Science & Sensibility

By Geradine Simkins, CNM, MSN, Executive Director of Midwives Alliance of North America

This week, the American Academy of Pediatrics released a policy statement on home birth. While the statement affirmed “the right of women to make a medically informed decision about delivery”, many advocates expressed concerns. The statement failed to recognize Certified Professional Midwives, the providers most likely to attend a home birth in the United States. In this response, the Midwives Alliance of North America helps families, providers, and policy makers understand the critical role CPMs play in safe, healthy birth options. – Sharon Muza, Community Manager, Science & Sensibility

High-quality out-of-hospital newborn and postpartum care is standard for midwives

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The Midwives Alliance of North America welcomes the primary concept communicated in the American Academy of Pediatrics’ April 24, 2013, policy statement entitled “Planned Home Birth.” As should be expected, AAP reminds its practitioners that newborn infants—regardless of the setting in which they are born—deserve an equal and unbiased, high-quality standard of care. The Midwives Alliance joins with AAP in affirming the need for a collaborative and integrated maternity care system that addresses the needs of all mothers and infants, regardless of the provider type or birth setting a woman chooses.

We are disappointed, however, in AAP’s decision to align with the American Congress of Obstetrics and Gynecologists’ policy on home birth. Serving the needs of the growing number of families choosing to birth at home, Certified Professional Midwives attend the majority of intended home births in the U.S., when a skilled attendant is present, making them the primary care providers for newborns in the home setting.

Certified Professional Midwives are skilled maternity care providers

AAP’s itemized recommendations for infant and newborn care, contained in their policy statement, are standard practice for credentialed midwives. In that respect, we find much with which we agree. These standard newborn exams, screens, and preventative care practices are wholly part of a credentialed midwife’s scope of practice, and further endorsed by individual state health departments. We also note that as AAP Neonatal Resuscitation Program certificate holders (required for certification and recertification), credentialed midwives follow guidelines laid out in AAP’s recommendations, and typically surpass those standard recommendations by having at least two NRP- and CPR-trained attendants at out-of-hospital births.

In fact, the AAP’s guidelines for the care of infants intentionally born at home parallel those standards practiced by trained midwives in all birth settings. The practices listed—such as working medical equipment, emergency plans of transfer, thorough newborn exams, and so forth—are professional standards exhibited and documented by credentialed midwives, regardless of the place of birth.

The AAP policy statement, however, did not recognize or acknowledge Certified Professional Midwives (CPM), indicating that AAP may not have a thorough understanding of the training, skills, knowledge, and abilities of this country’s primary maternity care provider for infants born out of the hospital. The Certified Professional Midwife is the only national midwifery credential that requires practitioners to be trained specifically to provide prenatal, intrapartum, and postnatal care in out-of-hospital settings. CPMs are knowledgeable, expert and independent midwifery practitioners who have met the standards for certification set by the North American Registry of Midwives (NARM). NARM is accredited by the National Commission for Certifying Agencies (NCCA) to issue the professional credential of Certified Professional Midwife, which is the same agency that accredits the American Midwifery Certification Board to issue the professional credentials of Certified-Nurse Midwife, and Certified Midwife.  

Midwives are the providers of choice for out-of-hospital births, whether they occur at home or in freestanding birth centers. Offered since 1994, the CPM is currently the basis for licensure in 27 states while 11 additional states are actively seeking CPM licensure. In fact, one in nine newly certified midwives in the U.S. are Certified Professional Midwives.  

The AAP policy statement endorses birth center maternity care, which is another area in which we are in agreement. Recent numbers from the American Association of Birth Centers (AABC) indicate that a significant proportion of accredited birth centers are owned and operated by Certified Professional Midwives. A January 2013 study, The National Birth Center Study II , conducted by AABC and published in the Journal of Midwifery & Women’s Health, the official journal of the American College of Nurse-Midwives (ACNM), highlights the benefits for women who seek care at midwife-led birth centers. Findings also reinforce longstanding evidence that providers at midwife-led birth centers provide safe and effective health care for women during pregnancy, labor, birth, and the postpartum period.  

Midwives provide high-quality care that meets both national and international guidelines 

In highlighting the ethic of high-quality care for all infants across the spectrum—regardless of the site of birth—it should be noted that Certified Professional Midwives provide care intentionally similar to that of nurse-midwives and physicians. Yet we also know that CPMs are able to offer additional and valued care in terms of frequency of home visits and intense monitoring of newborns in their homes in the first weeks of life—a benefit not normally conferred to women and babies who have experienced hospital births.

This high-quality midwifery care includes routine newborn APGAR assessments, comprehensive head-to-toe physical examinations, measurements of length, head, abdomen and birth weight, monitoring vital signs including thermoregulation, assessment of respiratory sounds and patterns, assessments of cardiac sounds and peripheral pulses, assessment of gestational age and physical maturity, neuromuscular assessments, and assistance with initiation and ongoing assessment of breastfeeding. All findings are recorded in patient records and shared with mothers, per professional standards.

In addition, CPMs provide newborns with Vitamin K treatment, antibiotic eye ointment, umbilical cord care, metabolic newborn screening, glucose and bilirubin testing as indicated, and either perform Otoacoustic Emissions (OAE) hearing screens or refer to area audiologists. Midwives in a number of states are moving toward, or already offering, pulse-oximetry screening for Critical Congenital Heart Defects (CCHD) per AAP guidelines, in advance of many hospital systems. In the rare cases when newborns require consultation or referral, infants are transferred to the tertiary care system, and pediatricians where available, for active management.

Not only do Certified Professional Midwives and Certified Nurse-Midwives who attend home births provide the level of care outlined by the AAP, they provide it in a personalized, woman-centered, family-centered, culturally competent, and individualized manner that is qualitatively different from the customary assembly-line postpartum care commonly experienced in U.S. hospitals.

For example, in a home birth setting, the midwife typically conducts the initial newborn exam in the presence of the mother and family, which does not disrupt the crucial process of mother-infant bonding and breastfeeding, and is focused on being instructive to the family. Midwives provide holistic care to the mother-baby dyad in concordance with World Health Organization’s Baby-Friendly best practices.

As a way of illustrating important differences in care practices, we can point to the recent Breastfeeding Report Card issued by the CDC (2012) that indicates only six percent of U.S. hospitals are offering care that aligns with the international best practices outlined by Healthy People 2020.   By contrast in a 2005 study, 95% of babies born at home under the care of Certified Professional Midwives were exclusively breastfeeding at six weeks of age (Johnson & Daviss, 2005). This is just one area where midwives are well-trained, skilled, and uniquely positioned to help families succeed.

An opportunity for collaboration and integrated care 

Physician conversations about home birth and midwife-led birth will be better informed and more useful to maternity care consumers if AAP is able to become more cognizant of important changes in the landscape of U.S. midwifery. 

The release of the AAP policy statement on care of newborns born at home is an opportunity to reinforce the need for professional and seamless collaboration with members of community health care teams. We view this statement’s release as an opportunity to align best practices for all parties who care for and support families choosing home birth.

The Midwives Alliance stands ready to work with other pediatric and maternity care providers to establish best practices in the postpartum period to not merely provide the basic level of care in the first hours, days and weeks of life for the newborn as outlined in the latest AAP statement, but to elevate that standard to include support for breastfeeding and the personal attention that can prevent infant death and improve maternal and child health.  Babies born in all settings deserve this kind of care.

About Geradine Simkins

Geradine Simkins, CNM, MSN is an activist, midwife and author. She began as a direct-entry home birth midwife in 1976 and became a nurse-midwife twenty years later. For over thirty years she has provided health care for women, infants and families in a variety of settings, including attendance at births in the home, a freestanding birth center, and hospitals. Geradine’s work with migrant farmworkers and American Indian tribes focuses on addressing health care disparities and engendering a more equitable maternity care system for all women and infants.  Geradine is currently the Executive Director of Midwives Alliance of North America, a professional organization that promotes excellence in midwifery and is dedicated to unifying and strengthening the profession, thereby increasing access to quality health care and improving outcomes for women, babies and their families. She is the editor of the recently published book entitled Into These Hands: Wisdom from Midwives, an anthology of the life stories of 25 remarkable women who have dedicated their lives and careers to the path of midwifery and social change.  More info about Geraldine Simkins can be found here.

Sharon Muza ACOG, American Academy of Pediatrics, Babies, Delayed Cord Clamping, Home Birth, informed Consent, Maternity Care, Midwifery, Transforming Maternity Care AAP, ACNM, ACOG, CNM, CPM, Geraldine Simkins, Home Birth, MANA, Midwifery Care, Midwives Alliance of North America, newborn

My first reaction to the now-infamous Time magazine cover was to groan out loud. Like many of you, I was horrified by that cover’s mean-spirited tone. If we didn’t get the message from the picture, there was also the antagonistic caption: “Are you mom enough?” It wasn’t until later that I recognized that this cover, and the controversy that followed, actually reflected a positive shift. Many things had changed since I first became aware of this topic more than 20 years ago.

In 1992, I was just finishing my post-doctoral fellowship at the University of New Hampshire and was expecting my second baby.  My first experience had gone not particularly well, so I spent months educating myself about birth, breastfeeding, and postpartum. During this time, I became friends with Dr. Muriel Sugarman. We were both on the board of a local child abuse organization in Massachusetts. Muriel was a child psychiatrist at Harvard’s Massachusetts General Hospital and an amazing ally to the breastfeeding community. She was interested in long-term breastfeeding and had collected some data. (“Long-term” was operationally defined for that study as “six months or longer.”)  We started working on it together, and bit by bit, had some findings to report.

We submitted one of our first articles on weaning ages to [a well-known journal in pediatrics].  Consistent with studies in other parts of the world, when weaning was child led, it tended to occur at ages 2.5 to 3. So far, so good.

But then there were our outliers….the babies who weaned at age 5…and a couple of babies were even older. The reviewers, all women we later learned, went completely nuts. If it had been up to them, we would have been both rejected…and flogged. (Eighteen years later, these are still the worst reviews I’ve ever received.) They hated us, our study, and mostly definitely our “weird” mothers.

I wasn’t sure what to do next, until a colleague handed me an article called, “Darwin takes on mainstream medicine.” It described how extended breastfeeding, babywearing, and cosleeping  conferred a survival advantage for moms and babies, and was presented at the American Association for the Advancement of Science meetings. That was radical stuff in the mid-1990s. I sacked our introduction and rewrote it using this framework.

The next question was where to send the revised manuscript. I called a pediatric researcher I knew in Philadelphia. He said, “Oh, I never send articles to [well-known pediatric journal]. They’re mean!” That had certainly been my experience. He recommended Clinical Pediatrics, where we got a much more positive reception. The article came out. We were happy. End of story….or so we thought.

In 1997, AAP Statement on Breastfeeding was released. Controversy swirled around that statement for months about one bit in particular: that women breastfeed for at least 12 months and “as long thereafter as is mutually desired.” I was going about my business, blithely unaware that Muriel and I were smack in the middle of the controversy. What reference did the AAP cite to support “as long thereafter as is mutually desired”? You’ve got it: Sugarman and Kendall-Tackett (1995)!

That paper taught me a lot. Ten years later, when I applied for APA Fellow, I identified it as one of the most important in my career. I learned firsthand about the intense negative stigma surrounding extended breastfeeding. I was equally amazed to discover a quiet underground of women who were defying cultural norms and nursing their older babies right under the radar of family, friends, and healthcare providers. Avery described this phenomenon as “closet nursing,” and noted that extended breastfeeding had a lot in common with revealing sexual orientation. Brave souls who chose to be up front faced marginalization—or worse.

Through much of the decade that followed publication of our article, Muriel and I, along with Liz Baldwin and Kathy Dettwyler, frequently had to write letters to courts and child protection agencies on behalf of mothers who were being investigated for child abuse. Their crime? Extended breastfeeding.

Which brings us up to the present time. Yes, the Time magazine article said mean things. But look at it this way: extended breastfeeding is being discussed in a mainstream publication. In addition, thanks to social media, the “quiet underground” is quiet no more. I’ve been amazed at outpouring of support from both celebrities—and ordinary moms—speaking opening and positively about extended breastfeeding. It was something I couldn’t even imagine in 1995. I think it’s safe to say that extended breastfeeding is officially out of the closet.

In closing, I’d like to suggest that we all owe a debt of gratitude to Drs. Ruth Lawrence and Larry Gartner, and the other brave members of the 1997 AAP Committee on Breastfeeding. Their statement did much to move extended breastfeeding out of the margins and into the public square (and Muriel and I were happy to have a small part in that). We still have a ways to go. But let’s take a moment and savor this small victory.

And to the members of the 1997 AAP Committee, I say this: We, the quiet underground, salute you!

The two articles published from that data set are:

Kendall-Tackett, K.A., & Sugarman, M. (1995). The social consequences of long-term breastfeeding.  Journal of Human Lactation, 11, 179-183.

Sugarman, M., & Kendall-Tackett, K.A. (1995). Weaning ages in a sample of American women who practice extended nursing. Clinical Pediatrics, 34(12), 642-647.

 About Kathleen Kendall-Tackett

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press, a new small press specializing in women’s health. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. www.KathleenKendall-Tackett.com

Kathleen Kendall-Tackett American Academy of Pediatrics, Breastfeeding, Guest Posts, Research AAP, American Academy of Pediatrics, breastfeeding, breastfeeding in the news, breastfeeding statistics, extended breastfeeding, Kathleen Kendall-Tackett, stories about breastfeeding, Time Magazine

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I was recently asked my thoughts on private cord blood banking by a couple expecting their first child.  This was something that they were considering and wanted to know what information was out there.  I had read various articles and commentaries on private cord blood banking in recent years, but I viewed this as an opportunity to refresh my knowledge before I provided an answer to them.  I wanted to share this information with Science & Sensibility readers, so that you may use it with your classes, clients and patients as well, if you wish.

Kimmelin Hull wrote a very comprehensive post on Science and Sensibility in April, 2011, discussing “Should we, or should we not retrieve Umbilical Cord blood at all?” along with providing information on delayed cord clamping current research, and referring readers to a fantastic Journal of Perinatal Education article, Umbilical Cord Blood: Information for Childbirth Educators, written by Renece Waller-Wise, MSN, CNS, CLC, CNL, LCCE.  Kimmelin Hull’s post and Renece Waller-Wise’s JPE article were great places for me to start my exploration to be able to answer this couple.

Today’s post is not about the benefits and/or risks of delayed cord clamping.  Information on that topic has been provided previously on this site.  What I was really looking for was more information on the likelihood that private banked cord blood might be used for that child or other relatives in the future.

Research indicates that pregnant women frequently do not have adequate information to make an informed decision about cord blood banking. (Fox, et al, 2007).   Additionally, the information sources for childbirth birth educators are frequently the private blood banks or their designated representatives, adding in the potential for bias. (Cord Blood Registry, 2009; Wolf, 1998, 1999) Interestingly, in the state of Washington, where I live, the state requires practitioners to provide information on cord blood donation and banking. (but not on delayed clamping.)

Revised Code of Washington (RCW) 70.54.220  All persons licensed or certified by the state of Washington to provide prenatal care or to practice medicine shall provide information to all pregnant women in their care regarding:

(1) The use and availability of prenatal tests; and

(2) Using objective and standardized information: (a) The differences between and potential benefits and risks involved in public and private cord blood banking that is sufficient to allow a pregnant woman to make an informed decision before her third trimester of pregnancy on whether to participate in a private or public cord blood banking program; and (b) the opportunity to donate, to a public cord blood bank, blood and tissue extracted from the placenta and umbilical cord following delivery of a newborn child.

Nationwide, 26 states have legislation on providing cord blood information. This legislation is intended to guide health care providers and inform parents about their options concerning donation and banking.  You can access this information on a state by state basis here. In Washington, exactly what information should be provided is not spelled out.

Stem cells are available from a variety of sources, but umbilical cord stem cells are the easiest to collect, collection is painless, and according to studies can be done before or after the placenta is delivered. (Gonzalez-Ryan, VanSyckle, Coyne, & Glover, 2000; Percer, 2009). The stem cells are quickly available to be used. But, according to one study, approximately 50% of all cord blood collection samples contain an insufficient volume of blood.  (Drew, 2005).

Private cord blood banking is often marketed as “biological insurance” for potential problems with that child in the future. “Autologous transplant” is where the cord blood is given back to the child it was taken from.  The chance that a child will need its own cord blood is extremely small; a 1:400 to a 1:200,000 chance over the child’s lifetime (Sullivan, 2008). In the case of some illnesses, it would be unwise to transfer the same cord blood cells as they are considered “contaminated” with the very disease that is hoping to be cured.

There is not a lot of research on the period of time that a collected cord blood sample would be viable after storage, and no research on viability over the course of the average human lifespan.

Private cord blood banking is not without significant expense and cost.  Collection and initial processing can run approximately $3000, and then there is an annual fee that can run several hundred dollars for storage each year after that.

Private cord banking services are not regulated, either on the federal level or by the state, so without oversight, regulations and a quality assurance program managed by a third party, consumers may find themselves dealing with programs that could not be financially viable over the long term or may not be handling or storing stem cell products appropriately.

What do various organizations say about private cord blood banking?

 American Congress of Obstetricians and Gynecologists (ACOG)

ACOG has a statement on Umbilical Cord Blood Banking and in their recommendations and conclusions they state:

• If a patient requests information on umbilical cord banking, balanced and accurate information regarding the advantages and disadvantages of public versus private umbilical cord blood banking should be provided. The remote chance of an autologous unit being used for a child or a family member (approximately 1 in 2,700 individuals) should be disclosed.
• Discussion may include information regarding maternal infectious disease and genetic testing, the ultimate outcome of use of poor quality units of umbilical cord blood, and a disclosure that demographic data will be maintained on the patient.
• Some states have passed legislation requiring physicians to inform their patients about umbilical cord blood banking options. Clinicians should consult their state medical associations for more information regarding state laws.
• Directed donation of umbilical cord blood should be considered when there is a specific diagnosis of a disease known to be treatable by hematopoietic transplant for an immediate family member.
• Obstetric providers are not obligated to obtain consent for private umbilical cord blood banking.
• The collection should not alter routine practice for the timing of umbilical cord clamping.
• Physicians or other professionals who recruit pregnant women and their families for for-profit umbilical cord blood banking should disclose any financial interests or other potential conflicts of interest.

American Academy of Pediatrics

The American Academy of Pediatrics also has a policy statement out on cord blood banking.  Their recommendations are similiar to ACOG.

• Cord blood donation should be discouraged when cord blood stored in a bank is to be directed for later personal or family use, because most conditions that might be helped by cord blood stem cells already exist in the infant’s cord blood (ie, premalignant changes in stem cells). Physicians should be aware of the unsubstantiated claims of private cord blood banks made to future parents that promise to insure infants or family members against serious illnesses in the future by use of the stem cells contained in cord blood. Although not standard of care, directed cord blood banking should be encouraged when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation.

• Cord blood donation should be encouraged when the cord blood is stored in a bank for public use. Parents should recognize that genetic (eg, chromosomal abnormalities) and infectious disease testing is performed on the cord blood and that if abnormalities are identified, they will be notified. Parents should also be informed that the cord blood banked in a public program may not be accessible for future private use.

• Because there are no scientific data at the present time to support autologous cord blood banking and given the difficulty of making an accurate estimate of the need for autologous transplantation and the ready availability of allogeneic transplantation, private storage of cord blood as “biological insurance” should be discouraged. Cord blood banks should comply with national accreditation standards developed by the Foundation for the Accreditation of Cellular Therapy (FACT), the US Food and Drug Administration (FDA), the Federal Trade Commission, and similar state agencies.

I will provide this information to the family who asked me.  I will encourage them to talk to their doctor or midwife, and determine if it is appropriate for them to consult with a genetic counselor, to address family history and other information that may make it more likely for this child or another family member to need collected cord blood.

I would also provide information on the timing of umbilical cord clamping and suggest they discuss with knowledgable providers and the potential bank, the likelihood of an adequate collection when cord clamping is delayed.

After receiving this information from a variety of sources, I trust the parents will be able to make a decision that feels appropriate to them and I will feel that I have provided evidenced based sources that they found useful in their decision-making process.

How do you answer the question “Should we private bank our baby’s cord blood?” What do you say?  What have been your favorite resources on this topic?  Please share information that you feel we can all benefit from.  I welcome your discussion.

References

American Academy of Pediatrics:Policy Statement: Cord blood banking for potential future transplantation.  PEDIATRICS Vol. 119 No. 1 January 1, 2007 pp. 165 -170 (doi: 10.1542/peds.2006-2901)

American Congress of Obstetricians and Gynecologists. (2008) Umbilical Cord Blood Banking. ACOG Committee Opinion No. 399. Obstet Gynecol 2008;111:475–7.

Cord Blood Registry. (2009). Cord blood spotlight: Childbirth educator’s guide, 1(2), 1–4.

Drew, D. (2005). Umbilical cord blood banking: A rich source of stem cells for transplant. Advance for Nurse Practitioners, 13(Suppl. 4), S2–S7.

Fox, N. S., Stevens, C., Cuibotariu, R., Rubinstein, P., McCullough, L. B., & Chervenak, F. A. (2007). Umbilical cord blood collection: Do patients really understand? Journal of Perinatal Medicine, 35, 314–321.

Gonzalez-Ryan, L., VanSyckle, K., Coyne, K. D., & Glover, N. (2000). Umbilical cord blood banking: Procedural and ethical concerns for this new birth option. Pediatric Nursing, 26(1), 105–110.

Percer, B. (2009). Umbilical cord blood banking: Helping parents make informed choices. Nursing for Women’s Health, 13(3), 216–223

Sullivan, M. J. (2008). Banking on cord blood stem cells. Nature Reviews Cancer, 8, 554–563

Waller-Wise, Renece. (2011) Umbilical cord blood: information for childbirth educators. Journal of Perinatal Education, 20(1), 54–60, doi: 10.1891/1058-1243.20.1.54

Washington State Legislature, Revised Code of Washington 70.54.220 Practitioners to provide information on prenatal testing and cord blood banking. http://apps.leg.wa.gov/rcw/default.aspx?cite=70.54.220  Accessed September 21, 2012.

Wolf, S. (1998). Cord blood banking: A promising new technology. Neonatal Network, 17(4), 5–6.Wolf, S. (1999). Storing lifeblood: Cord blood stem cell banking. American Journal of Nursing, 99(8), 60–68.

Sharon Muza Babies, Childbirth Education, Delayed Cord Clamping, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Journal of Perinatal Education, Newborns, Research, Third Stage, Uncategorized AAP, ACOG, cord blood banking, Delayed Cord Clamping, informed Consent, Journal of Perinatal Education, Kimmelin Hull, placenta, Renece Waller-Wise, Sharon Muza, umbilical cord

Deena Blumenfeld follows up my recent post on the AAP’s new policy statement on circumcision with a great look into what it means to have parental autonomy for minor children and how childbirth educators need to look out into the faces of their students, recognizing that the families in our classes come from a wide variety of backgrounds and bring a diverse set of cultural norms as they enter the world of parenthood. – SM

On Monday, August 27, 2012 the American Academy of Pediatrics released their new Policy Statement on Male Circumcision. This is a follow-up post to the Science & Sensibility post written last week by Sharon Muza. In that post, Sharon did a lovely job of explaining the Policy statement and asking some pertinent questions to us, the childbirth educators, regarding how this affects the classes we teach.

Photo Image Creative Commons Anthony J

The majority of other pregnancy, birth and parenting organizations have played it very safe, by doing nothing more than noting that the AAP has updated their policy. ACOG affirms and supports the AAP’s policy on circumcision, but it is the obstetricians who do the majority of the circumcisions in a hospital setting, so this is logical.  I’ll be the brave one and step out into the frying pan.

This article is not intended to examine every aspect of the policy for its validity, strength of evidence or research points left untouched. My intention is not to debate condom usage, Medicaid, money, the usability of the Africa studies or the fact that the AAP did not mention anything about the function of the foreskin. Enough of this dissecting is going on elsewhere online, in both conference rooms and living rooms.

I wanted to look at the AAP’s circumcision policy statement from a different perspective. In much of the coverage I’ve read online, I find much vitriol, anger and self-defensiveness, as well as overly aggressive behavior and dismissive or patronizing attitudes. This is entirely unsurprising. Circumcision has been a “hot button” issue for many years. This reaction comes not only from the mainstream media and individuals but also from the anti-circumcision organizations as well.

I’d now like to look at something that has been touched on, but glossed over by the mainstream media with regards to this policy. It’s also been virtually ignored by the opponents of circumcision as well.

That is, these series of statements made by the AAP in their policy statement:

“Parents should determine what’s in the best interests of their child.”

“Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.”

“Parents and physicians each have an ethical duty to the child to attempt to secure the child’s best interest and well-being. Reasonable people may disagree; however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other. This situation is further complicated by the fact that there are social, cultural, religious, and familial benefits and harms to be considered as well. It is reasonable to take these nonmedical benefits and harms for an individual into consideration when making a decision about circumcision.” (Emphasis mine)

 “It emphasizes the primacy of parental decision-making…”

This theme of parental choice is written throughout the document, overshadowing the medical evidence presented.

Circumcision is a fundamental part of the core belief system for many people, whether stemming from religious practice or social norms. When we have new scientific evidence that is in contrast to such a core belief, people feel rattled and defensive. A mother recently said,

“I really think they took a stance on the issue because Medicaid dropped coverage. And I agree that it should be covered. But now those of us who choose to leave our sons intact can be left to feel irresponsible.” (Emphasis mine)

On the medical side, just as we do with prenatal testing, medications or procedures during labor, vaccines for our children, etc., we look at the benefits of the treatment and the risks. We compare these to our own risk tolerance levels and then decide “Is this treatment / medication / procedure right for me?”

On the softer, but no less valid side, are our belief systems. We use our religion, our upbringing, and our societal norms to help us determine the right course of action. For example, a Jehovah’s Witness will decline a blood transfusion or other blood products because it is not within their framework. There are those who say this is “silly” or “dangerous,” yet we respect this practice in hospital because it is appropriately respectful of that individual’s autonomy.

When it comes to circumcision, the decision making process should be no less than it is for any other medical procedure. Primum non nocere, first do no harm, must include religious beliefs and societal norms to preserve patient autonomy. By ignoring these, in favor of a strictly medical practice, the physician does emotional harm to the patient. If we are to foster an environment of trust and respect between doctor and patient, then the doctors need to respect the patient’s social norms and mores. Conversely, the patient must respect the doctor’s position providing the best evidence to support or oppose a procedure / treatment / medication, etc.

With circumcision, the patient is an infant. This presents an interesting ethical dilemma. The medical decision may or may not jive with the parents’ personal paradigm. The infant has not the capacity to make the decision for himself. He is, by legal definition, incapable of making such choices for himself, and at a practical level a two day old baby cannot understand nor communicate his desires or reservations about circumcision.  Therefore the decision regarding circumcision lies solely with his parents and the argument for infant or child autonomy becomes moot. The AAP acknowledges as much.

 “The practice of medicine has long respected an adult’s right to self determination in health care decision making. This principle has been operationalized through the doctrine of informed consent. The process of informed consent obligates the clinician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives so the patient can make an informed choice. As a general rule, minors in the United States are not considered competent to provide legally binding consent regarding their health care, and parents or guardians are empowered to make health care decisions on their behalf.”

This brings me full circle to the first post regarding the AAP’s policy on circumcision and Sharon’s question regarding how as childbirth educators, do we address this in class? Personally, I find it a daunting topic to broach, and I have a vain hope that all my students are having girls, so that I don’t need to discuss it at all.

It’s a tough game of balance to negotiate my own bias towards leaving boys intact, the factual information I need to provide to my students, and their predetermined decision regarding circumcision. From the AAP’s recent policy statement;

 “There is fair evidence that parental decisions about circumcision are shaped more by family and sociocultural influences than by discussion with medical clinicians or by parental education.”

“For parents to receive nonbiased information about male circumcision in time to inform their decisions, clinicians need to provide this information at least before conception and/or early in the pregnancy, probably as a curriculum item in childbirth classes. Information to assist in parental decision-making should be made available as early as possible.”

So, I do broach the subject. I find most parents are receptive and open to the information I offer in class. The comments I hear most are “Oh, I didn’t know I couldn’t go with my son for the procedure.” “I didn’t know I had a choice, I thought everybody circumcised.” “That’s how they do it?!?”

Parents need to know all of their options, with regards to circumcision. Do it, or not; do it in hospital, in the doctor’s office or at home in a religious setting; do it now, do it later; benefits and risks, and so on.

 They also need to know that their upbringing, social norms, religion, etc. matter. Not only does the AAP think they matter, but I do too. I don’t walk in my student’s shoes. I don’t know their life experience, their religion or their conventions. We are relative strangers, yet we discuss some very personal topics. I find it imperative that I give my students all the information I can, so they can make the best choices for their family.

“Be kind, for everyone you meet is fighting a hard battle.” -Plato

We can never fully understand from whence another person’s opinions rise. Our beliefs polarize us. The middle is often lost in the shuffle because we defend our ideals to the death. The other person is wrong, no matter what. Somewhere along the way we lost compassion and empathy. When we have such strong feelings towards another group we lose sight of the others’ humanity.  “Remember, the other person is you.” – Yogi Bhajan

 Please, keep your sense of compassion when discussing the issue of circumcision with new parents in your classes and with those whom you interact with online.

 “If you want others to be happy, practice compassion. 

If you want to be happy, practice compassion.”

–Dalai Lama

Deena Blumenfeld American Academy of Pediatrics, Babies, Childbirth Education, Circumcision, Evidence Based Medicine, Guest Posts, informed Consent, Newborns, Parenting an Infant, Research, Social Media AAP, ACOG, American Academy of Pediatrics, Childbirth Education, circumcision, Deena Blumenfeld, informed Consent, research

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On August 27th, 2012, the American Academy of Pediatrics (AAP) released their updated policy on newborn male circumsion along with their updated technical report reviewing current research. This official statement follows a week or so of speculation in the media that the AAP’s new statement would fall on the side of supporting newborn male circumcision, stating that the benefits outweigh the risks.

The new policy statement replaces the last AAP recommendation on this topic released in 1999 (1). The just released statement makes the following recommendations:

• Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.

• Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.

• Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.

• Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

• Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.

• Elective circumcision should be performed only if the infant’s condition is stable and healthy.

• Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.

• Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.

  • Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.

  • If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.

• Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:

  • Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;

  • Teach the procedure and analgesic techniques during postgraduate training programs;

  • Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;

  • Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.

• The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.

As a result of research by the AAP Task Force commissioned for the purpose of updating their policy statemen, specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/ sensitivity or sexual satisfaction. This task force was made up of AAP representatives from specialty areas, including anesthesiology/ pain management, bioethics, child health care financing, epidemiology, fetus and newborn medicine, infectious diseases (including pediatric AIDS), and urology. The Task Force also included members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the CDC

Male circumcision consists of the removal of some or all of the foreksin (prepuce) from the penis. It is one of the most commonly performed procedures in the world and in the United States is most commonly done during the newborn period. The current estimated rate of male circumcision in the United States ranges from 42% to 80% among various populations.(2–6)

Circumcision rates were highest in the Midwestern states (74%), followed by the Northeastern (67%) and Southern states (61%). The lowest circumcision rates were found in the Western states (30%) (See Table 1)

Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990

The AAP discussed the ethical issues of newborn male circumcision, recognizing that the law allows parents or guardians to make medical decisions on behalf of the minors that they are responsible for, when provided unbiased information by a health care provider and taking into account cultural, religious, ethnic traditions and medical factors. The parents or guardians should be advised to take this into consideration. The AAP reccomends HCPs counseling families that are choosing to circumcise their male newborns to use a qualified medical provider in a medical facility rather than a traditional/religious provider in a nonmedical environment. There was also discussion on counseling parents about the potential risks of delaying the procedure beyond the newborn period, The AAP Task Force stated that there is less risk to the child when the procedure is done as a newborn.

Prevalence of male circumcision, according to self-report; United States, 1999–2004 Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990.full.pdf+html

The AAP does acknowledge that this procedure is elective and the parents should be informed that this is considered an elective procedure.

The AAP Task Force, in their technical report, shares their current literature review and research findings that provided for the basis of each of the current recommendations. Additionally, the technical report discusses studies that provide information on risks and complications of this elective procedure. The technical report is a comprehensive review of the information the AAP used to formulate their current recommendations and I encourage you to not only read it for your own information, but to have it available as a resource for parents who are looking for the full statement and the research behind it.

Future Research is Needed

The Task Force identified important gaps in their knowledge of male circumcision and urges the research community to seriously consider these gaps as future research agendas are developed. Although it is clear that there is good evidence on the risks and benefits of male circumcision, it will be useful for this benefit to be more precisely defined in a US setting and to monitor adverse events. Specifically, the Task Force recommends additional studies to better understand:

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• The performance of elective male circumcisions in the United States, including those that are hospital- based and nonhospital-based, in infancy and subsequently in life.
• Parental decision-making to develop useful tools for communication between providers and parents on the issue of male circumcision.
• The impact of male circumcision on transmission of HIV and other STIs in the United States because key studies to date have been performed in African populations with HIV bur- dens that are epidemiologically dif- ferent from HIV in the United States.
• The risk of acquisition of HIV and other STIs in 0- to 18-year-olds, to help inform the acceptance of the procedure during infancy versus deferring the decision to perform circumcision (and thus the procedure’s benefits) until the child can provide his own assent/consent. Because newborn male circumcision is less expensive and more widely available, a delay often means that circumcision does not occur. It will be useful to more precisely define the prevention benefits conferred by male circumcision to inform parental decision-making and to evaluate cost-effectiveness and benefits of circumcision, especially in terms of numbers needed to treat to prevent specific outcomes.
• The population-based incidence of complications of newborn male circumcision (including stratifications according to timing of procedure, type of procedure, provider type, setting, and timing of complications [especially severe and non- acute complications]).
• The impact of the AAP Male Circumcision policy on newborn male circumcision practices in the United States and elsewhere.
• The extent and level of training of the workforce to sustain the availability of safe circumcision practices for newborn males and their families.

The Role of The Childbirth Educator

The decision of whether to circumcise a male newborn is frequently made early in the pregnancy and even before conception.(7-9) In a cross-sectional study of parents of 55 male infants presenting to a family practice clinic for a well-child visit, 80% of parents reported that the circumcision decision was made before a discussion occurred with the clinician about this issue. Only 4% of parents reportedly discussed circumcision with their clinician before the pregnancy.(6) This finding is substantiated by the 2009 AAP survey of 1620 members with a response rate of 57%, in which most respondents reported that parents of newborn male patients generally do not seek their pediatrician’s recommendation regarding circumcision; only 5% reported that “all” or “most” parents “are uncertain about circumcision and seek their recommendation” about the procedure. (10) There is fair evidence that parental decisions about circumcision are shaped more by family and socio- cultural influences than by discussion with medical clinicians or by parental education.(7, 11)

The AAP states that parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception and/or early in pregnancy, which is when they are making choices about circumcision.

I found it interesting that research indicated that most parents have most likely made a decision on newborn male circumcision prior to participating in any childbirth classes that they may be attending. I also know that talking about circumcision in a childbirth class can be a sticky, uncomfortable and emotional discussion for both attendees and educators. It may be difficult but it is important to share information on this topic in the same way that we share other information about pregnancy, labor, birth and parenting; providing resources, sources of information and avenues for additional information that the parents can access later for information.

I invite you to share your thoughts on the new AAP recommendation on newborn male circumcision and how you discuss this topic in your childbirth classes. Do you avoid speaking about it altogether because it makes you uncomfortable? How do you bring it up? What do you do when the topic becomes emotional amongst participants? Will you change what you do based on this newly released recommendation? I invite discussion but ask that you follow Science & Sensibility’s policy on participation and keep all comments polite and respectful. – SM

References

1. American Academy of Pediatrics. Circumcision Policy Statement. Task Force on Circumcision. Pediatrics. 1999;103(3):686– 693. Reaffirmation published on 116(3): 796
2. Centers for Disease Control and Prevention (CDC). Trends in in-hospital newborn male circumcision—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2011;60(34): 1167–1168
3. Warner L, Cox S, Kuklina E, et al. Updated trends in the incidence of circumcision among male newborn delivery hospitalizations in the United States, 2000-2008. Paper presented at: National HIV Prevention Conference; August 26, 2011; Atlanta, GA
4. Overview of the Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; 2009. Available at: www.hcup-us. ahrq.gov/overview.jsp
5. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005;173(3):978–981
6. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis. 2007;34(7): 479–484
7. Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract. 1999;12(1):16–20
8. Walton RE, Ostbye T, Campbell MK. Neonatal male circumcision after delisting in Ontario. Survey of new parents. Can Fam Physician. 1997;43:1241–1247
9. Ciesielski-Carlucci C, Milliken N, Cohen NH. Determinants of decision making for circumcision. Camb Q Healthc Ethics. 1996;5 (2):228–236
10. American Academy of Pediatrics. Periodic Survey of Fellows: Counseling on Circumcision. Elk Grove Village, IL: American Academy of Pediatrics; 2009
11. Binner SL, Mastrobattista JM, Day MC, Swaim LS, Monga M. Effect of parental education on decision-making about neonatal circumcision. South Med J. 2002;95 (4):457–461

Sharon Muza American Academy of Pediatrics, Childbirth Education, Circumcision, informed Consent, Newborns, Parenting an Infant, Research AAP, ACOG, American Academy of Pediatrics, Childbirth Education, circumcision, informed Consent, newborns, Pediatricians, Sharon Muza