Science & Sensibility

© Robin Gray-Reed, RN, IBCLC
mindfulmidwife.com

“Do women really eat their placentas?” I am asked this question in every Lamaze class I teach. This question is often accompanied by a raised eyebrow and a giggle. Many times, at least one mother will sheepishly avert her eyes and mention that she’s thinking about doing it because she’s heard of the amazing benefits that can be achieved by consuming her placenta. Our class discussion commences with differing opinions, theories, vague and distorted facts and many grunts of “ugh, gross!” It then becomes my job as the childbirth educator to sort this out and offer my students evidence based information with regards to placentophagy.

There’s been quite a bit in the news this last week or so about placenta eating.  Recently, Kim Kardashian, on her show, “Keeping up with the Kardashians,” queried her doctor about consuming her placenta after birth. She wanted to know if he thought that by consuming it, it would help keep her looking younger – a veritable fountain of youth. “Don’t you think it makes you look younger?” Kim asks her doctor during the episode. “Some people believe in that,” her doctor replies. “There are cookbooks on placentas.”

In 2012, Mad Men star, January Jones let it be known that she consumed her encapsulated placenta after her baby was born, per her doula’s suggestion.  ”Jones’s secret to staying high energy through the grueling shooting schedule? ‘I have a great doula who makes sure I’m eating well, with vitamins and teas, and with placenta capsulation.’ “

Hollywood seems to have picked up on the trend. Locally, in Pittsburgh, were I practice, there are at least three placenta encapsulation specialists and a few others who dabble in it. Talking to one recently, she mentioned that she was busy enough that she needed to bring in a partner to help her. It would appear that the trend is indeed on the rise.

Let’s take an in-depth look into the modern practice of placentophagy and the evidence behind it.

 How can placenta be consumed?

• Eaten raw
• Cooked in a stew or stir fry, or other recipes
• Made into a tincture
• Dehydrated and put into smoothies
• Dehydrated and encapsulated in pill form

Most modern mothers will choose to encapsulate their placenta. Taking it in a pill form seems to be most palatable for many women interested in consuming their placenta. The placenta is washed, steamed (sometime with other ingredients such as jalapeño, ginger and lemon), sliced, dehydrated, pulverized and encapsulated. Within 24-48 hours after birth, the mother has her placenta back in pill form and will ingest a certain number of pills each day.

Why would a woman want to take placenta capsules?

There are many claims made about the benefits of consuming placenta. The list below is from Placenta Benefits.info

The baby’s placenta, contained in capsule form, is believed to:

• contain the mother’s own natural hormones
• be perfectly made for that mother
• balance the mother’s system
• replenish depleted iron
• give the mother more energy
• lessen bleeding postnatally
• been shown to increase milk production
• help the mother to have a happier postpartum period
• hasten return of uterus to pre-pregnancy state
• be helpful during menopause

This is a rather amazing list. It would appear that consuming placenta postpartum is a bit of a magic bullet. This, in and of itself, makes me wary of the claims. There are a number of oft cited studies to back these claims up. However, my research turns up only studies in animals, anthropological studies and a recent survey of mothers who consume placenta.

© Bjorna Hoen Photography
bjornahoen.com

Animal studies are good preliminary research and may provide indication for further study in humans. In and of themselves, they provide insufficient information to recommend placentophagy in human mothers.

Anthropological studies are a fascinating peek into human evolution, history and practice. They may provide clues as to why humans, as a rule, do not consume placenta. Or for those limited cultures that did/do consume it, the rationale behind doing so may be revealed. However, as with animal studies, anthropology alone does not give us cause to say that we should or should not be participating in placentophagy.

There is ongoing research out of Buffalo, NY by Mark Kristal, as well as from the University of Nevada, Las Vegas by Daniel Benyshek and Sharon Young on placentophagy. I look forward to their further contributions and hope their work provides impetus for additional hard science.

To date, there is not one double-blind placebo controlled study on human placentophagy.

Although advocates claim that these nutrients and hormones assumed to be present in both the prepared and unprepared forms of placenta are responsible for many benefits to postpartum mothers, exceedingly little research has been conducted to assess these claims and no systematic analysis has been performed to evaluate the experiences of women who engage in this behavior. (Selander et al. 2013)

 A note on Selander, et al: Jodi Selander is the owner of Placenta Benefits LTD. Her financial conflict of interest is noted in the survey.

What we have is anecdotal evidence from mothers who have consumed placenta (Selander 2013). Care providers who witness the effects of placentophagy in the mothers have been noted as well. There are a number of studies in animals, both with regards to behavioral and, chemical and nutritional benefits.  There are a number of anthropological studies, as well as a recent survey (Selander 2013).

What we truly lack is a double-blind, placebo controlled human study of the affects of placentophagy.

“While women in our sample reported various effects which were attributed to placentophagy, the basis of those subjective experiences and the mechanisms by which those reported effects occur are currently unknown. Future research focusing on the analysis of placental tissue is needed in order to identify and quantify any potentially harmful or beneficial substances contained in human placenta… ultimately, a more comprehensive understanding of maternal physiological responses to placentophagy and its effects on maternal mood must await studies employing a placebo-controlled double blind clinical trial research design.” (Selander 2013)

 This leaves us with a few unanswered questions. 

1. Is the benefit we see in the human mother after consuming placenta because she has consumed it, or is this placebo effect?
2. Are their benefits or risks to consuming amniotic fluid after birth?
3. If there is no biological imperative for human mothers to consume placenta, is there a reason for that? Is this a reason suggesting harm from eating placenta, a social norm, or something larger with regards to our need for bonding with our community of women during and after birth?

“This need for greater sociality during delivery then, in combination with the consequent pressure to conform to cultural norms, led to a strengthening of socials bonds and a reduction in the likelihood of placentophagia.” (Kristal 2012)

Coming full circle; how do we approach the topic of placentophagy in our Lamaze classes? Keep it simple. As of today, consuming placenta is not an evidence-based practice. Therefore, we cannot directly recommend it to our students.

However, to support our students’ autonomny, I believe a mother should be able to take her placenta home and do with it as she will. If your students wish to engage in this practice, I’d encourage them to speak to their care providers prenatally, to ensure safe handling of the placenta and to set appropriate expectations at birth.

References:

Kristal, M. B. (1980). Placentophagia: A biobehavioral enigma (or< i> De gustibus non disputandum est</i>). Neuroscience & Biobehavioral Reviews,4(2), 141-150.

Kristal, M. B., DiPirro, J. M., & Thompson, A. C. (2012). Placentophagia in humans and nonhuman mammals: Causes and consequences. Ecology of Food and Nutrition, 51(3), 177-197.

Selander, J. (2013), Placenta Benefits, placentabenefits.info. Retrieved June 09, 2013, from http://placentabenefits.info/index.asp.

Selander, J., Cantor, A., Young, S. M., & Benyshek, D. C. (2013). Human Maternal Placentophagy: A Survey of Self-Reported Motivations and Experiences Associated with Placenta Consumption. Ecology of food and nutrition, 52(2), 93-115.

Soykova-Pachnerova E, et. al. (1954)  “Placenta as Lactagagen” Gynaecologia 138(6):617-627

Young, S. M., Benyshek, D. C., & Lienard, P. (2012). The conspicuous absence of placenta consumption in human postpartum females: The fire hypothesis. Ecology of Food and Nutrition, 51(3), 198-217.

Deena Blumenfeld Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized Childbirth Education, Deena Blumenfeld, guest post, maternity care research, placenta, placentophagy, postpartum depression, postpartum mood and anxiety disorders

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

_________________

© 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

http://flic.kr/p/KCS5

Occasional Science & Sensibility contributor Rebecca Dekker of Evidence Based Birth has spent the last month writing a blog article about Group B Strep and it is finally here! In her painstaking but clear review of the evidence on GBS in pregnancy, Rebecca came to the conclusion that universal screening and treatment for GBS is more effective than treating with antibiotics based on risk factors alone. She also found that although “probiotics, chlorhexadine, and garlic have the potential to reduce vaginal and newborn colonization with GBS, we do not have evidence yet to show that these strategies can prevent early GBS infections, since GBS infection usually occurs when GBS gains access to the amniotic fluid and gets into the fetus’s lungs during labor.”

To read Rebecca’s just released article, Group B Strep in Pregnancy: Evidence for Antibiotics and Alternatives in its entirety, click here.

Today, Rebecca joins us on Science & Sensibility to talk about her latest addition to Evidence Based Birth.

Sharon Muza: What inspired you to write this article?

Rebecca Dekker: I received more requests to write about Group B strep than any other topic! Over the past few months, I had weekly, sometimes daily emails and Facebook messages from women—all asking me to provide them with evidence about antibiotics, hibiclens, or garlic for preventing GBS infections. After about the 50th request, I figured I better set aside my other plans and focus on this topic, because it was clearly weighing heavily on many women’s minds! 

SM: What was the most difficult thing about writing this article?

RD: Probably the most difficult thing was sorting through the stacks and stacks of research articles that have been published about Group B strep in pregnancy. This was one of the reasons it took me almost a year of blogging before I decided to dive into group B strep. I knew it would be a monumental task. And it was. But I was fortunate enough to have an expert in GBS who helped point me to the most important or “landmark” studies.

SM: Who was this expert?

RD: I met Dr. Jessica Illuzzi via email earlier this year. She and I had corresponded about a different blog article, and at that time I found her to be incredibly helpful. I knew that in addition to being an OB, Dr. Illuzzi was a research expert in GBS. So I asked her if she would review my article for me. To be honest, I could not have written this article without her guidance. She read my first draft and basically told me that I needed to go back to the drawing board. She encouraged me to dig deeper into the evidence so that I would really understand it. Whenever I had questions about something, she sent me research articles that immediately answered my question. In the end, I knew the article was ready when she said it was a great summary of the state of the science of GBS. 

I was also lucky enough to have 2 other GBS experts give me feedback on the article—a GBS researcher and a microbiologist. And then I have several physicians who faithfully review all of my articles and give great suggestions. I am very grateful to all of them as well!

SM: I know that you usually begin your articles with an exploration of your own biases, in order to tease the bias out of your writing. Did you have any pre-existing biases about GBS? 

RD: To be honest, I actually had no biases up front. I was fortunate to always test negative for GBS myself, and so I never had to struggle with this issue before. I was pretty open-minded to the entire issue. I was open-minded to antibiotics. I was open-minded to hibiclens or other alternatives. I had no personal agenda. I simply wanted to get to the facts. Hopefully this lack of bias will shine through and help people respect the article even more.

 SM: What surprised you most as you wrote this article?

RD: One of the things that surprised me was how people have such different reactions when they read the evidence about GBS. I had several friends preview the article for me. Some of them instantly said, “Oh yeah, that sounds like a really high risk. I’d definitely take the antibiotics to prevent an infection in my newborn.” Others would say, “Really? That’s all? That’s not a very high risk at all. I wouldn’t take antibiotics for that level of risk.” This is a great example of how everyone perceives risk differently. But at least in this article I have been able to put some evidence-based facts out there. Let people interpret the risks as they may. I only ask that they talk with their health care provider before making any decisions!!

 SM: What do you think is the future of GBS evidence?

RD: Ten years from now I am guessing that I could write a very different article. I would like to think that by then we may have a vaccine on the horizon that could prevent both early GBS infections and GBS-related preterm birth. It would also be nice if the rapid test was affordable and widely available by then. I would also LOVE to see some solid research evidence on the use of probiotics for decreasing GBS colonization rates in pregnant women. As far as I know, probiotics for decreasing GBS hasn’t been studied yet in pregnant women, and I think it deserves further inquiry.  

SM:What makes your blog article about GBS different than all the other blog articles out there on this topic?

Rebecca Dekker

RD: I purposefully didn’t look at any of the other GBS blog articles out there until I finished my article. Yesterday, I read through a variety of blog articles (there are a lot!). Most of them were about 90-95% accurate in their facts. A couple of them had serious errors (in particular, I found one blog article that had inaccurate information about hibiclens). Most didn’t list any references, and I could tell that most of the blog authors had used secondary sources (other blogs or summary articles) instead of looking at the research evidence themselves. This can be fine, but sometimes it’s a bit like playing telephone: You just keep repeating the same facts over and over without checking to see if the evidence has changed or if the summary you are parroting was accurate in the first place. I’d like to think that my blog article is a very accurate assessment of the research evidence on GBS in pregnancy—translated into regular language so that women and their family members can understand the evidence. 

SM: What are you going to write about next?

RD: I don’t know!! What would YOU like to see me write about?

SM: I want to thank you Rebecca, for your contributions to Science & Sensibility and for sharing Evidence Based Birth with the world!  I know that these articles take a huge amount of time and you are very diligent and conscientious about researching the literature and providing only the best analysis possible,  and seeking out experts on the topic to help you really be sure that you are offering the best of the best of information.  I always enjoy reading your blog and find it a great source of information for my doula and CBE students and my birth doula clients as well. I know that I speak for all the readers here on Science & Sensibility when I say, keep on keeping on!  Do please let Rebecca know what you would like her to write about next!   

Sharon Muza ACOG, American Academy of Pediatrics, Babies, Childbirth Education, Evidence Based Medicine, Guest Posts, informed Consent, Maternity Care, Medical Interventions, New Research, Newborns, NICU, Push for Your Baby, Research antibiotics, Evidence Based Birth, GBS, group B strep, guest post, informed Consent, newborns, prenatal testing, Rebecca Dekker, research, Sharon Muza, tests in pregnancy

 Regular contributor Henci Goer, author of several books including Optimal Care in Childbirth as well as the expert on Lamaze International’s “Ask Henci” site, takes a look at a recent study that examines the wide divergence in cesarean rates amongst U.S. hospitals.  Read Henci’s take and see what she concludes might be behind this rate variability. – Sharon Muza, Community Manager, Science & Sensibility

__________________

© Patti Ramos Photography

If any doubt remained that the likelihood of cesarean depends mostly on care provider philosophy and practices, a study of variation in cesarean rates in U.S. hospitals has laid it to rest. Investigators plotted cesarean surgery rates during 2009 by their percentile at 593 U.S. hospitals with at least 100 deliveries, comprising 817,318 women in all (Kozhimanni 2013). Rates ranged from 7% to 70%, a 10-fold variation.

Thinking that hospital factors might explain some of the variation, the investigators compared rates according to hospital size, whether the hospital was a teaching hospital, and whether it was rural. None had any effect. Average cesarean rates were similar to the overall average rate regardless of hospital characteristics.

Variation in population characteristics likewise could explain variation in cesarean rates. Accordingly, investigators looked at a more homogeneous low-risk subset of women who were at term (37 weeks or more), carrying one head-down baby, and who had no prior cesareans. This, they reasoned, should reduce the variation in rates. Wrong again. The range widened. Rates among low-risk women ranged from a little over 2% to nearly 37%, a 15-fold variation instead of a 10-fold one.

The investigators stopped with expressing concern over the large variation in cesarean rates, writing: “There is an urgent need to address maternity care quality in general and rising cesarean rates and variation in practice patterns in particular” (p. 531), but their data tell us something more: few hospitals had anything close to reasonable rates.

The mean cesarean rate among women overall was 33%. The World Health Organization holds that cesarean rates should not exceed 15% because research shows that as cesarean rates rise above this threshold, they necessarily are performed in less clear cut situations, and the risks of the surgery begin to outweigh its benefits. Beyond 15%, maternal and neonatal morbidity and mortality rise in parallel with further increase. Only 2 of the 593 hospitals had cesarean rates of 15% or less. Indeed, only 21 hospitals had rates of 20% or less.

In the low-risk population, the mean cesarean rate was 12%. The recent analysis of 18,084 women planning birth center births gives us a fix on whether this is a reasonable rate for low-risk women (Stapleton 2013). Of the 14,881 women admitted in labor to the 79 participating birth centers, 6% delivered by cesarean, and perinatal outcomes were equivalent to those in similar women planning hospital birth. Only 23 of the 593 hospitals had a cesarean rate of 6% or less in their low-risk cohort.

To be fair, the low-risk hospital dataset wasn’t able to identify women with problems that would increase their likelihood of cesarean but who would have been excluded from birth center care. The birth center data, however, provides a handle on the possible effect on cesarean rate. Six percent of women planning birth at the birth center were risked out because of pre-eclampsia, non-reassuring fetal testing, postdates, or prelabor rupture of membranes and no labor. Let us assume that these problems occurred at the same rate in the low-risk hospital population. Let us further assume that all women with these problems ended up with a cesarean, which is highly unlikely. Those assumptions would boost the birth center baseline cesarean rate of 6% by another 6% or to 12% for the low-risk hospital population. Even making this extreme assumption, 271 hospitals, nearly half, had rates greater than 12%.

What’s the take-home? Practitioners with appropriate cesarean rates are thin on the ground. Women need to seek out care providers whose judgment on when a cesarean is indicated can be trusted. (I should add that they are likely to have better luck with a midwife, but it isn’t a sure thing.) Women free of medical or obstetrical risk factors may wish to plan to birth in a free-standing birth center or at home because while individual practitioners’ rates may vary within institutions, a high hospital rate—true of nearly all of them—creates a cesarean–friendly culture.

How would you use this research study when teaching classes or working with clients or patients?  Do you think that women do enough research and investigation when selecting a provider and a birth facility? Please share your thoughts. – SM

References

Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues. Health Aff (Millwood), 32(3), 527-535. doi: 10.1377/hlthaff.2012.1030 http://www.ncbi.nlm.nih.gov/pubmed/23459732

Stapleton, S. R., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: demonstration of a durable model. J Midwifery Womens Health, 58(1), 3-14. doi: 10.1111/jmwh.12003 http://www.ncbi.nlm.nih.gov/pubmed/23363029

Henci Goer Cesarean Birth, Guest Posts, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Push for Your Baby, Research birth centers, cesarean, cesarean rates, guest post, Henci Goer, research, WHO

© http://flic.kr/p/bS581K

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.

______________________

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