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To Vaccinate or Not to Vaccinate: Influenza Vaccination During Pregnancy

October 31st, 2011 by avatar

I recently followed a listserve discussion, the topic of which revolved around the influenza vaccine and its safety/efficacy/recommendation during pregnancy.

Vaccination has, of course, been a dicey topic approached within this blog community in the past—a divisive topic to be sure.  But when we are considering vaccination of a pregnant woman—the stakes feel even higher, with two (or more) individuals being involved.

There are certainly many resources out there which question the safety of childhood vaccination such as this one.  Likewise, numerous resources abound, describing the justification for and safety of vaccination.

If nothing else, the decision about whether or not to vaccinate—for a pregnant woman hoping to avoid influenza, or a parent hoping to protect their child from various illnesses—becomes a cost-benefit analysis:  Is the potential (physical/health) cost of vaccination worth the benefit of avoiding a given disease?

Now entering flu season, this debate over whether or not to vaccinate includes the influenza vaccine and pregnant women.  From the listserve, here are the comments of Dr. Mark Sloan, pediatrician and author of the *fabulous* book, Birth Day:

 

 

Here’s a pediatrician’s perspective:  This is my 32nd flu season working with children, and I strongly recommend influenza vaccine to the pregnant women I encounter, both for their own health and that of their babies. Infants (0-6 months) with influenza have a 30-fold increased risk of hospitalization compared with children ages 5-17 years. They’re much more prone to bacterial complications too, like pneumonia, and they have the highest mortality rate of any age group except the > 65 year old demographic. If a mother catches influenza, it’s almost a given that her baby will, too.

Personal experience: We hospitalized 15 children with influenza from our pediatric clinic last year – 8 were less than 6 months old. 6 of the 8 had no risk factors for severe disease, and 4 of that 6 were solely breast fed.

It’s good to emphasize less obvious complications as well. For example, even in milder cases, influenza can disrupt breast feeding from the baby’s perspective, whether from fussiness, lack of appetite, frequent cough, nasal congestion, or general exhaustion. And a mother with influenza can easily become dehydrated, compromising her milk supply. All in all, influenza is an excellent disease to avoid, and the best way to do that is vaccination.”

 

 

Those who may have experienced influenza in the past year or so will likely vividly recall the misery of high fevers, body aches, exhaustion, cough, lost time at work, etc., etc.  But, beyond the woeful symptoms caused by influenza, contracting the virus while pregnant can have additional negative effects on the mother and fetus.  The Organization of Teratology Information Specialists (OTIS) has this to say about influenza during pregnancy:

 

 

The influenza virus itself has not been shown to cause birth defects. However, having a high fever during pregnancy may increase the risk for birth defects. Therefore, fever during pregnancy should be treated. Acetaminophen is the drug of choice for reducing fever during pregnancy. Tylenol® is one brand of acetaminophen.  Being very sick from the flu may increase the risk of pregnancy complications such as miscarriage or premature delivery. It is important to talk with your doctor if you are pregnant and have symptoms of the flu.”

 

 

(You can read the rest of the information form OTIS regarding influenza/flu vaccine during pregnancy here.)

There are, of course, many, MANY more resources out there—both supporting and advising against—influenza vaccination in pregnant women, such as this paper published in the 2006 Journal of American Physicians and Surgeons.  Many of the dissenting opinions are based on a concern for inclusion of neurotoxic Thimerosal—a mercury-based ingredient used to preserve the vaccine and disallow bacterial growth within the vaccine vial.  Per the CDC, this year’s flu vaccine does contain Thimerosal in the multi-dose vials but does not contain the preservative in the single dose vials.  So, for pregnant women seeking influenza vaccination that is free of Thimerosal—asking for a vaccination from a single dose vial would be advisable.

 

As always, regardless of whether you (or someone you know) chooses to vaccinate or not, the other important prevention methods still hold:  wash your hands often, avoid touching your eyes/nose/mouth whenever possible, avoid being around people you know to be sick with the flu, stay well-hydrated, focus on eating healthy foods, and get plenty of rest.

I know many readers will have their own two cents to add to this discussion.  I encourage you to do so, including references to your pro/con points, as well as respectful and professional dialogue.

Wishing you all (and the expectant families with which you interact) good health!

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

News about Pregnancy, Vaccinations , , , , , , ,

Homicide and Suicide: An Unacknowledged Cause of Death for Pregnant Women

October 28th, 2011 by avatar

 

In a recent Science Daily report, “Homicide, suicide outpace traditional causes of death in pregnant, postpartum women”, caught my attention.  Outpace traditional causes of death in pregnancy and postpartum?  What about all of our concern regarding mortality rates as a result of C-section?  I bought the study.

According to Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. J. (2011), in the November issue of Obstetrics & Gynecology:

In total, we identified 233 pregnancy-associated violent deaths, yielding an overall pregnancy-associated violent death mortality rate of 4.9 per 100,000 live births; 64.8% of the pregnancy-associated violent deaths in our sample (n = 151) occurred during pregnancy (compared with the first year postpartum).  The overall pregnancy-associated violent death rate was fairly stable of the study time period, ranging from 4.3 to 5.4.  In addition the rates of pregnancy-associated homicide and suicide were each higher than mortality rates attributable to common obstetric causes. (Palladino, et al., 2011, p. 1059)

Mortality Rates Higher than OB Complications

The rate of death for pregnant women due to homicide, or suicide is higher than hemorrhage, eclampsia/pre-eclampsia, and amniotic fluid embolism.

Hemorrhage/placenta previa: 1.7  deaths per 100,000 live births2
Eclampsia/pre-eclampsia 1.7 deaths per 100,000 live births2
Amniotic Embolism 1.1 deaths per 100,000 live births2
Homicide 2.9 deaths per 100,000 live births1
Suicide 2.0 deaths per 100,000 live births1

 

 

 

 

Suicide:

  • 45.7 percent of suicides occurred during pregnancy
  • 51% of suicides occurred during postpartum
  • Victims were significantly more likely to be Caucasian, or Native American, and unmarried
  • Women ages 40 and over represented 17.0% of suicides
  • Suicide rates between states did not differ
  • 54.3 percent of suicides involved intimate partner conflict contributing to suicide

Homicide:

  • 77% of homicides occurred in pregnancy (not postpartum)
  • 45.3% of homicides were associated with intimate partner violence
  • 53.9% of victims were under 24 years of age
  • 44.6% of victims were African American
  • Homicide rates did not differ between states

 

These findings suggest that effective prevention methods aimed at perinatal psychosocial health are imperative.  Unlike some obstetric complications, violence is potentially preventable.

With continued focus on maternal violent death and a continued push toward the development of effective psychosocial interventions…we may be able to reduce the effect of this unfortunate killer on American women, their children, and their families. (Palladino, et al., 2011, p. 1062)

As birth advocates, intimately involved with the health and well-being of pregnant and postpartum women, what do we do?  What is our part in addressing this unfortunate killer of American women?

Posted by:  Walker Karraa, MFA, MA, CD(DONA)

 

 

References

  1. Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. J. (2011). Homicide and suicide during the perinatal period: Findings from the National Violent Death Reporting System. Obstetrics & Gynecology, 118(5). 1056-1063. doi: 10.1097/AOG.0b013e31823294da
  2. Berg, C., Callaghan, W. M., Syverson, C., & Henderson, Z. (2010). Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology,116:1302-9.
  3. Homicide, suicide outpace traditional causes of death in pregnant, postpartum women. ScienceDaily. Retrieved October 21, 2011, from http://bit.ly/qCN06m

Maternal Mortality, New Research, News about Pregnancy, Perinatal Mood Disorders, Research , , , , , , ,

Insights into the Efficacy of Pre- and Postnatal Group Care

October 27th, 2011 by avatar

Do your expectant clients ever ask you whether other pregnant women are sensitive to strong smells?  Do they wonder about the different ways to hold a baby while nursing?  Do postpartum women with whom you interact, wonder if their babies are hitting the right milestones?

Group care in both prenatal and postpartum periods of the childbearing years has been shown to improve birth, breastfeeding and parenting outcomes, parent satisfaction, and parent empowerment. Sharon Schindler Rising first took women out of the exam rooms and into a group setting for education, support, and prenatal care in 1994.  Her vision was to bring women together with the goal of empowering them, and giving them autonomy and responsibility for their care.  Centering Pregnancy® (CP) , CenteringParenting, and CenteringDiabetes can now be found in more than 300 U.S. locations and in several foreign countries as well.

The University of North Carolina’s Department of Family Medicine started providing CenteringPregnancy® group care in 2002 and about half of our 170 prenatal patients annually choose group care, as an extension of their () individual care, versus individual care, alone.  UNC Family Medicine provides an average of 250 group visits per year.

Group care was successful for both diabetics (starting in 2001) and prenatal parents and was followed in 2006 with group care for well child visits.  The program is called WellBabies and follows the routine preventive schedule developed by the American Academy of Pediatrics.  Like group prenatal care, the intention is to educate, to empower, and to provide care for parents and their babies .  Both groups meet in the same friendly room where the initial prenatal visit takes place.   There are differences in numbers and types of visits that appears below:

Group Prenatal Care Group WellBabies Care
Length of visits 90 minutes 120 minutes
Timing of visits Groups meet around the 15th-17th week of their pregnancies.  After the initial prenatal visit and an individual visit with their resident physician, they are scheduled for group care at the standard times for prenatal visits. WellBabies starts at the baby’s 2- month well child visit.  Babies may have been born within 1-3 weeks of each other. A total of 5 visits occur at 2,4,6,9, and 12 months.
Care providers Faculty physician, resident physician, and perinatal nurse coordinator Faculty physician or pediatric nurse practitioner along with resident physician.
Structure Check-in.  Self-monitoring and charting of date, gestational age, weight, blood pressure, and fetal movement.  Parents write concerns on the board. Check-in and assessments. Parents with facilitator assistance document child’s length, weight, head circumference, complete the well-child form and write concerns on the board. Facilitator leads group discussion and explains growth charts as parents review their child’s chart.  Children are placed on colorful mats and the discussion focuses on parent concerns, development and anticipatory guidance.   Parents complete the Parents’ Evaluation of Developmental Status© (PEDS) Questionnaire and/or the Ages and Stages Questionnaires© (ASQ) for babies over 6 months with Medicaid or with developmental concerns.  Immunizations are given as needed.
Education Parents’ concerns, facilitators’ discussion points and anticipatory guidance.  Topics are taken first from needs to know group and then from nice to know group. Community resources and personal experiences give depth to the discussion. Parents’ concerns, growth and development, infant cues, sleep/wake states, communication, feeding, sleeping and other activities of daily living, normal infant behaviors, and anticipatory guidance.
Health Assessment Self-monitoring and charting. Physician assessments and communication with parent. Infant monitoring and charting. Physician interprets findings and shares with parents.
Supportive Care Group members become learners and teachers.  Sharing of experiences and knowledge empowers them in both ways. Parents see the normal differences in behavior and temperament among the children and share lessons learned while adapting to the ever-changing baby.
Recruiting Begins with initial prenatal visit. Many who have been in prenatal group together like to remain together for WellBabies.  Others are recruited by phone.

 

Not many assessments of group versus individual care have been done.  However, evidence shows that after experiencing group care, parents valued support from other women, developmental comparisons, learning from others’ experiences, increased parental involvement in well-child visits, and more time with care providers.  In the Fall 2011 issue of the Journal of Perinatal Education a study of “Midwives’ Perceptions Of Implementing the CenteringPregnancy Model of Prenatal Care” recommends, “that individual providers and professional organizations embrace the CP model of group prenatal care and that more midwifery, nursing, and medical schools integrate CP into their obstetrical/maternity curricula.” (Baldwin and Phillips, 2011).

Group care embodies the definition of patient-centered care by the Institute of Healthcare Improvement and the Institute of Medicine’s (2001) report, “Crossing the Quality Chasm”.  Shared decision making and respecting patients and their families as partners in health-care are assets of patient-centered care found in group care and are endorsed by the National Committee on Quality Assurance, Institute of Medicine, Institute for Healthcare Improvement, as well as other professional healthcare organizations.

References_B Hotelling_blog post

 

Posted by:  Barbara Hotelling, MSN, WHNP-BC, LCCE, CD(DONA)

Barbara has been an active birth doula and Lamaze educator for over 25 years. She maintains her certifications with DONA International and Lamaze International, is on the Lamaze Faculty and is an approved DONA Doula Trainer. In addition to teaching Lamaze seminars for training childbirth educators and doula trainings, she has taught Labor Support for Nurses, Labor Support and the Teen Specialist programs of Lamaze throughout the United States , Canada, and in Korea. Barbara has served as President of DONA International, Chair of the Coalition for Improving Maternity Services (CIMS) and President of Lamaze International. Presently she serves on the Certification Council of Lamaze International and the Leadership Team of CIMS.

 

 


Childbirth Education, Guest Posts, Patient Advocacy, Preconception Care, Science & Sensibility, Uncategorized , , , , , , , ,

On Our Radar…

October 24th, 2011 by avatar

Here are a few things I’d like to draw your attention to this week:

 

Tomorrow, the University of Washington will be hosting a webinar, Current Issues and Leadership Challenges in Maternal and Child Health.  To register for the event, go here.  As an MCH grad student, you can bet I’ll be attending (virtually!).

 

An article in yesterday’s Washington Post National reminds us of the continued concerns over a woman’s chemical exposure during pregnancy, and the potential outcomes in her offspring.  The article highlights a prospective cohort study recently released in Pediatrics (Braun et al, 2011) in which urine levels of BPA (bisphenol) were recorded in pregnant women and then later on in their children.  Although the study was small (n=244), it looked at urine levels of BPA at the 16th and 26th weeks of gestation in the study participants, and then later on in the children at ages 1, 2 and 3.  The study found that the children (particularly girls) demonstrated altered neurobehavior (anxiety, hyperactivity, emotional control, and behavioral inhibition.)   Interestingly, maternal prenatal urine BPA levels were more strongly correlated with these behavioral findings than childhood BPA urine levels.

 

And Dr. Braun and colleagues are not the only clinical investigators to recently release research on early childhood development and its implications upon behavior.  This article in the Winnipeg free press highlights the work of a Swedish researcher, Jonas Himmelstrand, who is concerned with the nearly ubiquitous rate of childcare in Sweden which includes 92% of children from ages 18 months to five years old.  The article goes on to describe the quickly growing field of neuroscience research that links social and cognitive behavior to early developmental experiences and how our early emotional experiences influence brain development and subsequent behavioral characteristics.   (The basic gist described in the article:  high-touch, attachment-style parenting fosters high levels of trust between child and parenting and general emotional well-being.  Children in daycare from an early age may suffer from the lack of extra parental influence in their behavioral development.)  This very much aligns with Lamaze’s sixth Healthy Birth Practice, and information on the third and fourth stages of birth that contributing writer Jackie Levine will expand upon in a forth-coming post.  This is admittedly upsetting news for families in which both parents have to work to make ends meet—an increasing challenge in our country as well where many mothers of infants find themselves heading back to work six, eight, or twelve weeks after a baby’s birth.

And on a more positive note…here’s just a really cool article about a University of Texas Arlington Anthropology grad student who helped unearth what may be the earliest depiction of childbirth in Western art.  The real kicker?  The student, William Nutt, is legally blind.  The artifact was discovered during an archaeological dig this past summer in Poggio Colla, northeast of Florence.

What’s on your radar? What have you recently read with interest?  Please take a moment to share with your fellow readers…

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Healthy Birth Practices, Healthy Care Practices, New Research, News about Pregnancy, Uncategorized , , , , , ,

A Meeting of the Minds: Planned Homebirth Consensus Summit

October 21st, 2011 by avatar

UPDATE:  The homebirth summit is underway, as we speak.  With numerous stake holders at the table together in Warrenton, VA , including OBs & FPs, midwives, nurses, insurers, childbirth educators, administrators, doulas, public health professionals, legislatures, and researchers…there is certainly hard work afoot as the hand-selected meeting attendees work to hammer out consensus on the role homebirth does (and should) play in our country, how best to implement inter-discipline collaboration, as well as ensuring situations like seamless (and respectful) transfers from home to hospital when the need arises.  With several Lamaze International members attending the conference, I hope to bring you some commentary on the summit in the weeks to come. -KMH]

 

This coming October, midwives, doctors, childbirth educators, hospital administrators, health policy regulators, and public health professionals will get together with key representatives from organizations such as ACNM, MANA, ACOG, AAP,  NACPM, ICTC, Lamaze, AABC,  Our Bodies Ourselves, and AWHONN.  This collective group–all stakeholders in the planned home birth debate–will descend upon a yet-to-be-decided venue to discuss the various sides of the issue, and seek common ground that will, ultimately, benefit mothers opting for planned home birth and their babies.

Says Judith Lothian, RN, PhD, LCCE, FACCE, Associate Professor of Nursing at Seton Hall University, Associate Editor of the Journal of Perinatal Education, and Lamaze International’s representative to the planned home birth consensus committee:

 

The planning for the home birth consensus meeting began several years ago. I was fortunate to be part of “making history” at the first planning meeting in San Francisco in 2009. For the first time, obstetricians, pediatricians, midwives (including certified professional midwives), childbirth educators, maternity nurses, and birth advocates guided by the courageous vision and commitment of Saras Vedam, sat at the same table and talked (and listened). It was amazing. We left that meeting excited and hopeful. In the last few months, with some funding, the planning for the consensus meeting is finally moving forward. The consensus meeting planned for October 2011 will be the first time that all those with a stake in the planned home birth issue will talk, listen, reflect and, hopefully, find areas of agreement that will ultimately make a difference for mothers and babies. It is so important that Lamaze, representing childbearing women, childbirth educators, and birth advocates, is at the table. This will be a historic and hopefully “birth altering” event.

 

 

To find out more about the Home Birth Summit, go here.

 


Posted by:  Kimmelin Hull, PA, LCCE

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