24h-payday

Archive

Archive for March, 2011

Babies and No Woman, No Cry: Stories, Culture and Birth

March 31st, 2011 by avatar

The mother’s womb is replaced by the womb of culture, which, comfortably or uncomfortably, cradles us all (Robbie Davis-Floyd 1992: 149).

 

Pregnancy, birth, breastfeeding –these practices are simultaneously natural and universal,  connecting women across the world and over history. They are profoundly local and culturally shaped, with the potential to divide women from men, but also from other women in different circumstances.

In the past couple of weeks, I’ve had the pleasure of viewing two documentary films that examine reproductive experiences across culture, and stimulate a reconsideration of culture and birth.  The first, Babies, is a French

Photo credit: http://focusfeatures.com/babies

documentary released in 2010 which centers on four babies from birth to their first birthday: Mari in Tokyo, Japan; Hattie in San Francisco, CA, US; Opuwo in Namibia, and Bayar in Baynchandmani, Mongolia.   Babies is a delight to watch, and interestingly, it features no dialogue, no subtitles and no narration.  The babies really are the center of the film—we see the world as they encounter it, whether a pet cat swishing by on the hard wood floors or a goat checking out the bath water through the window of a yurt.  Each baby’s lifeworld is vividly and intimately shared.   The film’s balanced portrayal of each culture means that we see the US as only one of many places a baby can be born and grow up.  Even things we think are universal and timeless, such as birth and breastfeeding, are profoundly shaped by the cultural context in which they occur. Robbie Davis-Floyd’s quote is apt here:  culture can be a comfortable cradle, as it is for these individual babies, who are loved, healthy and safe.

However, without a cultural context, we have no way of knowing how their mothers’ journey through pregnancy and birth affected their outcomes and life chances.   Not all babies and mothers have an equal chance at a healthy pregnancy, birth and first year of life.   A new documentary film on maternal health, No Woman, No Cry, introduces us to at-risk pregnant women in four parts of the world: a remote Maasai tribe in Tanzania, a slum of Bangladesh, a post-abortion care ward in Guatemala, and a prenatal clinic in the United States. Directed by Christy Turlington Burns, former fashion model, now mother of two, a public health master’s student at Columbia University, NYC and an ambassador for CARE – the film is a courageous and inspiring look at the reality of women’s lives when pregnancy occurs in the context of ill health, lack of access to timely and quality care, so that birth is a precarious, life-threatening event.

No Woman No Cry had its world premiere at the Tribeca Film Festival in NY last year, and is on a select west coast tour during which I saw it in the company of many public health students and professionals at the University of California, San Francisco campus in Mission Bay, SF.  Speaking on the panel after the film were Suellen Miller, PhD, CNM, Associate Professor at UCSF [Director, Safe Motherhood Programs, Dept. Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy,  Center of Expertise, Women's Health and Empowerment, Global Health Institute]; Nan Strauss, a researcher at Amnesty International USA and the co-author of 2010 report on US maternal mortality, “Deadly Delivery: The Maternal Health Care Crisis in the US” and Christy Turlington Burns herself.

No Woman, No Cry is a beautifully photographed film, with haunting images.  The music is a perfect accompaniment, never obtrusive.   I admire Ms. Burns’ vision for this film:  to tell a story “giving viewers an informative and powerful look at this compelling global issue without having to leave their ZIP code.”  One such story is that of Janet from Tanzania, whose labor in her third pregnancy was long and protracted, and for whom the $30 bus fare to the hospital was a nearly insurmountable obstacle.  Another story portrays the immense cost of anti-abortion policies on women’s health with a focus on a Guatemalan physician, Dr. Linda Valencia, whose mission is to educate women about contraception and

Country Estimated MMR* Lifetime Risk of Maternal Death:  1 in __
Bangladesh 340 110
Guatemala 110 210
United Republic of Tanzania 790 23
United States 24 210

provide nonjudgmental medical care to them following self-induced abortions.   In Dhaka, Bangladesh, the focus is on Monica, a young mother living in the slums whose labor requires a visit to the hospital, where she is helped , but experiences as very traumatic due to her poverty and how she is treated.  Finally, the US context, while not in the same scale as the other countries, is an important part of this story, showing that developed countries cannot be complacent. The US has fallen in world ranking to 50th, with maternal mortality ratios (24) higher than almost all European countries, as well as several countries in Asia and the Middle East  according to statistics released in September 2010 by the United Nations.*   The burden of worsening maternal health outcomes is felt most strongly by African American women, who face a three-four fold higher risk of death than women of other race/ethnicities, the largest and most long lasting disparity in public health.  But as the film points out, some maternal causes of death do not distinguish by race or class – as the example of the woman who died from an amniotic fluid embolism, a common yet less preventable cause of death than more prevalent issues such as cardiovascular disease, hypertensive disorders and hemorrhage.

The film invites questions and dialogue.  For those not familiar with pregnancy and associated risks, the stark presentation of women whose lives are at risk due to their cultural and individual circumstances may overshadow the reality that for many women, pregnancy is a low risk event.  Even in Dhaka, where the lifetime risk of maternal death is 1 in 110, many women have babies without incident.   The comparative risks are less elaborated, as is a discussion of the dual problems in maternity care – under utilization of medical care for some women and over utilization of medical interventions, including cesareans for others.  Evidence of our greater misunderstanding of the gravity of this problem, the audience gasped when panel member Nan Strauss informed them that the US cesarean rate is now 33%.

Pregnancy and childbirth can be a joyous, rather than feared and dangerous time, but this requires a global reprioritization of women’s reproductive health care.   This can be done, with enough political, and moral, will.  The obvious cost of a maternal death is seen in the eyes and heard in the voice of the US widower, who is clearly bereft after the death of his wife.  Yet the  hidden costs of maternal death are found in the torn social fabric remaining when a woman dies needlessly in childbirth — as a worker and major contributor to the household income and food sources, and as a mother, sister, friend.

There are more stories to tell than this film had the time or space to do.  These include stories of poor women in the US, the voices of politicians who vote for increases in certain types of spending over that of maternal health – and of course, the voices of women in the US and the world, speaking out for the mothers who die.

Posted by:  Christine Morton, PhD, CD

 

 

Disclaimer: Christine Morton provided consultation to the film’s producers, and has retweeted and been retweeted by Christy – we follow each other on Twitter.

 

[For both documentaries, much more information, background and context, is provided on the websites and here].

*WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf.


Films about Childbirth, Maternal Mortality, Maternal Mortality Rate, Uncategorized

Outrageous Price Charged for 17 alpha-hydroxyprogesterone caproate (17OHP): A Blessing in Disguise?

March 30th, 2011 by avatar

A recent New England Journal of Medicine commentator was shocked, shocked, to find that a drug company was price gouging. Joking aside, this is a particularly egregious example of Big Pharma behaving badly. After locking in the right to manufacture 17OHP, K-V Pharmaceutical Company raised the price of treating one pregnant woman at risk for preterm birth by virtue of a prior preterm birth from $300 to more than $29,000, limiting access, according to the commentary, to “the drug’s demonstrated clinical efficiency against a complication for which there are few effective preventive options.”

Why might this be a blessing in disguise? Earlier, I did a blog post, “Does Progesterone Treatment Prevent Preterm Birth? A Case of ‘Skim Milk Masquerades as Cream’”, questioning the effectiveness of progesterone in women with prior preterm birth, including a critique of the trial the commentary cites as demonstrating the effectiveness of intramuscular injections of 17OHP. In that trial, progesterone did not reduce the rate of preterm birth. The rate remained what it had been in similar women before the trial began. Instead, the rate in the control group was much higher than before, and that’s what created the difference between groups. Moreover, the rationale for progesterone is quieting the uterus, but it didn’t do that either. Just as many women in the progesterone group as the placebo group needed treatment for bouts of preterm contractions. Furthermore, another, bigger trial reported no difference in preterm birth rates. So much for “effective.” As I also pointed out in the earlier post, we have no data on the long-term effect of exposing fetuses to weeks of excessive levels of a sex hormone. True, exposure starts after sex organs have developed, but there is more to differentiating boys from girls than looking different, and it is mediated by an ongoing interplay of hormones. The new price barrier could, therefore, protect women and their babies from a treatment that probably doesn’t do them any good and might do their babies harm.

As for lack of preventive options, a social intervention holds great promise. A randomized controlled trial of group prenatal care by midwives (A.K.A. “Centering Pregnancy” ) was published in 2007 in Obstetrics and Gynecology—in other words, hardly buried in an obscure journal. Participants were 1000 women, most of whom were low-income black women, a group at high socioeconomic risk for preterm birth, who were assigned to either group prenatal care or standard care. The preterm birth rate was 14% in the standard care group versus 10% in the group prenatal care group, a one-third risk reduction after controlling for factors that increase risk of adverse perinatal outcomes. In African-American women, the reduction was even more striking: 16% versus 10%. Nothing, nothing anyone ever has tried has reduced preterm birth by a third in a general population.

Why would group prenatal care work? Because preterm delivery is strongly associated with chronic maternal stress. Group prenatal care builds community and helps women feel more competent and confident, as shown by the trial’s other positive outcomes: women in group sessions were less likely to have suboptimal prenatal care, knew more about pregnancy, felt better prepared for labor, were more likely to initiate breastfeeding, and were more satisfied with their prenatal care. With social interventions, everyone wins, not just women spared a preterm birth. Best of all, there is NO downside to group prenatal care, no worries about adverse effects of treatment short- or long-term. As has been said about doula care, another social intervention—which, BTW, is thought to work the same way to reduce cesareans by reducing fear and stress in labor—if group prenatal care were a drug, clinicians would have rushed to obtain it for every hospital pharmacy in the country. And you can bet that providing group prenatal care would cost a lot less than $30,000 per person and probably not even as much as $300, the cost of the cheap version of 17OHP.

Of course it is disappointing that 17OHP isn’t what it’s being cracked up to be. But social interventions have yet to be tried, and at the very least, as the 18th century French surveyor Cassini de Thury said,

 

“It is better to have absolutely no idea where one is than to believe confidently that one is where one is not.”

 

Posted by: Henci Goer

Doula Care, Evidence Based Medicine, Pre-term Birth, Science & Sensibility , , , , , , , , ,

Birth Matters: The Latest Book from Midwife Ina May Gaskin

March 29th, 2011 by avatar

In my recent response to the editor about an article published in Clinician Review (which, by the way, still remains unanswered), I discussed my beliefs on why more than just pregnant women, and the birth workers with whom they interact, ought to care about pregnancy and birth.  Last week, during a long drive home beside the barely-thawing Yellowstone River, I discussed this same issue with a dear doula friend of mine:  birth has got to matter to more than just those of us working in this field, and the women we tend to.

And so, hackles still raised, I am particularly refreshed to see Ina May Gaskin has released yet another book, entitled Birth Matters, which apparently discusses just this issue:  why does and should childbirth matter to the whole of our human species…not just an isolated segment of us?

To read a lovely interview with Gaskin about her new book, check out what Babble posted recently.

To you, the reader:
*Why does the issue of childbirth matter to you?  *Who else do you think needs to be apart of this ongoing dialog?
**I challenge each and every reader of this post to forward it onto one person who might not otherwise be drawn to frequently thinking and talking about birth.

Birth matters to all of us–whether we think so or not, whether our work lives bring us adjacent to childbirth or not–because it affects all of us in one way or another.

Posted by:  Kimmelin Hull, PA, LCCE

Uncategorized , , , ,

Breastfeeding: The First Few Weeks of Life

March 27th, 2011 by avatar


Colostrum We know that a mother produces colostrum in pregnancy and continues to do so for up to 10 days or so after her baby is born.  We know that newborn babies require nothing other than colostrum and that though it is not there in plentiful amounts it is adequate for baby’s growth and health[1].  Yet, how often do we hear that a mother must begin expressing her milk because she probably won’t have enough?  We know that a baby who is well latched with an asymmetric latch will get the colostrum that is there, and a poorly latched baby won’t[2], and yet we see thousands of mothers in our clinic who have been taught to latch baby symmetrically.  Instead of adjusting the latch for better milk

Image Source

transfer mothers are being told to pump.  And incidentally, colostrum does not respond well to a pump, it responds better to hand expression.  And so when mothers can pump nothing,  they are told they have no milk.  Best to adjust the latch and use breast compressions[3] and watch for baby’s drinking (don’t listen, you are unlikely to hear a baby drinking at that age)[4].


Engorgement
Contrary to popular belief engorgement is not a sign mother has a lot of milk.  Engorgement is a sign things have gone wrong.  And worse off, if the engorgement is severe enough it can cause depletion in mother’s milk significantly on that breast, perhaps even for the breastfeeding experience of that baby.  To avoid this, latch asymmetrically and deeply.  Ensure baby drinks well, use breast compressions (see the video clip and info sheet at www.nbci.ca for the “how to”) to ensure the milk continues to flow.  Keep baby skin to skin so mother will be able to read baby’s early cues and thus the necessary frequency of feeding that needs to happen (no timing how long per side or how long in between feeding, no counting sucks or drinking, no schedules[5]—just following baby’s early cues and keeping baby drinking) and that will suffice.  If mother does become engorged then using RPS [6],[7](Reverse Pressure Softening), developed by Jean Cotterman, will allow the baby to latch on immediately and drain the breast, see www.nbci.ca for the info sheet on engorgement.  It is very important not to pump engorged breasts, nor to massage downward toward the nipple.  Once baby is on, use breast compressions (which are always stationary) to keep baby drinking.

 

Sore Nipples We also know that a well-latched baby should not cause mother pain[8] and yet women are told around the world to put up with the pain, or grin and bear it because it is supposed to hurt.  A troubling practice is one where the mother is told to unlatch baby and re-latch over and over until she gets it right—this repeated activity can cause damage to the nipple and is not only painful, mothers become so dejected by doing it.  Instead, it’s best to adjust the latch mother has already by ensuring the nose stays far away from the breast and keep baby drinking.  Of course, if mother felt that the latch was absolutely unbearable and she could get a better one if she tried again, by all means.   Mothers are also told to prepare their nipples (a completely non-evidenced informed practice!!) and to apply various creams and ointments on their nipples: petroleum jelly, lanolin-based creams, nipple balms—none has been supported by research.  Some make matters worse.  Again, simly by adjusting the latch the pain is dealt with—if not, there is something else going on.

[Lastly, if the above measures have failed to reduce soreness,] check for tongue tie [9],[10],[11].


[1] GamePlan for Protecting and Supporting Breastfeeding in the First 24 hours of Life and Beyond. Kernerman, E. 2010

[2] L-eat Latch and Transfer Tool, Kernerman, E. Park, E, Newman, J, Kouba, J. 2010

[3] Breast compressions info sheet, www.nbci.ca

[4] L-eat Latch and Transfer Tool, Kernerman, E. Park, E, Newman, J, Kouba, J. 2010

[5] Kent JC, Mitoulas LR, Cregan MD, et al. Volume and frequency of breastfeedings and fat content of breastmilk throughout the day. Pediatrics. 2006;117(3):e387-95

[6] Engorgement info sheet, www.nbci.ca

[7] Cotterman KJ. Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement. J Hum Lact 2004 20: 227-237.

[8] Righard L Alade MO. Effect of delivery room routines on success of first breast-feed. The Lancet 1990; 336:1105-07

[10] Dollberg S, Botzer E, Grunis E, Mimouni FB. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study. J Pediatr Surg. 2006; 41(9):1598-600.

[11] Geddes DT, Langton DB, Gollow I, et al. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008; 122(1):e188-94

 

Breastfeeding, Uncategorized , , , , , , , ,

Childhood Vaccinations – Safe and Healthy

March 25th, 2011 by avatar

[Editor's Note:  Recently, Science & Sensibility reader and childbirth educator, Lucy Juedes, wrote in hoping to see a blog post on the topic of childhood vaccinations.  After very little arm twisting, Lucy was coerced excited to compile the following post, complete with guidance as to how she approaches this topic, while teaching classes.]

 

Introduction
My community, perhaps like yours, seems to have a growing number of parents who don’t vaccinate their kids.  These diseases, such as highly contagious pertussis (whooping cough) and measles, are showing up in more and more outbreaks, affecting more and more of our families.

As Lamaze Certified Childbirth Educators, we are in an excellent position to share the strong evidence supporting childhood immunization, while listening to and addressing parents’ concerns in an open, caring setting.

 

Evidence-Based Vaccine Information
From a parental perspective, the primary issue to address regarding vaccines is safety.  And, from an evidence perspective, the overwhelming majority of immunology and public health experts have found the currently recommended vaccines to be safe for the overwhelming majority of children.  Vaccines are tested on more people for longer durations than any other drugs.  Innovations have decreased the number and scope of side-effects.  And there is a full-circle program to promptly notify governmental health experts of any rare adverse events.  (Offit)  It would be nice if there was this much expert consensus about the use of common interventions in childbirth, such as continuous electronic fetal monitoring or denying food to a laboring woman!

And, whether we look at the Centers for Disease Control and Prevention, the World Health Organization, medical organizations such as the American Academy of Pediatricians or The American Academy of Family Physicians, leading medical facilities such as the Mayo Clinic, or established organizations like The March of Dimes, they all have the same message:  vaccination against preventable childhood diseases is safer and healthier than not vaccinating.  We only need to examine history to see the alternative to not vaccinating:  natural selection.  (Diamond)

 

Vaccination Talk
A little context first.  By the time I share the vaccine information, the moms and partners are pretty steeped in three key ideas:  evidence-based decision making, the parents as the best decision-makers for their families, and that mirroring each others’ decisions isn’t necessary.  Most of the moms and partners talk a lot in class (Any question, any time!), so I’ve had ample opportunities to share how they can use these ideas in the wide range of decisions they’ll make about their own and their child’s care.  These key ideas help parents to hear the very strong evidence-based nature of vaccinations as well as that they are the best people to decide what to do, and that they can decide differently than their friends and remain good friends.

So, what do I do in my class?  I share that vaccinations do a great job of preventing childhood diseases—the best we’ve come up with so far.  Vaccinations are safe for just about everyone and will keep their baby healthier than not vaccinating.  I suggest that their doctor or nurse will ask specific questions to prevent an allergic reaction, such as if the child is allergic to eggs (some vaccine viruses are grown in chicken eggs).  And I share the above information about the evidence-based foundation supporting vaccinating according to the suggested CDC/AAP/AAFP schedule.

This discussion takes about five minutes, and I hand out the list of childhood diseases and vaccines that prevent them and the suggested time line, downloaded from the CDC’s web site.  I also offer the web sites of the above listed organizations should folks want more information.



 

Specific Questions from Participants
Inviting participants to share details of what they’ve heard or read is a great way to encourage class dialog about this topic.  My goal here is to discover concerns, as well as common myths or misgivings about vaccination, and to address these simply and quickly.  Here are the three most often asked questions and my responses.

 

I’ve heard that vaccines have mercury in them and that they cause autism.”

 

“Vaccines contain very little mercury, and they don’t cause autism.  About autism, there’s absolutely no evidence of a link between vaccines and autism.  It’s understandable that a parent might think there is because autistic characteristics are often noticed around 18 months, and by that time, at least one part of all the suggested vaccines have been given.  But specialists in the academic and public health areas have studied this up and down and have found no link.  And not just doctors, but specialists in immunology and child health. (Offit)  Actually, the closest researchers have come to finding a cause for autism are recently discovered rare, very unique genetic variations in children with autism. (Shute)

“You also mentioned mercury.  The active ingredients in vaccines need to be preserved in order to stay effective.  Some vaccines, like the Measles, Mumps, and Rubella vaccine that was used before 2001, use thimerosal as this preservative, and thimerosal has mercury in it.  However, since 2001 thimerosal has been taken out of all vaccines recommended for young infants.  But autism has increased, not decreased.” (Offit)

 

“We’re thinking about doing an alternative schedule — it seems like there are so many vaccines given to a baby.  Too many for their little bodies to handle.”

 

“Actually your baby is exposed to many, many more microbes, bacteria, and viruses every day—many more than are in vaccines.  And a single infection of the common cold causes a much stronger reaction in a baby than if we were to give all the suggested vaccines at one  time to him or her.  The science behind vaccines has been refined a lot in the century+ that we’ve been making them. Now, there are very few ingredients in them—even with the grouping of vaccines into one shot like in the MMR and DTaP.  And nothing else will help their little bodies develop strong defenses against these diseases than the associated vaccines. The sooner babies are immunized, the sooner they’ll become more protected.”  (Offit)

 

“I’m worried about our baby being allergic to something in the vaccine, and if we give several vaccines to our baby at the same time, how will we know which one caused it?”

“On its web site, the CDC has a thorough list, likelihood, and timing of all vaccine allergic reactions or side effects.  As you look at each new round of suggested immunizations, it could be that the vaccines’ possible side effects don’t overlap, so it would be clear which vaccine caused a reaction.  Or, if side effects were similar, most reactions usually show up a few hours to a few days later, so you could space the shots a few days apart.  And the side effects are generally nothing that a little TLC and maybe a fever or pain reducer won’t take care of.  And I want to stress that even the mild side effects are uncommon and the difficult side effects are rare, or why would our health experts recommend the vaccines?

“Be ready to comfort your baby after the shots while still in the Dr.’s office, especially with breastfeeding.  And I don’t tell my baby not to cry; that’s how they communicate with us.  Often babies are fine a few minutes after.”

 

Our overall vaccination discussion generally takes about 10 minutes.  By the end of it, the moms and partners know the strength of the evidence supporting vaccinating.  They also have more information to use in discussions with each other, family members and friends, and to supplement their search for information.

 

Other Class Discussions Related to Vaccination
Vaccination discussions don’t only come during the specific talk at the end of class.  At the beginning of class when we talk about staying healthy while pregnant, I talk about the protection that the current seasonal and H1N1 flu vaccination gives pregnant women.

When we talk about choosing the baby’s doctor, we talk about finding a caregiver with a similar approach to health as they have.  I also note that as many as 4 in 10 practitioners won’t see non-vaccinating families. (Offit)  Also, if a parent decides not to follow the suggested schedule, I suggest they should be prepared for the doctor or nurse practitioner to ask why, out of concern for the health of the baby, the family and the community at large.

Lastly, if we talk about choosing a child care provider to watch our babies when we go back to work or school, I suggest that they can ask if the child care provider and other children present are up-to-date on vaccinations.

 

Closing
As Lamaze Certified Childbirth Educators, most of what we share is about childbirth.  Yet, we are also helping new families prepare for life beyond birth, well into their little ones’ toddler years and beyond.  By focusing on the evidence-based support for vaccinations with parents as the best decision makers for their children, we are helping create healthier babies, healthier families, and healthier communities.

 

References

1. Diamond, J.  (1999). Guns, Germs, and Steel:  The Fates of Human Societies.  New York, NY, W. W. Norton & Company.

2. Offit, P. A.  (2011). Deadly Choices:  How the Anti-Vaccine Movement Threatens Us All. New York, NY, Basic Books.

Shute, N.  (2010). Desperate for an Autism Cure.  Scientific American, October, 80 – 85.

3. 2011 Recommended Immunizations for Children from Birth Through 6 Years Old. The Centers for Disease Control and Prevention.  http://www.cdc.gov/vaccines/spec-grps/infants/downloads/parent-ver-sch-0-6yrs.pdf

Posted By:  Lucy Juedes 

Lucy is an LCCE and created Birth Prep Basics, serving the needs of growing
families in Southeastern Ohio. She is also the mother of three young children.
Prior to this she worked in public relations and marketing.

 

 

 

 

Evidence Based Medicine, Guest Posts, Research, Science & Sensibility, Uncategorized , , , , , , , , ,