Science & Sensibility

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?

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

 

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) have joined the campaign, drawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

• Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

• Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. 

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)  

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, a confluence of quality improvement programs and public awareness campaigns have made it increasingly difficult for providers to perform non-medically indicated inductions or c-sections before 39 weeks.

But as the public and the health care community have accepted the “39 weeks” directive, concern about unintended consequences has grown. Christine Morton, a researcher at the California Maternal Quality Care Collaborative and regular contributor to Science & Sensibility, sums up concerns shared by many, including Childbirth Connection:

It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own.  Additionally, is it possible that 39 weeks could become the new “ideal” gestational age, because it will be assumed that 39 completed weeks is the best time to be born?

The second Choosing Wisely statement aims to mitigate these unintended consequences. Inducing with an unripe cervix significantly increases the chance of a c-section and its many associated harms. Women considering induction for a non-medical reason deserve to know about these excess risks, and should question whether it is worth any non-medical benefits of elective delivery they perceive or expect. Lamaze International has spoken to the importance of letting labor begin on its own, as it is the first topic in the Six Healthy Birth Practices.

But will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe? Through the Choosing Wisely campaign ACOG and AAFP have made powerful statements acknowledging that scheduled delivery is unwise if the baby or the woman might not be ready for birth. Although gestational age and the Bishop score are tools to estimate readiness for birth, the best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.

This summer, our collaboration with the Informed Medical Decisions Foundation will culminate in the release of our first three Smart Decision Guides. These evidence-based, interactive decision support tools will help women learn the possible benefits and harms of scheduled delivery versus waiting for labor to start on its own and to weigh these based on what is most important to them. These tools help women choose wisely – to identify when an option is not appropriate or safe for them, and to thoughtfully weigh options when there are both pros and cons to consider.

Interested in learning more about shared decision making in maternity care? Sign up for a free webinar on March 13 sponsored by the Informed Medical Decisions Foundation to hear more about what clinicians, consumers, employers, and others thinking about the importance of maternity care shared decision making.

 

Amy Romano ACOG, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, Practice Guidelines, Pre-term Birth, Webinars AAFP, ABIM Foundation, ACOG, Amy Romano, avoiding labor induction, Childbirth Connection, Foundation for Informed Medical Decision Making, induction, informed Consent, labor induction, Webinars

by Mark Sloan M.D.

Today’s guest post is written by Dr. Mark Sloan, pediatrician and author of Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth.  Dr. Sloan shares information and current research on delayed cord clamping after birth, in a helpful Q&A style format that consumers and professionals can use to discuss this important topic.

_____________________

Many maternity care providers continue to clamp the umbilical cord immediately after an uncomplicated vaginal birth, even though the significant neonatal benefits of delayed cord clamping (usually defined as 2 to 3 minutes after birth) are now well known.

In some cases this continued practice is due to a misunderstanding of placental physiology in the first few minutes after birth. In others, human nature plays a role: We are often reluctant to change the way we were taught to do things, even in the face of clear evidence that contradicts that teaching.

Though there is no strong scientific support for immediate cord clamping (ICC), entrenched medical habits can be glacially slow in changing. Here are some often-heard objections to delayed cord clamping (DCC), and how an advocate for delayed clamping might respond to them:

1) I have a very busy practice. DCC takes too much time!

Not really, especially when you consider the benefits. Nearly one-third of a baby’s total blood volume resides in the placenta at birth. Half of that blood is transfused into the baby by 1 minute of age. By 3 minutes, more than 90% of the transfusion is complete. (1)

 2) Immediate clamping helps prevent severe postpartum hemorrhage.

There is no convincing evidence to support this view. Several large studies, including a 2009 Cochrane review of 5 trials involving more than 2,200 women, have found no significant difference between ICC and DCC in terms of postpartum hemorrhage or severe postpartum hemorrhage. (2-6, 10)

 3) A healthy, term baby doesn’t get much benefit from delayed clamping.

Though this is a commonly held belief, it’s definitely untrue.

Whether a fetus is premature or full term, approximately one-third of its total blood volume resides in the placenta. This is equal to the volume of blood that will be needed to fully perfuse the fetal lungs, liver, and kidneys at birth.

In addition to the benefits that come with adequate iron stores (see below), babies whose cords are clamped at 2 to 3 minutes—and thus, who have an increased total blood volume compared with their immediately-clamped peers—have a smoother cardiopulmonary transition at birth.

A third benefit: stem cells, which play an essential role in the development of the immune, respiratory, cardiovascular, and central nervous systems, among many other functions. The concentration of stem cells in fetal blood is higher than at any other time of life. ICC leaves nearly one-third of these critical cells in the placenta. (1,3,4,6-10)

 4) Okay, so delayed clamping means a baby gets more blood and more iron. But iron deficiency isn’t really a problem in first-world countries, right?

Wrong. At least 10% of the general U.S. toddler population (1-3 years of age) is iron deficient, with the prevalence rising well above 20% in selected ethnic and socioeconomic populations.

Immediate cord clamping is only one of many factors that contribute to iron deficiency in early childhood. But babies who start out life low on iron have a very difficult time catching up. Delayed cord clamping provides a baby with as much as a 4- to 6-month supply of iron. (1,3,6-10)

 5) Doesn’t iron deficiency just make kids tired?

Iron deficiency does much more damage than that. Early infancy is a time of rapid brain growth and development, and iron is essential to that process. Studies of infants with iron deficiency have found specific deficits in cognitive processing (including attention and memory) which may lead to permanently decreased intellectual functioning. Making matters even worse, children with severe iron deficiency often exhibit “emotional dulling”—difficulty engaging with caretakers and their environment—which can lead to long-lasting social-emotional deficits. For many reasons, early infancy is a particularly bad time to be low on iron. (1,11)

 6) Don’t babies get plenty of iron from breast milk? 

Unfortunately, no. While breast milk contains a remarkable array of healthful components, a high concentration of iron isn’t one of them. This most likely has to do with maternal recovery from childbirth. A recuperating mother has her own urgent iron needs; replacing the blood typically lost in childbirth takes a lot of it. Nature intends babies to get most of the iron they’ll need for their early development from the placental blood reservoir, rather than from mother, and so comparatively little iron goes into breast milk.  (3,7)

 7) But the baby can lose significant blood volume back into the placenta (aka “backflow bleeding”) if clamping is delayed.

This is extremely unlikely in an uncomplicated birth. With some brief exceptions (e.g., between uterine contractions, or when a baby bears down during crying), blood flow immediately after birth is primarily one-way, from placenta to baby. Here’s a brief explanation of why this is true:

In a process that begins during labor and accelerates as the newborn begins to cry, the pulmonary blood vessels, which receive very little blood flow during pregnancy, open and fill. This relatively sudden change causes the newborn’s blood pressure to fall below the pressure in the placenta. Placental blood, driven by strong uterine contractions, follows the pressure gradient and flows through the umbilical vein into the baby.

As the newborn’s oxygen saturation increases, the umbilical arteries close, which stops nearly all blood flow from baby to placenta. The umbilical vein, which isn’t sensitive to oxygen, remains open somewhat longer, allowing a final bit of blood to flow from placenta to baby before it, too, closes.

The lack of significant “backflow bleeding” is confirmed by the fact that DCC results in ~ 30% greater neonatal blood volume than does ICC.  (1,12)

8) DCC can lead to dangerously high levels of neonatal jaundice.

Since bilirubin, the source of neonatal jaundice, originates in red blood cells, it seems logical that the increased blood volume associated with delayed clamping could lead to severe hyperbilirubinemia.

Yet while some studies have demonstrated mildly increased bilirubin levels in DCC babies in the first few days postpartum, most have found no significant difference between DCC and ICC.

This seeming paradox—relatively stable bilirubin levels in the face of substantially increased blood volume—may have to do with increased blood flow to the neonatal liver that comes with the higher total blood volume associated with DCC. Yes, more blood means more bilirubin, which in turn could mean more jaundice, but better blood flow allows the liver to process bilirubin more efficiently.  (3,4,6,7,9,10)

 9) Delayed clamping can lead to neonatal hyperviscocity—“thick blood” that can cause kidney damage and strokes.

DCC can lead to a somewhat higher neonatal hematocrit than ICC, which isn’t surprising given the additional blood volume. Yet, despite fears of thicker blood “sludging” in organs like the brain and kidneys, no studies have demonstrated this to be the case from DCC alone. (4,6,9,10)

 10) You can’t have both the benefits of DCC and immediate skin-to-skin contact. If you place a newborn on his mother’s abdomen (i.e., above the level of the placenta), gravity will reduce the flow of blood from placenta to baby.

Gravity does matter, but mainly in terms of the speed of the placental transfusion. A baby held below the level of the placenta will receive a full transfusion in about 3 minutes; one held above the placenta (e.g., a baby in immediate skin-to-skin contact) will also receive a full transfusion—it just takes a little longer (about 5 minutes). (1,13)

 11) But what if the baby needs resuscitation? Isn’t it best to hand her over to the pediatrician immediately?

One of the first things a truly sick baby in the NICU is going to receive is fluid support—often as a 20 to 40 ml/kg bolus of normal saline or blood. Yet that is exactly what’s left behind in the placenta with ICC—about 30 ml/kg of whole blood. There is considerable evidence that sick babies, both term and preterm, have better outcomes with DCC. It’s better to let nature do its own transfusing. (14-16)

Summary: 

Delayed cord clamping promotes a healthy neonatal cardiopulmonary transition, prevents iron deficiency at a critical time in brain development, provides the newborn with a rich supply of stem cells, and helps sick neonates achieve better outcomes—all with little apparent risk to mother or baby. The evidence of benefit from DCC is so compelling that the burden of proof must now lie with those who wish to continue the practice of immediate clamping, rather than with those who prefer—as nature intended—to wait.

What do you tell your patients, students and clients about delayed cord clamping?  Do you have a favorite resource or two that you like to share?  What are the community standards around delayed cord clamping in your community?  Are health care providers discussing this with their patients?  Do they have recommendations one way or another that you are hearing?  Please join in the discussion.- SM

References

1) Mercer JS, Erickson-Owens DA. Rethinking placental transfusion and cord clamping issues. Journal of Perinatal & Neonatal Nursing. July/September 2012 26:3; 202–217 doi: 10.1097/JPN.0b013e31825d2d9a

2) Andersson O, Hellstrom-Westas L, Andersson D, et al. Effects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial. Acta Obstetricia et Gynecologica Scandinavica. Article first published online: 17 Oct, 2012. DOI: 10.1111/j.1600-0412.2012.01530.x

3) Chaparro, CM. Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutrition Reviews. Volume 69, Issue Supplement s1, pages S30–S36, November 2011.

4) Ceriani Cernadas JM, Carroli G, Pellegrini L, et.al. The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial. Pediatrics. Vol. 117 No. 4 April 1, 2006 pp. e779 -e786 (2,3 8,9(doi: 10.1542/peds.2005-1156). Published online March 27, 2006.

5) WHO. Department of Making Pregnancy Safer. WHO recommendations for the prevention of postpartum haemorrhage. Geneva: World Health Organization, 2007.

6) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub2.

7) Andersson O, Hellstrom-Westas L, Andersson D, Domellof M. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. British Medical Journal. 2011; 343: d7157. Published online 2011 November 15. doi:  10.1136/bmj.d7157

8) Ceriani Cernadas JM, Carroli G, Pellegrini L, et.al. The effect of early and delayed umbilical cord clamping on ferritin levels in term infants at six months of life: a randomized, control trial. Arch Argent Pediatr. 2010; 108:201-208.

9) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 2007 Mar 21;297(11):1241-52.

10) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub2.

11) Carter RC, Jacobson JL, Burden MJ, et al. Iron deficiency anemia and cognitive function in infancy. Pediatrics. 2010; 126:2 pp e427-e434 (doi: 10.1542/peds.2009-2097).

12) Mercer JS, Skovgaard R. Neonatal Transitional Physiology: A New Paradigm. J Perinat Neonat Nursing 2002; 15(4) 56-75

13) Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet. 1969; 2:505-508.

14) Mercer JS, Vohr BR, Erickson-Owens DA, et al. Seven-month developmental outcomes of very low-birth-weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping. J Perinatol. 2010; 30:11-16.

15) Kinmond S, Aitchison TC, Holland BM, et al. Umbilical cord clamping and preterm infants: a randomized trial. British Medical Journal. 1993; 306:172-175.

16) Rabe H, Wacker, A, Hulskamp G, et al. A randomized controlled trial of delayed cord-clamping in very low-birth-weight preterm infants.  Eur J Pediatr. 2000; 159:775-777.

About Mark Sloan, M.D.

Mark Sloan has been a pediatrician and a Fellow of the American Academy of Pediatrics for more than 25 years. Since 1982, he has practiced with the Permanente Medical Group in Sacramento and Santa Rosa, California, where he was Chief of Pediatrics from 1997 to 2002. He is an Assistant Clinical Professor in the Department of Community and Family Medicine at the University of California, San Francisco. Dr. Sloan’s first book, Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth was published in 2009 by Ballantine Books. His writing has appeared in the Chicago Tribune, the San Francisco Chronicle, the San Francisco Examiner, and Notre Dame Magazine, among other publications.  Dr. Sloan can be reached through his blog.

 

Sharon Muza American Academy of Pediatrics, Delayed Cord Clamping, Do No Harm, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Medical Interventions, Newborns, Research, Third Stage, Uncategorized guest post, informed Consent, leaving the umbilical cord patent in third stage, Mark Sloan, newborn immune system, newborn iron stores, newborns, placenta, risks of early clamping and cutting umbilical cord, umbilical cord clamping, why is placental blood important?

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.

Online Resources on Cord Blood Banking to Share with FamiliesParents Guide to Cord Blood Foundation American College of Nurse–Midwives—“Cord Blood Banking—What It’s All About” (from 2008 Journal of Midwifery & Women’s Health, 53[2], 161–162) National Marrow Donor Program—“Cord Blood Donation: Frequently Asked Questions” compiled by Renece Waller-Wise

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.

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