Science & Sensibility

Press time update: Over the course of my research on Monday 4/22/13, I noticed that by the end of the day, Milkscreen’s main website no longer shows links to the Breastfeeding Assesment Calculator. The Facebook page for this product has also been removed.  An email received from the company confirms that the product has been removed from the website and retailers have been instructed to pull the product from the shelves. I can only speculate that this is due to pressure from social media. ~ Deena

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© Deena Blumenfeld

I recently became aware of a new product, the Milkscreen Breastfeeding Assessment Calculator by Upspring Baby, designed to help new breastfeeding mothers be more confident in their breastfeeding abilities. This product tells them whether their milk supply is “low, normal or high” and how they can correct problems.  

This product assumes that many mothers are worried about having a low milk supply and therefore this product will reassure mothers that they are normal. To use this product, a mother must pump her milk. Additionally, this product assumes that pumping breastmilk will yield the same quantity as when a baby nurses.  We know: what a mother pumps is not indicative of what she may be producing to feed her baby. 

From the product description: 

“The Milkscreen Assessment home test determines daily breast milk supply. It was created to address the common concern many moms have: how much breast milk do I make and is that enough for my baby? Milkscreen Assessment gives mom confidence to keep breastfeeding by telling her how much breast milk she makes and how that relates to baby’s growth, identifying possible breastfeeding issues and providing recommendations on how to overcome these issues.”

This description may play directly into a mother’s fear that she isn’t making enough breastmilk for her baby. 

From the product box:

“Problem: About 50% of moms stop breastfeeding because they are concerned they don’t make enough milk for their baby. Solution: Milkscreen Calculator”

How do we know that this percentage is accurate? 

The company does not cite a source for this statement. Moms cease to breastfeed for many reasons, including, but not limited to; going back to work, pain while breastfeeding and personal preference. 

The real data on low milk supply

 An estimated 5% to 15% of all mothers experience either primary or secondary lactogenesis failure, with the actual numbers being unknown. 

Hypoplasia or Insufficient Glandular Tissue is a rare condition that some women may have. and it needs a clinical diagnosis to confirm. Many women with this condition supplement with donated breastmilk or formula while continuing to breastfeed.

I believe that the Milkscreen Calculator doesn’t help to eliminate low production worries, as advertised. I believe that it promotes this fear! 

How does Milkscreen test the breastmilk?

After scouring their website, I am not able to find any information on what nutrients they are testing for or what testing procedures they use because they don’t actually test the breastmilk! A mother doesn’t send the breastmilk to their lab for testing. A mother fills out a questionnaire and enters the amount of milk pumped in three pumping sessions, one hour apart. Milkscreen looks at a mother’s production level as “low, normal, or high” and gives her results and recommendations as to what to do if she’s having a problem, and then makes suggestions as to their other products she might like to purchase. 

From Milkscreen’s FAQ: 

How accurate is this test?

Milkscreen Assessment is modeled after a scientific paper, published in a peer-reviewed journal, and interpretation and recommendations provided in report are based on published scientific literature found in our list of references. However, each woman will respond differently to pumping breast milk. If a woman gets a result that shows low production, it’s possible that pumping was not as efficient for her as feeding at the breast.  In this case, the report will suggest to explore this possibility with a Lactation Consultant.

When I took a look through their references list, I was unable to find the paper they referred to.. They do offer useful citations and background information, but nothing supports the need or usefulness of this product.

From the video with breastfeeding expert Dr. Landers:

“This test is based on data that are normative. Hundreds of mothers have had very special calculations of daily milk supply. Our test takes an estimated amount of breastmilk supply over a shorter period of time and lets a mother know if she’s low, normal or high. Milkscreen calculator is an estimate of the day’s milk production, but in a scientifically studied, peer reviewed paper it’s actually a good approximation….. This test is an accurate estimate of daily milk supply…. It is the growth of the baby that is the most important thing. Gives mom an idea of whether baby’s weight gain is low, normal or high. (Uses the WHO growth chart)”

If the growth of the baby is “the most important thing” why don’t we weigh and measure the baby. That would tell us if the breastmilk supply is adequate.

This product oversimplifies the issue of low milk supply. “Low, normal or high,” doesn’t give a mother any real data to go on.

How do others test* for nutritional quality of breastmilk?

The Mayo Clinic provides us with some insight as to how breastmilk is tested and what it is tested for. They use thin-layer chromatography (TLC)/colorimetry/spectrophotometry (SP)/other methodologies as appropriate. With their testing, they use samples that are 4-5ml of breastmilk.

From the Mayo Clinic:

“The nutritional content of breast milk changes considerably from day 1 to day 36 postpartum. Subsequent to that time the nutritional content is considered to be stable.

Measured nutritional components are glucose, lactose, triglyceride, and protein. Deficiency of any of the measured or calculated parameters is suggestive of decreased nutritional quality of human breast milk.”

Mayo Clinic, Breast Milk Nutritional Analysis

“Several different methods are used in the analysis of human breast milk. The sample is analyzed for triglycerides using an enzymatic method. One aliquot of breast milk is tested for total protein using biuret reagent and titration methodology and for measurement of glucose using a glucose oxidase method. A second aliquot of breast milk is pre-incubated with beta-galactosidase and glucose is measured. Lactose is calculated using results obtained by the methods listed above.”

*These tests are not FDA approved.

What is the rate of false positive / false negative results from the Milkscreen test?

An incorrect assessment can have a huge impact on the mother’s breastfeeding relationship. If a mother is led to believe falsely reassured that she is making enough milk, she may not seek appropriate help from a lactation consultant or other breastfeeding professional and her baby may suffer, Alternately, a mother may choose to supplement with formula when in fact, there was no issue or her supply could have been corrected with professional help.

Breastfeeding confidence 

In the video explaining the science behind Milkscreen, Dr. Landers states;  

“Anything we can do to help a new mom, especially a first time breastfeeding mom, to have confidence in her body’s ability to make milk and nourish her baby would be a huge, huge addition to our tools to help breastfeeding moms and babies. We know from clinical studies that moms stop breastfeeding because they think they don’t have enough breastmilk supply. It’s the mother’s perception of an inadequate supply and that she doesn’t know what she’s doing… Modern women don’t have confidence in that process (supply and demand). So one of the reasons this product is so important is that it is a huge confidence builder for the average mom.’

Phrases like  “they think they don’t have enough milk” and “mother’s perception of inadequate supply” or “doesn’t know what she is doing” reinforce the idea that women are not capable of being knowledgeable or confident about breastfeeding. 

© Deena Blumenfeld

Milkscreen Assessment also claims that if a mother has too much milk, she will likely have growth issues with her baby as well. They attribute this to the foremilk/hindmilk imbalance, including the problem of ‘loose stools’ with the infant.  Current research no longer supports the foremilk/hindmilk theory, and exclusively breastfed babies normally have loose, mustardy stool.  According to Kellymom.com, “Your breasts don’t “flip a switch” at some arbitrary point and start producing hindmilk instead of foremilk. Instead, think of the beginning of a nursing session as being like turning on a hot water faucet.” In other words, there is always fat in breastmilk but the quantity varies dependent upon how long baby nurses. Feeding from a relatively empty breast will yield a higher fat content in the milk. However, it’s the fat over the course of the day, not just in a single feeding which is important.

As educators and professionals, we know to refer a mother who is questioning her milk supply to seek help from a qualified lactation consultant or other breastfeeding professional.  Additionally, we can be sure that our breastfeeding and newborn care classes are evidence based, offer useful information and instill confidence in new mothers so they can start their breastfeeding relationship off on the right foot.  We also make sure that new mothers are aware of support groups and local resources that can help them if they run into problems and concerns. 

Lamaze’s Healthy Birth Practice #6: Keep Mother and Baby Together- It’s Best for Mother, Baby and Breastfeeding is a great resource for parents and includes a wonderful video for use in class. 

Resources and References:

 AAP Breastfeeding and the Use of Human Milk (2012) 

American Academy of Pediatrics, Adequacy of Milk Intake During Exclusive Breastfeeding: A Longitudinal Study, (2011)

Butte NF, Garza C, Smith EO, Nichols BL. Human milk intake and growth in exclusively breast-fed infants. J Pediatr. 1984 Feb;104(2):187-95.

Daly SEJ, DiRosso A, Owens RA, Hartmann PE. Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk. Exp Physiol 1993;78:741-55.

Highlights of, and thoughts regarding the AAP’s Policy Statement “Breastfeeding and the Use of Human Milk”

Hurst, N (2007) Recognizing and Treating Delayed or Failed Lactogenesis II, Journal of Midwifery & Women’s Health

“Hypoplasia/Insufficient Glandular Tissue.” KellyMom RSS. N.p., n.d. Web. 22 Apr. 2013.

 World Health Organization on Breastfeeding

Deena Blumenfeld Babies, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Newborns, Social Media breastfeeding, breastmilk, Childbirth Education, Deena Blumenfeld, guest post, Healthy Birth Practices, power of social media, Social Media

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Regular contributor Deena Blumenfeld shares her recent experience with a “research” article that washed over social media outlets and was shared and discussed by many birth professionals.  Deena explains how she fell in step with others and ended up being lead down the wrong path.  Have you every made this mistake too?  Please share your thoughts in our comment section.- Sharon Muza, Science & Sensibility Community Manager.

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Gathering information from social media can be like playing a giant game of “telephone” with a million of your closest friends.

This is often how it goes:

• Someone reads an article. They post to Facebook (or other venue) a link and a comment.
• We read this person’s comment and add our own comment.
• Then we go back and skim the article, and comment again.
• Next we post a link to the article, with our own comments and opinions regarding the article.
• The next reader takes our opinion as gospel, only reads the headline of the article and then shares our opinion on their page, neglecting to link the article with their comment.
• So now we have a rumor about an opinion and after 345 more postings, no one knows where the original source was of what anyone is talking about anymore.  But, whatever it is, it sounds AWFUL and we are indignant about it.

Does this sound familiar to you? Have you ever taken a rumor, opinion or comment about an article or study to be gospel truth, without fully reading and researching the information on your own… and then go on to repeat that rumor or opinion? 

I’ll sheepishly raise my hand here…

Not too long ago, there was an article on medpagetoday.com entitled “New Form of Misoprostol Speeds Up Labor.” Now, without reading the article, doesn’t it seem that we now have a form of misoprostol being used for augmentation? 

This is the misinterpretation that was flying around Facebook, Twitter and other social media sites for days after the article was published on February 18, 2013. The outrage, fear and condemnation of anyone who thought it might possibly be a good idea to use misoprostol for augmentation was overwhelming. I read, and participated in, many discussions regarding the dangers of this drug; uterine rupture, mothers who have died, babies who have died, the Safe Motherhood Quilt Project, and so on. 

But yet we all missed it, me included.  That misleading headline leads us to believe that this was misoprostol for augmentation of labor; when in reality, it is an article about a new form of misoprostol, designed in the appropriate dosage, to induce labor.  This ‘little oops’ caused a big stir for not much. 

So, let’s look at what the article really talks about and what we should know.

• This is an article about an abstract which was presented at a conference. It is not a peer-reviewed, published study.
• We do not have access to the full study, since it isn’t published. So, we cannot evaluate it effectively.
• The study compared the efficacy of this new form of misoprostol suppository to the existing dinoprostone (cervadil) suppository for induction of labor.
• This study of 1,358 women found that the misoprostol suppository worked more quickly than the dinoprostone to get women to active labor as well as to birth.

“Along with the primary efficacy benefit of shorter time to vaginal delivery, the novel agent was also associated with faster delivery of any type, vaginal or cesarean (median 18.3 hours versus 27.3 hours with dinoprostone, P<0.001).”

“Other secondary outcome benefits were shorter time to active labor at 12.1 hours versus 18.6 hours, respectively (P<0.001), with substantially fewer women needing oxytocin prior to delivery (48% versus 74%, P<0.001).” 

Hang on a minute: “faster delivery of any type, vaginal or cesarean.” If the results of the induction end up as a cesarean, can we call it a successful induction? I’m not sure we can. I think this is a failed induction. Sure the medication worked to get labor started, but for whatever reason she ended up with a cesarean section. Faster to a cesarean section – wouldn’t it have been even faster to just schedule the cesarean section? 

“T’he primary safety outcome of cesarean delivery came out similar between groups at 26% with misoprostol and 27% with dinoprostone (P=0.65). Nor was there a difference in indication for cesarean section.”

When asked at the session why a faster vaginal delivery didn’t translate into fewer cesarean deliveries, Wing pointed to the myriad other factors that play into delivery mode. “We can flip the switch on but that doesn’t always get us the desired result,” she told the audience.” 

The article is leaning towards “faster is better” in terms of labor. We are left with more questions than answers. The answers may be found within the study itself, however, we don’t have access to the study. My questions:

But why? Why is a faster induction (or faster labor) better than a slower one?

Aren’t faster labors more painful? Aren’t contractions more challenging to cope with when they are more intense?

Do we have high rates of fetal distress with a faster labor vs. a slower one?

Who benefits from a faster birth?

The articles states that fewer women needed to be augmented with pitocin with a misoprostol induction vs. a dinoprostone induction. Is that a good thing? Bad? Neutral?

We also don’t know the researcher’s intentions. Without being able to read the study, we can only make assumptions. Do we assume the intention is a faster labor? Do we assume the intention is to make misoprostol safer for induction? Something else? Or maybe, just maybe, we don’t assume anything at all. Assumptions can be very dangerous and in most cases, they are wrong. 

My Take Away

The take away from all of this is that an article about an abstract presented at a conference leaves us with more questions than answers. We cannot accurately evaluate that which we cannot read in its entirety. Social media is a good tool, but we should be cautious about that which sounds too good (or bad!) to be true. We should take others opinions as just that – opinions, until we’ve done our own solid research. We should also be cautious about the ‘click and share’ phenomenon. Double check, do your homework and make sure the information we share is accurate. I’ll do better next time too.

For more on misoprostol for labor induction please read:

1. Science & Sensibility: Update on Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose
2. Science & Sensibility: ACOG’s 2009 Induction Guidelines: Spin Doctoring Misoprostol (Cytotec)
3. Journal of Perinatal Education: The Freedom to Birth—The Use of Cytotec to Induce Labor: A Non-Evidence-Based Intervention by Madeline Oden
4. WHO: Misoprostol for cervical ripening and induction of labour
5. WHO: WHO Recommendations for Induction of Labor, 2011
6. Induced and Seduced: The Dangers of Cytotec by Ina May Gaskin
7. Adverse Events Following Misoprostol Induction of Labor by Marsden Wagner, MD, MS

Deena Blumenfeld Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternity Care, Medical Interventions, New Research, Research, Uncategorized cytotec, Deena Blumenfeld, guest post, guest posts, induction, labor induction, misoprostol, power of social media, research, Social Media

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

When the study titled Elective birth at 37 weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins Timing of Birth Randomised Trial came out on June 13, 2012 both the BJOG:An International Journal of Obstetrics and Gynaecology in their press release: “BJOG release: Elective birth at 37 weeks gestation safer for mothers carrying uncomplicated twins, new research suggests” and Science Daily: “Earlier Birth, at 37 Weeks, Is Best for Twins, Study Suggests” reported the findings as strong evidence to support NICE’s (National Institute for Health and Clinical Excellence) guidelines.

“The findings of our randomised trial support the recent NICE recommendations. For women with an uncomplicated twin pregnancy at 37 weeks of gestation, elective birth was associated with a significant reduction in the risk of birthweight below the third centile, with no identified increase in the risks associated with early birth for either women or their infants.”

So what are the NICE recommendations?

• 1.7.1.5 Inform women with uncomplicated monochorionic twin pregnancies that elective birth from 36 weeks 0 days does not appear to be associated with an increased risk of serious adverse outcomes, and that continuing uncomplicated twin pregnancies beyond 38 weeks 0 days increases the risk of fetal death.
•  1.7.1.6 Inform women with uncomplicated dichorionic twin pregnancies that elective birth from 37 weeks 0 days does not appear to be associated with an increased risk of serious adverse outcomes, and that continuing uncomplicated twin pregnancies beyond 38 weeks 0 days increases the risk of fetal death.

Photo by www.photographybyjoelle.com licensed under Creative Commons

Let’s take a more in-depth look at the study. This is a randomized control trial where women with twin pregnancies were selected by phone to either be placed in the “standard care” bucket or the “elective birth” bucket. The goal of the study was to determine if an uncomplicated twin pregnancy delivered at 37 weeks gestation reduced the risk of death or serious outcomes for babies without increasing harm.

We do know that multiple pregnancies come with unique complications that singletons do not, such as high rates of prematurity, cerebral palsy, developmental delays and intrauterine growth restriction (IUGR) among others. Credit where credit is due, this study does not compare twins to singletons.  The authors maintain an apples-to-apples comparison by only looking at twins.  The researchers were specifically looking to see if elective birth (both induction and cesarean section) would reduce the risks of perinatal mortality, birth trauma, lung immaturity and admission to the NICU, necrotizing enterocolitis and systemic infection.

For the mothers, they looked at pre-eclampsia, eclampsia, protein-uria, renal insufficiency, liver disease, neurological disturbances, hematological disturbances, antepartum hemorrhage and abnormal umbilical artery.  They also looked at a number of labor and birth complications.  However, the focus of the study was primarily the infants, not the mothers.

“Multiple pregnancy is associated with both maternal and fetal complications. While women with a twin pregnancy are more likely to give birth prematurely, approximately 46% will give birth after 37 weeks’ gestation. For women whose twin pregnancy continues beyond 37 weeks’ gestation, there is a higher risk of perinatal mortality and morbidity with advancing gestational age. 

The Australian study looked at 235 women with an uncomplicated twin pregnancy at 36 weeks gestation. They were divided into women who planned an elective birth from 37 weeks (elective birth group) and women who planned birth from 38 weeks (standard care group).”

One problem I encountered was the relatively small sample size of 235 women.  The authors admit there should have been closer to 1100 mothers to validate their findings:

“There are several limitations to our findings. The current trial was stopped before completion of the estimated sample size for a lack of ongoing funding. We are therefore relatively underpowered to assess our primary outcome of serious adverse outcome for the infant, as well as uncommon maternal labour and birth complications. To detect  a 66% reduction in adverse outcome at term as suggested using plurality-specific data would require a sample size of approximately 1100 women with an uncomplicated twin pregnancy at term.”

Another problem I encountered while looking at the data was that the gestational age of the “Elective Birth” babies was roughly the same as the “Standard Care” babies, differing by only 0.5 weeks.

“Despite our trial protocol specifying birth for women in the Standard Care Group being after 38 weeks of gestation, and as close to 39 weeks as possible, 45% of women in this group gave birth between 37 and 38 weeks of gestation, reflecting the practicalities of scheduling induction of labour and caesarean section procedures in a busy maternity environment at close to 38 weeks of gestation. The resultant mean difference of 4 days in gestational age at birth is consistent with the identified difference of 90 g in mean birthweight. However, these identified differences do not explain the significant reduction in the risk of birthweight less than the third centile observed in the Elective Birth Group, raising the possibility that this was a chance finding.” (emphasis mine)

But, yet, one of the main reasons they suggest elective birth at 37 weeks is due to IUGR or small for gestational age. Out of the “Elective Birth” group, 7 babies were in the third percentile or less (3%), the “Standard Care” group had 24 babies (10.1%). On the surface, that is much higher.  However, the “Standard Care” numbers also accounts for emergency cesarean sections and induced labors for medical reasons.  For ethical reasons unplanned inductions and cesarean sections needed to occur.

The questions I have are:  how badly did that skew the data?  How accurate is the gestational age of the babies? There is no indication in the study to tell us that these pregnancies were accurately dated via early ultrasound, etc. so some amount of variability in gestational ages may have impacted results.

How is elective twin birth managed here in the U.S.?

ACOG

In the American Congress of Obstetricians  and Gynecologists’ ACOG Practice Bulletin #56, 2004, reaffirmed in 2009

“The nadir of perinatal mortality for twin pregnancies occurs at approximately 38 completed weeks of gestation and at 35 completed weeks of gestation for triplets; the nadir for quadruplet and other high-order multiple gestations is not known. Fetal and neonatal morbidity and mortality begin to increase in twin and triplet pregnancies extended beyond 37 and 35 weeks of gestation, respectively.  However, no prospective randomized trials have tested the hypothesis that elective delivery at these gestational ages improves outcomes in these pregnancies.”

At this time, ACOG is not recommending elective birth at 37 weeks for twins.  The data that ACOG provides reflects the same information as NICE and as in the BJOG study. So the data set is the same, it’s the recommendations for scheduled birth at 37 weeks that differ.

The March of Dimes

The March of Dimes makes no distinction between singleton and multiple gestation pregnancy with regards to their campaign, Healthy Babies are Worth the Wait™  to prevent prematurity. “In 2010, the Joint Commission established a new perinatal care core measure set that includes the number of elective deliveries (both vaginal and cesarean) performed at > 37 and < 39 weeks of gestation completed.”   I speculate that is because of the relative rarity of twin births in relation to singletons. Although I’d like to see a future statement specifically on twins in this regard.

Lamaze

“Lamaze Healthy Birth Practice #1 – Let Labor Begin on Its Own” would appear to be in conflict with the BJOG study and NICE’s recommended practices. However, there is always an exception for a true medical need. Induction and scheduled cesarean sections, when used judiciously, are lifesaving for both mother and baby.  Professor Jodie Dodd, one of the researchers in the BJOG study, believes strongly in her results. So much so, that she and the Univeristy of Adelaide put out this video regarding her findings.

Even with a smaller sample size than required for a full analysis, this study, plus previous others, as cited in the references, shows a correlation between birth at 37 weeks for twins and reduced risk for low birth weight and perinatal mortality. As a Lamaze educator, I feel an internal conflict with the March of Dimes information, Lamaze’s Healthy Birth Practice #1 and the study results. My belief is that all babies know their best time to be born, including twins. I think that every twin pregnancy should be taken on a case by case basis. Truly, there are increased risks with any twin pregnancy. However, the risks always need to be explained in context of the long term effects of a scheduled birth on breastfeeding; cesarean section complications; and long term complications of prematurity on the babies. As long as the mother has the full set of information she can make an appropriate decision with her individual care provider regarding scheduling the elective birth of her twins.

This post was written by regular contributor, Deena Blumenfeld, RYT, RPYT, LCCE  To read more about Deena or to contact her, please see our contributor page.

Deena Blumenfeld Babies, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, Newborns, NICU, Practice Guidelines, Pre-term Birth, Pregnancy Complications, Twins, Uncategorized ACOG, BJOG, Deena Blumenfeld, guest posts, Healthy Birth Practices, labor induction, Lamaze International, multiples, NICE, twins

Call for Guest Community Manager of the Month

Science & Sensibility is calling for bloggers interested in serving as the “Guest Community Manager of the Month.”  This is a prime opportunity for bloggers who have an online presence and demonstrated commitment to advancing evidence-based birth practices to take the lead for a full month on Science & Sensibility.   The interim assignment will give our current community manager, Kimmelin Hull, much needed time for a few months leave of absence to heal from a recent concussion. 

Interested bloggers are invited to send a message describing qualifications and vision for the month long assignment, along with a current resume and sample blog post to Linda Harmon, Executive Director by February 17, 2012 at lharmon@lamaze.org.  Additional information on the assignment and compensation will be provided to interested bloggers.

Deena Blumenfeld, RYT, RPYT, LCCE has been invited to take the lead in February as the first Guest Community Manager of the Month.  Please extend a warm welcome to Deena.   We look forward to hearing from Deena and other bloggers to follow in the coming months.

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