American websites to read about a story that the UK authorities had decided should not be published here.
The public were also asked their opinions on how any new press industry body should be paid for and whether a new system of regulation should help to make libel actions to be settled more quickly and cheaply. Critics argue that the current system can be too expensive for all but the wealthiest complainants.
Sixty eight per cent wanted a cheaper and quicker system, which was opposed by only nine per cent.
Eighty six per cent said that any new organisation to regulate the press and deal with complaints should be paid for by the newspaper industry, while eight per cent said the taxpayer should support the cost, and six per cent said complainants should support the costs of the new body.
The poll, carried out by Survation, was of 1,000 people from a representative cross section of the population.
British primary school teachers could face dismissal for refusing to promote homosexual marriage
Primary school teachers could face the sack for refusing to promote gay marriage once same-sex unions become law, a minister has signalled. Liz Truss, an education minister, refused to rule out the possibility that teachers, even in faith schools, could face disciplinary action for objecting on grounds of conscience.
Miss Truss said simply that it was impossible to know what the impact of the legislation would be at this stage. Her admission came in a letter to a fellow Conservative MP, David Burrowes, last month.
Mr Burrowes, a practising Christian, originally wrote to Maria Miller, the equalities minister, raising concerns about the impact on schools of the Coalition’s plans to change the marriage laws.
It followed the publication of a legal opinion by Aidan O’Neill QC, a barrister in the same London chambers as Cherie Blair, commissioned by the Coalition for Marriage, which campaigns against same-sex unions.
Mr O’Neill, an expert on human rights, was asked to advise on the impact redefining marriage to include same-sex couples could have on schools, churches, hospitals, foster carers and public buildings.
Among his conclusions was that schools could be within their statutory rights to dismiss staff who wilfully fail to use stories or textbooks promoting same-sex weddings. Parents who object to gay marriage being taught to their children would also have no right to withdraw their child from lessons, he argued. And, in theory, the fact that a school was a faith school would make no difference, he added.
One scenario he looked at was what would happen if a primary school asked a Christian teacher to use a book called King & King, a story of a prince who marries a man, and produce a play based on the tale.
Mr O’Neill concluded: “If the teacher refused to obey the otherwise lawful instructions of her employers then this would constitute grounds for her dismissal from employment.”
He said that the teacher would be unlikely to be able to use human rights law to challenge such a decision because the European Court of Human Rights in Strasbourg had previously been “notably unwilling” to allow employers to use religion to request changes to their conditions of employment.
Mr Burrowes wrote to ministers seeking reassurances that the situation would not arise.
Replying on behalf of the Government, Miss Truss said that parents currently have a right to withdraw their children from sex education classes and that schools must apply “sensitivity” in deciding what materials to use, taking into account pupils’ as well as their “religious and cultural background”.
She added that it is ultimately up to heads to determine what teachers should teach and that staff with concerns should try to reach a “mutual understanding on the way forward.”
However she underlined that teachers must act in an “un-discriminatory manner”.
But she said it was impossible to know how the balance might change further if same-sex marriage becomes law and what the implications might be.
“As you are aware, legislation on equal civil marriage has yet to be announced by the Home Office, following a consultation exercise earlier this year,” she wrote.
“I am, therefore, unable to advise on the specifics of any legislation and its future impacts at this time.”
It comes despite the Coalition publishing a detailed “impact assessment” on the introduction of same-sex marriage which even included details of how immigration forms might have to be changed to replaces references to husbands or wives with “more neutral” terminology.
Mr Burrowes said the letter confirmed that gay marriage would be taught in schools and offered no reassurances to teachers who object on grounds of conscience.
“The reality is that these questions that are raised which have not been fully answered mean that they have not been rebutted,” he said. “The fact that they have not been rebutted when we are so far down the line – the consultation will be coming out within the next weeks and no doubt the DfE has been consulted – now does raise more questions than answers.
“There is a big and serious question that gay marriage will undermine the liberty of conscience, that’s a big question that will hang over the legislation.”
Millions of pupils are being failed by ‘cult of the average’ in our schools says British business organization
A `cult of the average’ in Britain’s state education system is failing millions of bright children and lower achievers, business leaders warn today.
In a withering indictment, the CBI says that after 35 years of reforms and higher spending on schools than by many other nations the country is still facing `substantial’ failure rates.
The business lobby group claims some schools have become little more than `exam factories’ churning out average grades while failing to stretch both the brightest and lower attainers to the limit of their ability, leading to classroom disruption.
In a blueprint for reform, the CBI proposes radical changes. It says the raising of the school leaving age from 16 to 18 over the next few years means it is time to shift the focus of secondary education from GCSEs to A-levels, or vocational alternatives, at 18.
Instead of public exams, there should be assessments at ages 14 or 16 that check pupils’ progress and help them decide what subjects or career paths to take. More pupils should be able to begin a technical education at 14.
The CBI’s report, published as it meets for its annual conference in London, warns: `The education system fosters a cult of the average: too often failing to stretch the most able or support those that need most help.’
John Cridland, the CBI’s director-general, said: `Today we have a system where a large minority of our young people fall behind and never catch up.
‘It’s not the fault of any individual concerned. It’s not the fault of children, parents or teachers. It’s a system failure. It’s not acceptable any more than it’s not acceptable that the top 10 per cent are not stretched enough.’
Education Secretary Michael Gove has announced plans to scrap GCSEs and replace them with English Baccalaureate Certificates and reform A-levels and the national curriculum.
Britain’s Green Agenda Disintegrating
Plans to limit the carbon emissions of future power stations are on the brink of being delayed until next parliament, in what would be a blow to the climate and energy secretary, green campaigners and business chiefs.
Ministers have been wrangling over whether to include a 2030 “decarbonisation target” for the power sector in the energy bill, which is expected to be published in parliament within the next fortnight.
The Guardian understands a decision on such a target now risks being delayed until after the next general election. A senior source close to the talks said: “It’s been a very difficult negotiation, there has been talk of postponing the setting of a target until next parliament.
But if we are to address investor concerns, it has to be addressed this parliament.”
However, the source added that the talks were still ongoing and “it is still possible that there could be agreement on a target to be set this parliament, and that will come down to how hard they want to negotiate on the Liberal Democrat side.”
A spokeswoman for the climate and energy secretary, Ed Davey, denied the target had been dropped or delayed. “We’ve not actually reached an agreement in government on the various energy negotiations we’ve been having,” she told the Guardian.
The splits between the coalition on energy are reportedly so unresolved they were left off the agenda at the “quad” meeting on Thursday of the four most senior figures – David Cameron, George Osborne, Nick Clegg and Danny Alexander.
Dropping or delaying the target would clear the way for the “dash for gas” backed by the chancellor, and mark a defeat for Davey and the Liberal Democrats, who backed a motion in favour of a decarbonisation target at their conference.
Hate speech and social media: can public shaming go too far?
The comments below are from Britain’s Leftist “Guardian” so that is rather refreshing. It suggests that not all Leftist talk about free speech is hollow
The re-election of Barack Obama provoked, perhaps not surprisingly, some racist, offensive and just plain stupid reaction on social media.
But the decision of websites such as Buzzfeed and Jezebel to pick out some of the more egregious examples – many by high school students – has prompted a debate about the ethics of so-called “social media shaming”.
A discussion between Buzzfeed’s Matthew Buchanan and Read Write’s Fruzsina Eördögh came to a head on Monday night when Buchanan posted this piece in defense of the two news blogs:
When people say things out loud that the public has collectively – or like, a lot of it, anyway – agreed are offensive, hurtful, or stupid, it’s within the purview of the public to retort, to challenge, and to chasten.
Eördögh sees things differently. She says that since Twitter users are unaware when and where their content is being republished, the ethics of doing so are pretty murky, especially in the cases of minors.
Users have a right to know what is happening with their communication, and they don’t have to participate in surveys, research, or even in media articles if they don’t want to. Sometimes communication between friends really is just communication between friends. Collecting their data could even be a copyright violation.
This is just the latest in an ongoing discussion about free speech on the internet, one that’s often taken place on the Guardian. This time, however, teenagers are involved. On Jezebel, Tracie Egan Morrissey lamented how many of the racist tweets came from high school students: “If you believe the children are our future, then our future is f*cked” she wrote. She contacted the principals and superintendents of the students’ schools to “find out how calling the president – or any person of color, for that matter – a ‘n*gger’ and a ‘monkey’ jibes with their student conduct code of ethics”.
Did Morrissey go too far? Not according to Buchanan, who says that teenagers need to learn to take responsibility for their actions online. “The internet is real,” he wrote. “When you say things on the internet now, they carry real weight and meaning.”