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The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

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The health concerns that affect preterm babies are well documented and much is known about the impact of an early birth on the long term health of children.  Some of these issues were discussed in a recent post on Science & Sensibility highlighting World Prematurity Day.  The issue of babies being born too soon was highlighted by the American College of Obstetricians and Gynecologists (ACOG) in a new committee opinion recently published in the November issue of Obstetrics and Gynecology.

In a joint committee opinion, “The Definition of Term Pregnancy” released by ACOG and the Society for Maternal Fetal Medicine, these organizations acknowledge that previously it was believed that ”the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered ‘term’ with the expectation that neonatal outcomes from deliveries in this interval were uniform and good.”  More recent research has demonstrated that this is not the case.  The likelihood of neonatal problems, in particular issues related to respiratory morbidity, has a wide variability based on when during this five week “term” window baby is born.

ACOG has released four new definitions that clinicians and others can use when referring to gestational age; early term, full term, late term and postterm.

  1. Early term shall be used to describe all deliveries between 37 0/7 and 38 6/7 weeks of gestation.
  2. Term shall indicate deliveries from 39 0/7 and 40 6/7 weeks of gestation.
  3. Late term refers to all delivers rom 41 0/7 to 41 6/7 weeks of gestation.
  4. Postterm indicates all births from 42 0/7 weeks of gestation and beyond.

These new definitions should be put into practice by all those who work with birthing women, including researchers, clinicians, public health officials and organizations AND childbirth educators. We can and should be teaching and using these terms with our students.

As we move forward, we can expect to see these terms applied and research defined by the new categories, which will yield rich and useful information for those working in the field of maternal-infant health.

Lamaze International has long been focused on evidence based care during the childbearing year and continues to support childbirth educators, consumers and others by providing useful and fact based information that women and their families can use to make informed choices about their maternity care.  As part of this continued effort, Lamaze is pleased to share a new induction infographic created by the Lamaze Institute for Safe & Healthy Birth committee. This easy to read infographic is designed to highlight the facts about induction and encourage women to carefully consider all the information before choosing a non-medically indicated induction.  More than one in four women undergo an induction using medical means, and 19% of those inductions had no medical basis.

Since many women are pressured by providers or well-meaning but misguided friends and family to be induced, Lamaze encourages women to learn what are the important questions to ask during conversations with their providers and to get the facts about their own personal situation.  It is also recognized that a quality Lamaze childbirth education class can provide a good foundation for understanding safe and healthy birth practices.

Lamaze International is proud of their Six Healthy Birth Practices for safe and healthy birth, and this infographic supports the first birth practice; let labor begin on its own.  Women need to be able to gather information to discern between a medically indicated induction, which protects the baby, the mother or both from those induction that are done for a social or nonmedical reason which increases the risk of further interventions, including cesarean surgery for mothers and NICU stays for babies who were not ready to be born. This infographic can be shared with students, clients and patients.  It can be hung in classrooms and offices.  Educators can use it in creative ways during teaching sessions, when discussing the topics of inductions, informed consent and birth planning.

As the benefits of a term baby are more clearly understood, and research is revealing how critical those last days are for a baby’s final growth and development, it is perfect timing for Lamaze to share this infographic.  This tool will reduce unneeded inductions and help women learn how important it is to allow their babies to receive the full benefit of coming when the baby is ready.  There has been a huge push to stop inductions before at least 39 weeks.  March of Dimes has their “Healthy Babies are Worth the Wait” campaign. The new induction infographic provides an accessible and easy to use information sheet to help families reduce non-medical inductions. Many organizations, including Lamaze are joining together to make sure that babies are born as healthy as possible and women go into labor naturally when baby is ready.

You can find and download the full version of the Induction infographic on the Let’s Talk Induction page of Lamaze’s Push for Your Baby campaign website.  Alternately, if you are a Lamaze member, you can also download the infographic and many other useful handouts from the Teaching Handouts Professional Resource Page from Lamaze International.

Please take a moment to read over this great, new infographic and share in the comments below, both your thoughts on the finished product and how you might use this to help mothers to push for the best care. Lamaze International and its members are doing their part to help reduce the number of early term babies who arrive before they are ready.  I look forward to hearing your thoughts and your ideas for classroom use.

References

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No 579: Definition of Term Pregnancy. Obstet Gynecol 2013; 122:1139.

Declercq, E. R., & Sakala, C. (2013). Listening to mothers III: Pregnancy and childbirth.”. 

 

ACOG, Babies, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, New Research, Newborns, NICU, Practice Guidelines, Pre-term Birth, Push for Your Baby, Research , , , , , , , , , , ,

Evidence Based Birth Takes on Group B Strep: An Interview with Rebecca Dekker

April 9th, 2013 by avatar

http://flic.kr/p/KCS5

Occasional Science & Sensibility contributor Rebecca Dekker of Evidence Based Birth has spent the last month writing a blog article about Group B Strep and it is finally here! In her painstaking but clear review of the evidence on GBS in pregnancy, Rebecca came to the conclusion that universal screening and treatment for GBS is more effective than treating with antibiotics based on risk factors alone. She also found that although “probiotics, chlorhexadine, and garlic have the potential to reduce vaginal and newborn colonization with GBS, we do not have evidence yet to show that these strategies can prevent early GBS infections, since GBS infection usually occurs when GBS gains access to the amniotic fluid and gets into the fetus’s lungs during labor.”

To read Rebecca’s just released article, Group B Strep in Pregnancy: Evidence for Antibiotics and Alternatives in its entirety, click here.

Today, Rebecca joins us on Science & Sensibility to talk about her latest addition to Evidence Based Birth.

Sharon Muza: What inspired you to write this article?

Rebecca Dekker: I received more requests to write about Group B strep than any other topic! Over the past few months, I had weekly, sometimes daily emails and Facebook messages from women—all asking me to provide them with evidence about antibiotics, hibiclens, or garlic for preventing GBS infections. After about the 50th request, I figured I better set aside my other plans and focus on this topic, because it was clearly weighing heavily on many women’s minds! 

SM: What was the most difficult thing about writing this article?

RD: Probably the most difficult thing was sorting through the stacks and stacks of research articles that have been published about Group B strep in pregnancy. This was one of the reasons it took me almost a year of blogging before I decided to dive into group B strep. I knew it would be a monumental task. And it was. But I was fortunate enough to have an expert in GBS who helped point me to the most important or “landmark” studies.

SM: Who was this expert?

RD: I met Dr. Jessica Illuzzi via email earlier this year. She and I had corresponded about a different blog article, and at that time I found her to be incredibly helpful. I knew that in addition to being an OB, Dr. Illuzzi was a research expert in GBS. So I asked her if she would review my article for me. To be honest, I could not have written this article without her guidance. She read my first draft and basically told me that I needed to go back to the drawing board. She encouraged me to dig deeper into the evidence so that I would really understand it. Whenever I had questions about something, she sent me research articles that immediately answered my question. In the end, I knew the article was ready when she said it was a great summary of the state of the science of GBS. 

I was also lucky enough to have 2 other GBS experts give me feedback on the article—a GBS researcher and a microbiologist. And then I have several physicians who faithfully review all of my articles and give great suggestions. I am very grateful to all of them as well!

SM: I know that you usually begin your articles with an exploration of your own biases, in order to tease the bias out of your writing. Did you have any pre-existing biases about GBS? 

RD: To be honest, I actually had no biases up front. I was fortunate to always test negative for GBS myself, and so I never had to struggle with this issue before. I was pretty open-minded to the entire issue. I was open-minded to antibiotics. I was open-minded to hibiclens or other alternatives. I had no personal agenda. I simply wanted to get to the facts. Hopefully this lack of bias will shine through and help people respect the article even more.

 SM: What surprised you most as you wrote this article?

RD: One of the things that surprised me was how people have such different reactions when they read the evidence about GBS. I had several friends preview the article for me. Some of them instantly said, “Oh yeah, that sounds like a really high risk. I’d definitely take the antibiotics to prevent an infection in my newborn.” Others would say, “Really? That’s all? That’s not a very high risk at all. I wouldn’t take antibiotics for that level of risk.” This is a great example of how everyone perceives risk differently. But at least in this article I have been able to put some evidence-based facts out there. Let people interpret the risks as they may. I only ask that they talk with their health care provider before making any decisions!!

 SM: What do you think is the future of GBS evidence?

RD: Ten years from now I am guessing that I could write a very different article. I would like to think that by then we may have a vaccine on the horizon that could prevent both early GBS infections and GBS-related preterm birth. It would also be nice if the rapid test was affordable and widely available by then. I would also LOVE to see some solid research evidence on the use of probiotics for decreasing GBS colonization rates in pregnant women. As far as I know, probiotics for decreasing GBS hasn’t been studied yet in pregnant women, and I think it deserves further inquiry.  

SM:What makes your blog article about GBS different than all the other blog articles out there on this topic?

Rebecca Dekker

RD: I purposefully didn’t look at any of the other GBS blog articles out there until I finished my article. Yesterday, I read through a variety of blog articles (there are a lot!). Most of them were about 90-95% accurate in their facts. A couple of them had serious errors (in particular, I found one blog article that had inaccurate information about hibiclens). Most didn’t list any references, and I could tell that most of the blog authors had used secondary sources (other blogs or summary articles) instead of looking at the research evidence themselves. This can be fine, but sometimes it’s a bit like playing telephone: You just keep repeating the same facts over and over without checking to see if the evidence has changed or if the summary you are parroting was accurate in the first place. I’d like to think that my blog article is a very accurate assessment of the research evidence on GBS in pregnancy—translated into regular language so that women and their family members can understand the evidence. 

SM: What are you going to write about next?

RD: I don’t know!! What would YOU like to see me write about?

SM: I want to thank you Rebecca, for your contributions to Science & Sensibility and for sharing Evidence Based Birth with the world!  I know that these articles take a huge amount of time and you are very diligent and conscientious about researching the literature and providing only the best analysis possible,  and seeking out experts on the topic to help you really be sure that you are offering the best of the best of information.  I always enjoy reading your blog and find it a great source of information for my doula and CBE students and my birth doula clients as well. I know that I speak for all the readers here on Science & Sensibility when I say, keep on keeping on!  Do please let Rebecca know what you would like her to write about next!   

ACOG, American Academy of Pediatrics, Babies, Childbirth Education, Evidence Based Medicine, Guest Posts, informed Consent, Maternity Care, Medical Interventions, New Research, Newborns, NICU, Push for Your Baby, Research , , , , , , , , , , ,

Beyond Downton Abbey: The True Life Trauma of Pre-eclampsia, Eclampsia, and Its Psychological Aftermath—An Interview with Jennifer Carney of The Unexpected Project

February 5th, 2013 by avatar

By Walker Karraa

Regular contributor Walker Karraa interviews Jennifer Carney, a mother of two, who suffered from eclampsia at the beginning of her third trimester.  Jennifer shares her real life story, on the heels of a favorite character’s similar experience on the popular TV show “Downton Abbey.”  Today, we learn about Jennifer’s experience and on Thursday we learn more about resources and organizations working hard to make this potentially deadly disease less harmful to pregnant and postpartum women.  - Sharon Muza, Community Manager

Introduction: 

http://flic.kr/p/dJBJhW

The recent episode of “Downton Abbey” brought much needed attention to the maternal health issue of pre-eclampsia. Why is it we rely on fiction for permission to get real? Where is the line between evidence-based research and fictional representations of the lack of it? How do we encourage each other and the next generation of maternal health advocates to harness the undeniable power of media but not become part of a social construction of maternal mortality as not real? As a qualitative researcher, I believe that some of our best evidence stems from researching real experiences from real women. It is my pleasure to introduce a real woman who experienced the full range of eclampsia and its psychological aftermath: Jennifer Carney.

Note: Consultation with Science and Sensibility contributor, Christine Morton, PhD was conducted to insure accurate and current statistical data regarding pre-eclampsia and eclampsia. 

Walker: Jennifer, can you tell us your story?

JC: My second pregnancy was easier than my first. Up until it wasn’t. I conceived as soon as we started trying. We had no soft markers on the ultrasounds, no need for an amnio, and no borderline gestational diabetes. I was only 34 and with a successful full-term first pregnancy; I was considered “safe” from preeclampsia. The only risk factor I had was my weight, but even with that, statistically my risks were much lower than for a healthy first time mom. There was something about it that seemed too easy. I felt like the other shoe was going to drop – but I never imagined that it would fall with such force.

In my 32nd week, I began to feel ill – like I had the flu. I took a day off from work to rest and recover. I thought I was getting better, but that night I began feeling worse. I called in sick to work again – it was a Friday – and my husband and son went off to work and daycare. I was alone. I laid down and slept for about 4 hours. When I awoke, I felt much, much worse. The headache radiated out from behind my eyes. I was seeing spots. I was incapable of thinking clearly. The phone rang several times, but the receiver was not on the base. I couldn’t locate it before the answering machine picked up. By this point I was aware that something was very wrong, but I wasn’t able to do anything about it. I stayed on the couch, barely moving for as long as I could.

Signs and Symptoms of Pre-eclampsia

  •  High blood pressure. 140/90 or higher. A rise in the systolic (higher number) of 30 or more, or the diastolic (lower number) of 15 or more over your baseline might be cause for concern.
  • Protein in your urine. 300 milligrams in a 24 hour collection or 1+ on the dipstick.
  • Swelling in the hands, feet or face, especially around the eyes, if an indentation is left when applying thumb pressure, or if it has occurred rather suddenly.
  • Headaches that just won’t go away, even after taking medications for them.
  • Changes in vision, double vision, blurriness, flashing lights or auras.
  • Nausea late in pregnancy is not normal and could be cause for concern.
  • Upper abdominal pain (epigastric) or chest pain, some- times mistaken for indigestion, gall bladder pain or the flu.
  • Sudden weight gain of 2 pounds or more in one week.
  • Breathlessness. Breathing with difficulty, gasping or panting.

If you have one or more of these signs and symptoms, you should see your doctor or go to an emergency room immediately. 
Source: Preeclampsia Foundation

Sometime after 5:00, I realized that I was going to have to call someone else to pick up my son at daycare by the 6:00 closing time. I managed to get to my feet and stagger toward the kitchen. I reached out to steady myself on the counter and missed. I fell to my left, onto the hard tile floor in front of the stove. I knew this was bad, but all I could think was that I had to hold on and that someone would be coming. I told myself that I couldn’t let this happen. Shortly thereafter, I tried to scream and felt the beginning of what I later learned was a tonic-clonic or grand mal seizure.  

This was eclampsia – full blown seizures caused by extremely high blood pressure. Somehow, I held on. Somehow, I held on in this state for something like 3 full hours. I have no way of knowing how many seizures I had in that time. When my friend arrived after 8:00, she found me on the floor. I came to long enough to answer her question – “yes, I know where I am. I’m fine.” I tried to get up – and immediately started seizing again. She called 911 and within minutes the paramedics arrived. 

My son was born, not breathing, about an hour later. The doctors were able to revive him, thankfully. He went off to the NICU and I was sent to the ICU. Two days later, I regained consciousness. I was on a respirator and completely disoriented. I was later diagnosed with HELLP syndrome, eclampsia, pneumonia, acute respiratory distress syndrome (ARDS), and sepsis – any of which can be fatal on their own. My son was moved to another hospital with a larger NICU, and I spent 8 days in the hospital where he was born. I saw him briefly before they transferred him – but was unable to hold him until after I was discharged – more than a week after he was born. For the next 20 days, I was only able to see him and hold him during daily visits to the NICU. It would be 4 full weeks from his birth before we could take him home to meet his 4 ½  year old brother for the first time. This was definitely not what we had envisioned.

This experience changed my entire perspective on life. It was the first significant health crisis that I had ever faced and it shook my sense of security and safety. It took a long time to recover physically from the trauma and emotionally I was just a wreck. I was aware that Post-traumatic Stress Disorder (PTSD) was a possibility, but I think the picture I had in my mind of what PTSD was turned out to be very different from the ways in which I experienced it. I had envisioned a quick, big breakdown – but the reality was much subtler. At first, I experienced an aversion to seeing pregnant women. I wanted to warn them, but I also could barely look at them. It manifested in other ways, too – dreams about seizures, muscle spasms, intrusive thoughts. But it felt manageable and the antidepressants helped control the runaway anxiety that had hampered my first postpartum experience 4 years earlier.

Photo: J. Carney 

The mental health issues were helped by the antidepressants, but I wish that I had tried therapy much sooner. It’s doing wonders for me now – but I waited over 6 years to try it. Today, my preemie is in kindergarten and doing well. Aside from my son, getting involved with the March of Dimes and Preeclampsia Foundation has been by far the best part of the whole experience. I wouldn’t change that part, at all.

Walker: How is mental health neglected in the overall understanding of the topic, treatment, and recovery?

JC: This is a huge problem. I got great care while I was in the hospital. I saw social workers, chaplains, and a wide variety of people who inquired after my pain levels and my coping skills. The problem with this is that I was on massive pain killers the whole time. Percocet and morphine can mask emotional pain as well as physical pain. I’m sure I came off as reasonably well adjusted to the whole experience, despite the mental confusion left over from the seizures and the serious health issues that remained. And I was relatively okay. Even during the month-long NICU stay, I was doing all right. I was sleeping well, eating, taking care of myself – but I was also still on Percocet. It smoothed over the rough edges.

It wasn’t until the help dried up, the prescriptions ran out, and the reality of being at home by alone with an infant to care for that the walls started to come down again. Here I was at the scene of the initial trauma, cooking at the same stove that I had seized in front of for hours, responsible for a premature infant who needed drugs to remind him to breathe. This is when I needed the help. This is when I needed information on PTSD and postpartum depression (PPD). This is when I needed support. And as I began the long process of understanding what had happened and why, I found I needed even more support to help me wrap my head around it all.

As I noted while talking about myths, there is a pervasive culture of blame in the overall birth discussion regarding preeclampsia. It can be hard to find information that doesn’t make you feel that you somehow brought this condition on yourself. I looked at the risk factors and the arguments about lifestyle, obesity, and diet – and found a lot of things that sounded like they made sense. But they only made sense if I internalized them and blamed myself for the shortcomings. Maybe it was my fault. This, as you can imagine, does not help the feelings of depression and trauma. It took a LONG time for me to come to the conclusion that there was no way for me to have known that this would happen or to have prevented it. Statistically speaking, I had a very low chance of developing eclampsia even with the risks factored in. Statistically speaking, my son and I should not have survived, either. But we did – and now I want to make sure that I use that in a meaningful way. 

Walker: Did your childbirth education prepare you for your experience?

JC: Heck no. I only took classes with my husband before our first child. We weren’t planning to take the classes again with the second, but since he was born at 7 months, we probably would have missed most of them even if we had planned to. I distinctly remember the childbirth educator talking about her own response to sleeplessness, which was a sort of slap happy, giddy reaction. She mentioned PPD, but not in any real way that conveyed the depths or potential seriousness of the condition. We also received almost no information on pregnancy complications. To me, preeclampsia meant high blood pressure – and I had never had problems with that before. It was totally off my radar. Plus, Preeclampsia very rarely happens in a second pregnancy if it didn’t happen in the first. So, no one prepared me for it. Not my doctor, not my classes, not my books.

Walker: What recommendations do you have for childbirth educators and doulas regarding this issue?

JC: Really, I think it comes down to trusting that the moms you are helping can handle the information that they NEED to know. I was alone. If I had known that these symptoms could mean eclampsia or preeclampsia, I might have been able to save myself from the seizures – which would have also likely saved me from the ARDS and pneumonia. My ICU stay might have not happened. My son was going to be born early – but if I had gone to my doctor or called an ambulance myself, it might not have been so close a call. It’s not my fault that I didn’t know – but it could have been tragic.  

Know the signs and symptoms. Know that a woman with severe PE might be having cognitive issues – confusion, and vision problems. Don’t ask her to drive. Don’t downplay distress. And take complaints of headaches, upper quadrant pain, nausea, diarrhea, shoulder pain, visual disturbances, and a general feeling that something is “off” seriously. And if you have a client or patient that experiences something like this, please follow up and ask about mental health issues. Be careful not to ask questions that can be answered with the words: “I’m fine”. Dig deeper.

Closing Thoughts

How might we increase our understanding of this issue through Jennifer’s story? Is it possible to begin a dialogue here–one in which we agree to change paradigms of learning and knowing women’s experiences beyond an episode of a fictional television show?  Jennifer presents an exemplar synthesis of the fullest range of insight possible when empirical and phenomenological considerations are employed.. Her lived experience combined with and through her knowledge of the evidence creates an exemplar of how knowing and knowledge cannot be divided if the pursuit of knowledge is truly desired.

In the next installment, scheduled for February 7th,  Jennifer reflects on common myths about PE, and her work with the Unexpected Project and the Preeclampsia Foundation.   

Birth Trauma, Childbirth Education, Depression, Guest Posts, Maternal Mental Health, NICU, Postpartum Depression, Pre-eclampsia, Pre-term Birth, Pregnancy Complications, PTSD , , , , , , , , , , , , ,

The Wax Home Birth Meta-Analysis: An Outsider’s Critique

October 23rd, 2012 by avatar

Today’s post is a fascinating interview that took place between Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth and Kyoung Suk Lee, PhD, MPH, RN, APRN. Rebecca asked Dr. Lee to provide a review of the Wax Home Birth Meta-Analysis, as an “unbiased outsider”, but highly skilled researcher.  Dr. Lee’s comments and critique are fascinating and provided me with many further thoughts.  Please enjoy Rebecca’s interview and share your comments. – SM

__________________

http://www.flickr.com/photos/eyeliam/7353095052/

Shortly after starting my website, www.evidencebasedbirth.com, I had several people ask me if I could write an article about the research evidence on home birth. However, I was hesitant to do so for several reasons. Mainly, I was worried that I could not look at the evidence in an objective manner. My husband and I had recently chosen a home birth for our second child. I was worried that it would be difficult to objectively examine the research evidence on home birth, given my personal experience. The blogosphere is full of people who are strongly pro-home birth or anti-home birth, and their evaluations of the evidence are usually written through the lens of their own biases. I didn’t want to add to the plethora of biased articles already out there.

Then I had a sudden burst of inspiration. What if I asked one of my colleagues—who has no biases about childbirth—to review the home birth literature for me? In particular, I wanted to find someone who could review the Wax home birth meta-analysis (Wax, Lucas et al. 2010) and give me a fair assessment of its scientific value.

I chose the Wax meta-analysis for this review because in 2011, the American Congress of Obstetricians and Gynecologists emphasized the results of the Wax study in its official statement on home birth. Their statement said: “Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.”(ACOG, 2011)

Dr. Kyoung Suk Lee, PhD, MPH, RN, APRN

It did not take me long to figure out who I would ask to review the Wax study. Dr. Kyoung Suk Lee is considered by her colleagues to be a rising star in the field of cardiovascular research. She recently graduated with a PhD in Nursing, and she just accepted a job at a research university. People who work with Dr. Lee say that she is extremely intelligent, hard-working, and a future leader in her field. Dr. Lee’s expertise has been recognized with research awards from the Heart Failure Society of America, the Society for Heart-Brain Medicine, and the Cleveland Clinic Heart-Brain Institute, among others. She has published her work in nursing and cardiology journals. Furthermore, I knew that Dr. Lee did not have any biases about childbirth, home birth, or hospital birth. I asked Dr. Lee if she would be willing to review the Wax meta-analysis for me, and she kindly agreed.

What follows is my interview of her about the study and its results (RD in bold, KSL unbolded).

Do you have any biases or conflicts of interest related to home or hospital birth?

I do not have any biases related to home or hospital birth.

Could you summarize the methods and results of the Wax study?

The purpose of this meta-analysis was to compare maternal and neonatal outcomes between planned home-and hospital-births.

Using an electronic database search and bibliography search, the authors retrieved 237 articles and included 12 articles in their meta-analyses. Of 12 articles included, 3 were conducted after 2000 while 9 were conducted before 2000. Of 12 articles, 2 were conducted in the US (one was a retrospective design) while 10 were conducted outside US.

Women in the planned home birth group had better maternal outcomes than women in the planned hospital group. They had fewer interventions such as epidurals and episiotomies, and lower morbidity (infection, 3rd or 4th degree lacerations, hemorrhages, and retained placenta). There were no differences in cord prolapse between the two groups.

For neonatal outcomes, babies born to women in the planned home birth group were less likely to experience prematurity and low birth weight. However, babies born to women in the planned home birth group were more likely to experience neonatal death compared to women in hospital birth.

What is the difference between neonatal and perinatal mortality? What does this have to do with the results?

Based on the definitions given by the authors, neonatal mortality was defined as “death of live born child within 28 days of birth.” This is a subset of an overall outcome– perinatal mortality, which was defined as “stillbirth (of at least 20 weeks or 500g) or death of live born child within 28 days of birth.”

According to the authors, there were no differences in perinatal death (the overall outcome) between planned home birth and hospital birth groups. However, homebirth was associated with 2 times higher risk for neonatal death (the subset of deaths occurring 28 days after birth) in all infants and 3 times higher risk for neonatal death in infants who did not have any congenital birth defects.

Interestingly, if you look at page 243.e3, the authors did a sensitivity analysis. In this analysis, they excluded the studies that had home births that were not attended by certified midwives or certified nurse midwives. In this analysis, they found that there were no differences in neonatal deaths between the home birth and hospital birth groups. This means that in the studies in which midwives with certification of some kind attended home births, the outcomes were the same except there was no increase in the neonatal death rate. In my opinion, we have to pay attention to results of sensitivity analyses because this allows us to see the results based on studies which were definitely known to be eligible or clearly described their methods and outcomes.

What is your opinion on the scientific rigor of this meta-analysis?

One thing that was strange to me is the odds ratios (ORs) in the tables. For example, in table 2, under morbidity, the percentages of infection between home births and hospital births were 0.7 vs. 2.6 (its OR was 0.27) while percentages of perineal laceration were 42.7 vs. 37.1 (its OR was 0.66). To a researcher, these numbers don’t make sense.

Many of the studies included were older (half of the studies were conducted more than 20 years ago) so results may not reflect the current practice at home births or hospital births.

The authors did not provide detailed information on how they evaluated the quality of studies included, although they cited a paper describing the method of study evaluation. This makes it difficult if not impossible to determine whether the studies they included were of good or poor quality.

The authors mentioned that women with high risks would prefer hospital births so that it would expect that home births have better outcomes than hospital births in some maternal and neonatal outcomes. If this was a concern, I wonder why the authors didn’t just focus on only the studies that used matching methods, in order to minimize confounding factors.

What is the difference between relative risk and absolute risk, and how does that apply to women who want to have a home birth?

Absolute risk is the probability of something occurring. They may be expressed as percentages or ratios. For example, neonatal mortality rate in the United States is 2.01 per 1,000 live births. This is .201 percent (2.01/1000 = .201/100).

http://www.flickr.com/photos/mikeporcenaluk/3789756395/

Relative risk is a comparison between different risk levels, such as the neonatal mortality rate of home birth compared to the neonatal mortality rate of hospital birth. The researchers found that there was a higher relative risk in neonatal mortality at home births compared to hospital births, but the overall absolute risk for both was small.

How can women know whether the Wax study results would be applicable to their own individual situation?

Meta analysis is one way to generalize findings from different studies. However, women and clinicians should interpret these results cautiously because the studies included were very different from one another and some of the studies included may not have been of good quality. Also, it would be important to note that the overall neonatal death rate that they report reflects home births that were attended by midwives as well as those that may not have had any kind of certified midwife present.

Because this study seems to have some flaws, the conclusion is tentative. I do not know if this article has any implications for pregnant women.

What do you think is the value of asking someone with no conflicts of interest to evaluate controversial research? Does Dr. Lee’s even-handed critique make you view the results of this study any differently? How do you feel about Dr Lee’s conclusion that the study’s results are tentative, and that the Wax study might not have any implications for pregnant women? Please share your thoughts and comments with other readers.

References

(2011). “ACOG Committee Opinion No. 476: Planned home birth.” Obstetrics and gynecology 117(2 Pt 1): 425-428.

Wax, J. R., F. L. Lucas, et al. (2010). “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.” Am J Obstet Gynecol 203(3): 243 e241-248.

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

Babies, Childbirth Education, Evidence Based Medicine, Guest Posts, Home Birth, Metaanalyses, Midwifery, New Research, NICU, Research , , , , , , , , , , , ,

Donor Milk and Milk Banks; A Gift That Saves Lives

August 7th, 2012 by avatar
This week, in recognition of World Breastfeeding Week,  I am attending a fundraiser in my community, Seattle, for the Northwest Mothers Milk Bank, (NWMMB) which includes a reception and screening of the documentary, Donor Milk.  I am excited to support this important mission and am looking forward to viewing the film and participating in the Q&A afterwards with the filmmakers, NWMMB team members, a donor mom and a physician who routinely prescribes donor breastmilk for patients.
Science & Sensibility’s Lisa Baker and Deena Blumenfeld discussed the newest American Academy of Pediatrics’ statement on Breastfeeding and the Use of Human Milk, Donor Milk for Preterm Infants and the formation of a donor milk bank in Calgary, Alberta, Canada in some posts earlier this year.
I wanted to learn more about Northwest Mothers Milk Bank right in my own backyard, so I contacted Scotti Weintraub, Executive Board Member for the organization to get some of my questions answered.
Sharon Muza: Whose idea was it to start the NWMMB?

Scotti Weintraub:  A group of local lactation professionals had been talking about the need for a milk bank for several years.  In spring 2008, enough people were talking about it that an open meeting was held for anyone interested in starting a milk bank.  From that initial meeting grew the beginnings of a board of directors and a committed group of volunteers.

Sharon Muza: Why Portland, OR and the Pacific Northwest?

Scotti Weintraub:  Right now the closest nonprofit milk banks are in Denver and San Jose.  Oregon and Washington have the highest breastfeeding rates in the country so it makes sense that we’d have a milk bank in the Northwest.   Our volunteer effort grew in Portland and we incorporated as a nonprofit in Oregon.

Photo courtesy of NWMMB

 Sharon Muza: How has the vision of a milk bank been received in your community?

Scotti Weintraub: Very positively!  People involved in lactation are extremely supportive of our mission and want to see a milk bank open.  When we talk to the public, we often get asked, “Shouldn’t Portland already have a milk bank?” They are right – it would make sense that Portland and the Northwest would already have a milk bank.

Potential donor moms have been also very interested and supportive. We have a great deal of education and outreach work to do in the broader medical community.  The research is strongly in support of the use of donor milk and it is evidence-based best-practice.  But there are some who have been slow to embrace the unknown and have questions.  Part of our work up to and from here is to educate medical professionals and increase the use of donor milk.

Sharon Muza: Have there been any concerns or less supportive comments or actions?

Scotti Weintraub: Overwhelmingly people have supported our efforts.  When we are questioned about the safety of donor milk or why it’s so important, we point to the clear research.  Similarly, the AAP, WHO and the Surgeon General have all advocated donor milk as the next best food for babies if their own mom’s milk isn’t available.

Photo courtesy of NWMMB

 Sharon Muza: Are you modeling your bank after one already in existence?

Scotti Weintraub: The Human Milk Banking Association of North America has been hugely helpful in our start-up process.  Member milk banks have graciously shared their insight, time and wisdom.  We are modeling as much as can on their success.

But each community is unique and each milk bank is unique in its structure, how it’s funded and how it operated within its community. The Northwest Mothers Milk Bank is an independent 501c3 organization whereas many milk banks are part of a larger hospital system or hospital foundation.

 Sharon Muza: How many human milk banks are there in the US right now?

Scotti Weintraub: Right now there are 11 operating milk banks in the US.  There are several that are considered “Developing” like NWMMB – meaning that we have met some criteria set out by HMBANA and are in the works.  A couple other milk banks are not yet considered “Developing” but are moving in that direction.  Here’s the list.

Sharon Muza:  What is the cost to families who need milk?

Scotti Weintraub: Milk banks charge processing fees to cover the costs of screening donors, processing, pasteurizing, and culturing the milk and shipping.  This fee is set by the individual milk bank based on their costs, so we don’t yet know what NWMMB will charge for processing fees.

Donor milk that is dispensed while a baby is in the hospital is charged through the hospital.  Some of our NW hospitals are providing donor milk to their patients and are absorbing the costs into their budgets.  Some insurance companies cover donor milk.  There is more work to be done encouraging insurance companies to cover the costs of donor milk.

Photo courtesy of NWMMB

Since we are not yet open, I will share the policy from Mothers’ Milk Bank Austin, TX

“When your baby is hospitalized, the milk processing fee and shipping are billed to the hospital, and subsequently your insurance company. If a baby is not hospitalized, the fee will be billed to you. Texas Medicaid currently covers the cost for donor milk for a limited period of time, when medically necessary. If your family has private insurance, we encourage you to file a claim. We are happy to work with the family, the baby’s healthcare provider and insurance company to obtain coverage. If necessary, we can establish a payment plan. All babies with a medical need for milk, whose moms cannot provide milk, are eligible to receive it for at least a limited time, regardless of ability to pay.”

 Sharon Muza: What is the cost to collect, test, process and distribute milk?

Scotti Weintraub:  Nonprofit milk banks do not recoup their processing costs with the processing fees they charge and must raise additional funds.  Costs vary a bit depending on volume, equipment, etc.

Sharon Muza: Who will the milk be available to?  How will priority be determined?

Scotti Weintraub: Donor milk is available by prescription only.  Priority is given to the sickest and most vulnerable infants depending upon availability.  So there is a triage system for dispensing milk, especially during times of low supply.

 Sharon Muza: Under what circumstances are babies most likely to need donor milk?

Scotti Weintraub:

  • preterm birth
  • failure to thrive
  • malabsorption syndromes
  • allergies
  • feeding/formula intolerance
  • immunologic deficiencies
  • pre- or post-operative nutrition
  • infectious diseases

 Sharon Muza: What if a family cannot afford the milk?

Scotti Weintraub: Families are not turned away due to inability to pay.

 Sharon Muza: How is the donor milk tested and treated to insure its safety?

Scotti Weintraub: Here’s how the milk is processed.  The milk is pasteurized and then cultured to ensure the absence of bacteria.  Frozen donor milk is thawed, nutritionally analyzed, cultured, pooled and poured into bottles, then pasteurized at 62.5 C in a shaking water bath or automatic pasteurizer. Pasteurized milk is quick-cooled, then frozen at -20’C. Microbiological cultures are obtained by an independent laboratory from individual donors’ deposits prior to pasteurization and pooling, and from each batch of milk after pasteurization. This is done to verify that no heat-resistant pathogens are present before pasteurization, and that there is zero growth of bacteria after the heating process.

Sharon Muza: What are the obstacles to establishing the Northwest Mothers Milk Bank?

Scotti Weintraub: Fundraising!  If someone gave us a check for $150,000 tomorrow we could be open in a matter of months.  We have raised over $300,000 but must raise the remaining $150,000 before we can open.  As soon as we have secured the necessary funds, we will work quickly to open.

 

Photo courtesy of NWMMB

Sharon Muza: How much milk do you anticipate moving through your milk bank yearly?

Scotti Weintraub: We anticipate processing at least 40,000 ounces (more than 312 gallons) a year.  We also know that we are shipping a large volume of milk out of the region right now.  For instance, in June we shipped over 5,700 ounces of donated milk from four of our Donor Drop Off Sites to other milk banks.  And that’s only the milk from less than half of our current drop-off sites (the others haven’t yet reported their volume).  We anticipate growing the number of drop-off sites and donors once we open.  So we expect to have a large volume right away.

Sharon Muza: How can childbirth educators help spread the word about donor milk in their classes, both for potential donors and those in need?  

Scotti Weintraub: Everyone who works with pregnant and new parents can play a role in spreading the word.  Childbirth educators can tell expectant families about the availability of donor milk should they need it (most have no idea what donor milk is or that they could access it) and let them know that donation is also possible, if they have an abundance.

You can also encourage medical facilities and providers to utilize donor milk for their patients.  Find out if donor milk is available in your area NICUs and family birth units.  Share information about research and best practices to encourage the use of donor milk.

Sharon Muza: Can nursing mothers with babies of any age donate milk? Do you try and match new mothers’ milk with new babies?

Scotti Weintraub: Each milk bank sets their own donor requirements based on the HMBANA guidelines.  Generally milk is accepted from babies less than one year old.  All milk donations are pooled – meaning that the milk from 3-5 donors is mixed together within one batch.  This ensures even distribution of the milk components.  Occasionally, specialized milk is available – for instance preterm milk or dairy-free milk.

NWMMB Education Vid from Bob Eggleston on Vimeo.

Sharon Muza: What are some of the benefits of donor milk for babies?

Scotti Weintraub: According to the AAP, these are the benefits:

  • lower rates of necrotizing enterocolitis (NEC) and sepsis
  • fewer readmissions to hospital
  • higher intelligence testing scores and higher total brain volume
  • lower rates of retinopathy of prematurity
  • lower blood pressure and low-density lipoprotein concentrations
  • improved leptin and insulin metabolism

Sharon Muza: Can older children with severe allergies have access to the milk?

Scotti Weintraub: Milk is sometimes available to older children or adults for a variety of conditions depending on availability.

Sharon Muza: Any final comments to share with our educators and other birth professionals and readers? 

Scotti Weintraub: Donor milk is lifesaving for our most vulnerable babies and it’s very cost effective.  Just for NEC,

“Research shows that necrotizing enterocolitis (NEC), which donor human milk can help prevent, will increase a baby’s length of hospital stay by two weeks at an additional cost of $128,000 to $238,000. In addition, reductions in other complications such as sepsis through the use of donor human milk instead of formula means that the baby goes home sooner with fewer medical issues – and stays healthier.”

The remaining investment needed to open the NWMMB is less than the cost of ONE case of NEC!

Childbirth Educators, do you talk about donor milk and milk banks in your childbirth and breastfeeding classes?  How would you bring up this subject?  Do you think it is important to talk about with expectant and new parents?

Do any of our readers work in a facility that has human milk available for the tiniest patients in the hospital?

Have any of our readers chosen to donate breastmilk or been on the receiving end with their child?  I would love to hear your experiences. – SM

 References

American Academy of Pediatrics. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2012; 129: e827–e841.

Arnold LDW. The cost-effectiveness of using banked donor milk in the neonatal intensive care unit: prevention of necrotizing enterocolitisJ Hum Lact May;18, 2002, (2):172-7

Boyd, CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis.  Archives of Disease in Childhood – Fetal and Neonatal Edition 2007;92:F169-F175

Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 1.

McGuire, W, Anthony MY. Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: systematic review Arch Dis Child Fetal Neonatl Ed. 2003 8 F11-F14.

Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast milk for feeding preterm or low birth weight infants (review). Cochrane Database of Systematic Reviews 2007; 1-41.

Silvestre D, Ruiz P, Martinez-Costa C, Plaza A, Lopez MC. Effect of pasteurization on the bactericidal capacity of human milk. J Hum Lact. 2008 Nov;24(4):371-6. Epub 2008 Sep 10.

Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O’Shea TM. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. 2007. J Perinatol Jul;27(7):428-33

Sullivan S et al.  An Exclusively Human Milk-Based Diet Is Associated with a Lower Rate of Necrotizing Enterocolitis than a Diet of Human Milk and Bovine Milk-Based Products The Journal of Pediatrics 2010; 156:562-7.

Tully DB, et al. Donor milk: what’s in it and what’s not.  J Hum Lact. 2001. 17: 152-155.

United States Breastfeeding Committee. Statement on the Safe Use of Donor Human Milk. Washington, DC: United States Breastfeeding Committee. 2008.

 

 

Babies, Breastfeeding, Childbirth Education, Newborns, NICU, Pre-term Birth, Research , , , , , , , , , , , , ,