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News & Research Round-up: In Transition Edition

October 27th, 2010 by avatar

It’s been a busy week or so. In addition to my mad flurry to finish several projects before I begin with Childbirth Connection next week, we’ve been busy reviewing the many great applications we got for Community Manager of this blog. I’m glad I’m not the one who has to choose, because I love so many of the applicants and get excited about the different ways this blog could evolve under any of them.  (Lamaze should be able to announce the new Community Manager by early November. Watch this space!)

Meanwhile, the world hasn’t stopped offering up fascinating things to blog about. So, here’s a round-up!

Speaking of round-up, the Lamaze Annual Conference returns to Texas in 2011. Abstracts are being accepted.

On the heels of my recent post about the limitations of standard evidence, the media and internet have been full of thought-provoking articles about the integrity and best use of scientific research. The Atlantic Monthly profiled one of the most outspoken skeptics of medical research in the feature-length article, “Lies, Damn Lies, and Medical Science” and e-Patients.net followed it up with a nice companion piece aptly titled, “Fixing Those Damn Lies.” Kent Bottles at the Health Care Blog weighs in on the politics of comparative effectiveness research, and Rachel Walden from Our Bodies, Our Blog offers a round-up of her own, with links and insights from the recent joint meeting of Consumers United for Evidence-Based Healthcare, the Cochrane Collaboration, and the Campbell Collaboration.

The Institute for Healthcare Improvement will offer several sessions on perinatal care at their upcoming National Forum, taking place December 5-8, 2010 in Orlando, FL: a learning lab entitled “Reducing Elective Near-Term Deliveries: When Doing Nothing Is the Right Thing” and a workshop “The Next Evolution of Neonatal Intensive Care,” among others.

The Effective Health Care Program of the Agency for Healthcare Research and Quality (AHRQ) is offering a free webcast, “Applying Existing Evidence to Obstetric Care on November 10 from 12:00 – 1:00 pm ET. The program will highlight AHRQ’s patient-centered outcomes research and review ways it can be used to support decision-making in clinical settings.

Several bloggers have written posts for the forthcoming blog carnival to raise awareness about Agnes Gereb, a Hungarian doctor and midwife who was jailed for attending an out-of-hospital birth. Rixa at Stand and Deliver has a nice summary of the issues. I have a post up at Giving Birth with Confidence about my two home births, one of which took place in a state where my midwives could have been arrested for attending me.

And in the maternity care journals:

Through November 15, the journal, Midwifery, is offering free access to a suite of articles on patient safety in maternity care. The issue includes contributions from former Science & Sensibility guest contributors Debra Bingham and Christine Morton.

If you’ve been around women laboring out of bed, you may have suspected that the purple vertical line on a woman’s low back late in labor signifies full dilation. Someone has finally studied this. (It correlates, but isn’t foolproof.)

Kathleen Fahy and Carolyn Hastie, subjects of one of my Consider the Source interviews, have, along with several additional co-authors, published a study comparing the outcomes of “holistic physiologic third stage care” with active management of the third stage. Their study, which looks only at low-risk women who had spontaneous vaginal births and no risk factors for hemorrhage, showed a markedly lower rate of postpartum blood loss in the women receiving physiologic care.

A woman’s brain grows after giving birth, and that growth happens in the areas of her brain that regulate how she responds to her infant.  The same research team that conducted this study published a 2008 study in which they reported differences in brain activity between women who had vaginal births and other women who gave birth by cesarean. Both studies were small and limited, but I’m interested in watching for more research from the Yale Child Study Center. It has potential implications for labor and birth care as well as how we approach postpartum care and support.

I know I’ve missed plenty of other goodies. Feel free to leave your favorite links in the comments! I’ll be blogging for Lamaze for several weeks longer, then when the new Community Manager is all up to speed, I’ll be posting less frequently and on behalf of Childbirth Connection.  Transition is hard, but in the end leads to great things…

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Do Cesareans Cause Endometriosis (Redux): What could patient-driven research look like?

October 11th, 2010 by avatar

This post is part of the forthcoming Grand Rounds Blog Carnival at e-patients.net. Contributors were asked to write a post “inspired by, supportive of, or critiquing an article in the Journal of Participatory Medicine.” I chose as my inspiration Gilles Frydman’s Patient-Driven Research: Rich Opportunities and Real Risks.

When I started this blog a year and a half ago, my primary motivation was my belief that childbearing women deserved, above nearly all else, care that was “evidence-based.”  As I prepare to hand over the reins to a new Community Manager, I want to say to my readers and to my successor: I was wrong. Evidence doesn’t hold all of the answers.

There are many reasons I have come to believe this, but there are two I want to write about today. The first is that the way research is currently funded, conducted, and disseminated, it simply doesn’t address many outcomes that women care about.  The second is that we all arrive at the point of healthcare decision making with a different constellation of factors that affect our choices. We may have different financial resources, health situations, hopes and plans for the future, tolerance to pain, tolerance to risk, prior experiences, and so on.

In other words, with the exception of practices that cause harm with no counterbalancing benefit at all or benefit with no risk of harm at all, there is no such thing as a good or bad healthcare decision. There’s only such a thing as a good or bad healthcare decision for a certain person. Evidence cannot guide practice without the other piece of the equation – the person to which the evidence is to be applied.

The more I think and write about these issues, the more I begin to wonder if there’s a better way of creating and disseminating knowledge than evidence-as-we-know-it. Underscoring this is a phenomenon that has unfolded over the past year right here on this blog.  In May 2009, Science & Sensibility contributor, Henci Goer, presented the findings of her review of the literature on cesarean surgery and a little-known complication: new onset endometriosis.  She wrote:

So why is this reasonably common serious adverse effect of cesarean surgery something you have never heard of?…Cesarean wound endometriosis would never turn up in a randomized controlled trial (RCT). Even if the problem made it onto the researchers’ radar, the trial would have to be extremely large and follow-up impractically long to detect it. Where RCTs are considered the only evidence worth having, outcomes that cannot be picked up on by RCTs functionally don’t exist.

It was kind of a technical post about the limitations of the hierarchy of evidence, using cesareans and endometriosis as the example. But an awesome thing happened. Women started finding the blog post, and sharing their own experiences with sometimes terribly debilitating endometriosis after cesarean surgery. It started with a well known cesarean activist confirming that the association between cesareans and endometriosis was “not news” to her – through her work she had met many cesarean mothers dealing with cesarean scar endometriosis. Then women who had experienced it themselves shared their insights, and asked questions, and others answered, and they got interested in eachother’s experiences and a community formed.

I highly recommend you read the original post and all of the comments, but you can also get a flavor by looking at this excerpt of the presentation I will give next week at the Digital Pharma East Conference in Philadelphia.

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We Have To Start Somewhere: Emergency Funds to Pregnant Women on Bed Rest in Financial Need

October 8th, 2010 by avatar

[Editor’s note: This is a guest post from Darline Turner-Lee, Owner and Founder of Mamas on Bedrest & Beyond. Darline is an outspoken advocate for women with high-risk pregnancies. She has teamed up with Better Bedrest for a fundraiser I think Science & Sensibility readers can get behind. -AMR]

Mamas on Bedrest & Beyond is holding a fundraiser to benefit Better Bedrest. Better Bedrest is a non-profit organization that provides one on one phone support to pregnant women on prescribed bed rest as well as micro grants up to $500 to women on bed rest in financial need. Currently, they are the only organization that provides emergency funding specifically and exclusively to pregnant women on prescribed bed rest. Better Bedrest is dangerously close to being out of funds. Without funds they cannot provide their micro-grants. To support Better Bedrest, I am selling a fitness DVD that I produced called Bedrest Fitness for $19.95, and donating $10/DVD sold to Better Bedrest. My goal is to raise $1000 and DVD’s can be purchased at www.mamasonbedrest.com/shop/dvd-fundraiser. (To make a donation directly to Better Bedrest, go to www.betterbedrest.org.)

I first became involved with Better Bedrest when I received a call from a local hospital here in Austin last spring. Jennifer, a single mother on bed rest, was about to lose her job, her income and her benefits. They asked me if I knew of any ways to help her out. I called Better Bedrest. They sent information to pass onto Jennifer and as a result, she got plugged into the organization and received some much needed emergency funds.

Recently, I spoke to Jennifer. She is still struggling to make ends meet some 6 months later. Her employer fired her at the end of her 12 weeks of allotted unpaid Family Medical Leave Act (FMLA) leave. She has post partum anxiety and depression for which she is taking medication and has been put on disability by her obstetrician. However, this is not enough for her long term disability insurance carrier. They have denied her claim stating that her situation is not “severe enough”. She has filed for unemployment and has Medicaid to help with her hospital bills but none of her other expenses are covered. This once proud, self sufficient single mother has been reduced to relying on the generosity of churches, charities and donations to make ends meet and to care for herself and her two boys.

I started Mamas on Bedrest & Beyond to offer the supports and services I needed when I was going through my own high risk pregnancies; help around my house, someone to run errands for me, to take me to the doctor if my husband was not able, someone to be there if I fell or began cramping….

I was so naive. These are needs of women on bed rest, but their true needs often go much deeper. I have learned that women on bed rest often lose their jobs because they are out of work longer than 12 weeks. A few have lost their homes. Women and their families have filed bankruptcy after being on bed rest and then delivering a premature infant who stayed in the NICU for several weeks resulting in phenomenal hospital bills. I have talked with moms who struggle to give their older children the care and support that they need while mom is on bed rest and seen how that has broken these mamas’ hearts. But mostly I have learned that the need for support-physical, emotional and financial- for women and their families while a woman is on bed rest is not simply to keep the household running while mama is down, but to help hold the very fibers of the family together so that the family is not fractured-sometimes beyond repair.

Much of the strife of bed rest comes from the fact that in the United States there is no mandatory paid maternity leave. There is the Family Medical Leave Act which mandates that employers of companies with 50 or more employees must offer employees 12 weeks of unpaid leave annually for pregnancy and/or to care for a newborn or adopted child, to care for a sick relative or to be treated for a major illness, without threat of job loss. If the employee’s absence exceeds 12 weeks, the employee is no longer guaranteed job protection. If a woman works for a smaller company, she has no job protection unless there are state mandates or internal mandates within the company. Five states and Puerto Rico offer some short term disability through which women may receive a portion of their pay while on maternity leave1. Federal employees have some of the most liberal benefits for leave, some of which may soon be paid leave. H.R.626 – Federal Employees Paid Parental Leave Act of 2009 states,

The bill is intended to…Provide that 4 of the 12 weeks of parental leave made available to a Federal employee shall be paid leave, and for other purposes.2

H.R. 626 is still pending passage in the Senate. It has already passed in the House.

My client tried to do the right thing. She had a job, worked hard and paid for her benefits.  Yet when she really needed them, she was denied the very benefits she has paid for faithfully for 3 years before ever filing a claim! She did her best to provide for her little family, but now that she is unable to do so, assistance is hardly forthcoming. By virtue of congressional votes against social services, Jennifer has been reduced to a penniless beggar.

Melissa Harris-Lacewell, Ph.D, professor at Princeton University and contributor to MSNBC recently said it best, (and I am paraphrasing her words)

Although I come from a long line of God fearing women, in these United States it is a sad commentary on our culture if the best that we can offer women when it comes to their reproductive health is prayer and hope that God will intervene on their behalf.

Better Bedrest has paid out approximately $9000 this year and Mamas on Bedrest & Beyond’s goal is to raise $1000 (by selling 100 DVD’s) on Behalf of Better Bedrest. They are small steps on a very long road, but we have to start somewhere.

References:

1. Family Medical Leavewww.dol.gov/dol/topic/benefits-leave/fmla.htm

2. HR 626 Federal Employees Paid Parental Leave Act of 2009

www.govtrack.us/congress/bill.xpd?bill=h111-626

3. The International Partnership “Expecting Better: A State by State Analysis of Parental Leave Programs”. http://www.nationalpartnership.org/site/DocServer/ParentalLeaveReportMay05.pdf?docID=1052

4. The Work, Family and Equity Index: Where Does The United States Stand Globally

www.hsph.harvard.edu/globalworkingfamilies/images/report.pdf

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Midwifery Week, Disparities, and Models of Collaborative Care

October 6th, 2010 by avatar

nmw_logo_2010

It’s National Midwifery Week!  So far, I’ve celebrated by (ever so briefly) attending the Lamaze-ICEA mega-conference, chairing an event here in Connecticut with educational lectures and an inspiring presentation from a local midwives who helped in the Haiti relief efforts, honoring the midwives who cared for me during my son’s birth four years ago, and announcing publicly that I am hanging up my birth bags in exchange for a fantastic job at Childbirth Connection.  And it’s only Wednesday! There’s plenty more Midwifery Week to come…

This Midwifery Week has me more hopeful than I’ve been in past years, in large part because of all that I just mentioned.  In addition, a few recent events inspire me to believe that maternity care is poised to change for the better, and that midwives and midwifery advocates will be a major force for that change.

1. Last month, I took part in one of two regional roundtable events sponsored by the Office of Women’s Health and coordinated by the Center for Women in Politics and Public Policy at UMass-Boston. Midwifery Care in New England: Addressing the Needs of Underserved and Diverse Communities of Women were events aimed at initiating dialogue about health disparities in the region and the role that midwives play in ensuring that all women receive the care they need. This was the first meeting I’ve attended that addressed midwifery practice but was convened by people who were not midwives.  It gave midwives and other stakeholders a chance to really look at the public health and policy implications of midwifery practice, and to address the system barriers to providing optimal care to vulnerable populations. Even more exciting: it was just the first event in what will be a series of meetings and reports, and possibly funded demonstration projects.

2. ACNM and ACOG are jointly calling for papers describing successful and sustainable models of collaborative practice involving obstetrician-gynecologists and certified nurse-midwives/certified midwives. One of the major recommendations in the Transforming Maternity Care Partnership’s Blueprint for Action was to, “Develop, test and implement interventions to improve collaborative practice among primary maternity caregivers and other members of the maternity team.” This joint effort by ACOG and ACNM demonstrates an important step toward implementing that recommendation.

3. Representative Lucille Roybal-Allard (D-CA) introduced a bill called Maximizing Optimal Maternity Services for the 21st Century (also known as MOMS-21 and H.R. 5807) that has 42 co-sponsors in the House. The bill is in the early stages of the legislative process, but there is momentum on Capitol Hill to look seriously at maternity care quality improvement and rein in excess costs. More legislation is likely to follow so stay tuned about how to support these bills. You can start by telling the candidates and elected officials in your state that maternity care matters to you, and that you support MOMS-21!

Whether you are a midwife, had a midwife, work with midwives, or support midwives, Happy Midwifery Week!

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Beating the Winter Blues: Bright Light Therapy for Seasonal and Non-Seasonal Depression

October 3rd, 2010 by avatar

Some people dread the change of seasons. Shorter, darker days mean fatigue, oversleeping, too many carbs, and having a general sense of malaise: a pattern known as seasonal affective disorder (SAD). Seasonal affective disorder is depression that occurs during late fall and winter months, as darkness occurs earlier in the day.  Symptoms include depression, lethargy, difficulty waking, and craving carbohydrates, which often leads to weight gain (NAMI, 2007). With winter approaching, it’s important that we recognize that seasonal depression may be an issue for some of the women we see. Fortunately, safe treatments for pregnant and breastfeeding women are available.

For more than 20 years, clinicians have used bright light therapy to successfully treat seasonal affective disorder. Light therapy has far fewer side effects than medications and can provide relief within days (NAMI, 2007). In a recent clinical trial, light therapy was as effective as fluoxetine in relieving symptoms, and patients who received light therapy had an earlier response to treatment with fewer side effects (Lam et al., 2006).

Researchers have recently discovered that light therapy is also helpful for other affective disorders, including non-seasonal depression, antenatal and postpartum depression, bipolar disorder, some eating disorders, and certain sleep disorders (Oren et al., 2002; Terman & Terman, 2005).  In a 2005 meta-analysis, the American Psychiatric Association indicated that bright light therapy was an effective treatment for both seasonal and non-seasonal depression, “with effect sizes equivalent to those in most antidepressant pharmacotherapy trials” (Golden et al., 2005, p. 656).

Light therapy can also be safely combined with medications in most cases, and can boost the activity of medications in patients who are either not responding or who have had a partial response. Terman and Terman (2005) summarized the results of several recent clinical trials where patients were given either bright light therapy (10,000 lux) or dim light (2,500 lux) in addition to their medications. They noted that in all of these studies, bright light improved both remission rate and speed of improvement.

Light Intensity, Duration, and Timing of Light Exposure

Although a number of light intensities have been investigated, lights with intensities of 10,000 lux, with 30 to 40 minutes of exposure, appear most effective (Terman & Terman, 2005).  Two studies with light exposures of 30-40 minutes at 10,000 lux achieved a 75% remission rate. It took 2 hours to achieve similar remission rates with 2,500 lux. And in some cases, even with longer exposure, lower-intensity lights are not as effective (Terman & Terman, 2005). Also, when longer exposure times are necessary, patients are less likely to comply. This may particularly be true for mothers of young children who probably won’t find it practical to sit for two to three hours in front of a light box.

Timing of light exposure also makes a difference. Exposure to bright light is generally much more successful in achieving remission if it occurs in the morning.  Terman and Terman (2005) cited one analysis of 332 patients, across 25 different studies, that compared administration of light in the morning, mid-day and evening. They noted remission rates after one week of treatment, with significantly higher rates in the morning (53%), compared with mid-day (32%) and evening (38%) exposures.  According to their analysis, morning light should be administered 8.5 hours after a patient’s melatonin onset. Melatonin onset can be difficult, or impractical, to assess directly. However, the Center for Environmental Therapeutics (www.cet.org) has a free online questionnaire that will help patients estimate this and calculate individual treatment time.

Because of the effectiveness of morning light exposure, a variant to standard light therapy has recently been added to the repertoire of possible treatments: dawn simulation. As the name implies, dawn simulation refers to a light that comes on before a patient is awake, and gradually increases in intensity over a period of 15 to 90 minutes (the length of the sunrise can be tailored to individual preference). The advantage to this treatment is that it does not require sitting in front of a light box for an extended time, making it a more practical alternative for new mothers or mothers of young children. Although a relatively new technique, it is showing promise as a treatment for SAD (Golden et al., 2005). Some newer lighting devices are both light boxes and dawn simulators.

Why Light is Effective?

A number of possible mechanisms for light’s effectiveness have been proposed. Most explanations have to do with modifying the internal circadian clock.  Our circadian rhythms, or daily patterns of sleep and arousal, are regulated by the pineal gland, which secretes melatonin. The pineal gland responds to light via light receptors in the retina. Exposure to light in dark winter months appears to reset the internal clock. The antidepressant effect is stronger when patients are exposed to morning, rather than evening light. This is likely due to the diurnal variations in retinal photoreceptor sensitivity, with greater sensitivity to morning light. Indeed, exposure to evening light can lead to insomnia and hyperactivation in some people (NAMI, 2007; Terman & Terman, 2005). One exception to the use of morning light is in patients with bipolar disorder. Morning light exposure can increase risk of a manic episode. This problem can be addressed by timing light exposure later in the day and having them continue on their medications during light treatment (NAMI, 2007; Terman & Terman, 2005).

Safety Issues

Because light boxes can be relatively expensive (about $100 U.S.), and appear to be simple, patients often consider assembling a unit themselves. Just because they can, doesn’t mean they should. Clinicians generally recommend that patients don’t use homemade devices for several reasons. First, it is difficult for consumers to find lights that are of sufficient brightness to generate a therapeutic effect (despite advertising to the contrary). Second, some patients have experienced excessive irradiation, and corneal or eyelid burns with homemade devices. Finally, homemade devices often use incandescent lights. Some of these have been marketed for bright light therapy but are not recommended because approximately 90% of light output from incandescent bulbs is on the infrared end of the spectrum. Infrared exposure at high intensity can cause damage to the lens, cornea, and retina (Terman & Terman, 2005).

Light boxes with high levels of exposure to UV can also cause eye damage, and there is some controversy about the safety of blue lights. Safe light boxes are those encased in a box with a diffusing lens that filters out UV radiation (NAMI, 2007). “Full spectrum” bulbs are not necessarily advantageous and are often expensive. The National Alliance on Mental Illness (NAMI, 2007) recommends bulbs with a color temperature between 3000 and 6500 degrees Kelvin. These have not been shown to cause any harm to patients’ eyes. Patients wanting to try light therapy should only use a lighting apparatus from a reputable dealer (see Resources for a listing of possible sources). Since price may be an issue, many hospitals, and some manufacturers, have loaner programs that allow patients to try the lighting device in their homes before buying them.

Summary

Bright light therapy is a generally safe, well-tolerated treatment option for seasonal depression. It may relieve non-seasonal depression as well. Bright light therapy is also breastfeeding friendly and can be used during pregnancy. Although therapeutic light boxes can be costly at first, a single purchase will last for years. For patients who dread winter, this investment is often well worth the cost.

References

Golden, R.N., Gaynes, B.N., Ekstrom, R.D., Hamer, R.M., Jacobsen, F.M., Suppes, T., Wisner, K.L., & Nemeroff, C.B. (2005). The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry, 162, 656-662.

Lam, R.W., Levitt, A.J., Levitan, R.D., Enns, M.W., Morehouse, R., Michalak, E.E., & Tam, E.M. (2006). The CAN-SAD Study: A randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder. American Journal of Psychiatry, 163, 805-812.

National Alliance on Mental Illness (2007). Seasonal affective disorder. www.nami.org, downloaded 10/5/2007.

Oren, D.A., Wisner, K.L., Spinelli, M., Epperson, C.N., Peindl, K.S., Terman, J.S., & Terman, M. (2002). An open trial on morning light therapy for treatment of antenatal depression. American Journal of Psychiatry, 159, 666-669.

Terman, M., & Terman, J.S. (2005). Light therapy for seasonal and nonseasonal depression: Efficacy, protocol, safety, and side effects. CNS Spectrums, 10, 647-663.

Resources

Rosenthal, N.E. (2006). Winter blues: Everything you need to know to beat seasonal affective disorder, Revised Ed. New York: Guilford.

This book is the “bible” of self-help guides on SAD, written by the physician who first documented the phenomenon.

I’ve dealt with both of these companies and have found them to be reputable.

The Sunbox Company

www.sunbox.com

TrueSun.com

www.truesun.com

Kathleen Kendall-Tackett, Ph.D., IBCLC is a health psychologist, board-certified lactation consultant, and La Leche League Leader. She is clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. For more information, visit her Web sites: UppityScienceChick.com and BreastfeedingMadeSimple.com.

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