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Evidence on Water Birth Safety – Exclusive Q&A with Rebecca Dekker on her New Research

July 10th, 2014 by avatar

 

Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just today published a new article, “Evidence on Water Birth Safety“ that looks at the current research on the safety of water birth for mothers and newborns.  Rebecca researched and wrote that article in response to the joint Opinion Statement “Immersion in Water During Labor and Delivery” released in March, 2014 by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.  I had the opportunity to ask Rebecca some questions about her research into the evidence available on water birth, her thoughts on the Opinion Statement and her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: First off, is it waterbirth or water birth?

Rebecca Dekker: That’s actually good question! Research experts tend to use the term “waterbirth.” Google prefers “water birth.” So I used both terms in my article to satisfy everyone!

SM: Have you heard or been told of stories of existing water birth programs shutting down or being modified as a result of the recent AAP/ACOG opinion?

RD: Yes, definitely. There was a mother in my state who contacted me this spring because she was 34 weeks pregnant and her hospital decided not to offer waterbirth anymore. She had given birth to her daughter in a waterbirth at the same hospital two years earlier. With her current pregnancy, she had been planning another hospital waterbirth. She had the support of her nurse midwife, the hospital obstetricians, and hospital policy. However, immediately after the release of the ACOG/AAP opinion, the hospital CEO put an immediate stop to waterbirth. This particular mother ended up switching providers at 36 weeks to a home birth midwife. A few weeks ago, she gave birth to her second baby, at home in the water. This mother told me how disheartening it was that an administrator in an office had decided limit her birth options, even though physicians and midwives at the same hospital were supportive of her informed decision to have a waterbirth.

In another hospital in my hometown, they were gearing up to start a waterbirth program this year—it was going to be the first hospital where waterbirth would be available in our city—and it was put on hold because of the ACOG/AAP Opinion.

Then of course, there were a lot of media reports about various hospital systems that suspended their waterbirth programs. One hospital system in particular, in Minnesota, got a lot of media coverage.

SM: Did you attempt to contact ACOG/AAP with questions and if so, did they respond?

RD: Yes. As soon as I realized that the ACOG/AAP Opinion Statement had so many major scientific errors, I contacted ImprovingBirth.org and together we wrote two letters. I wrote a letter regarding the scientific problems with the Opinion Statement, and ImprovingBirth.org wrote a letter asking ACOG/AAP to suspend the statement until further review. The letters were received by the President and President-Elect of ACOG, and they were forwarded to the Practice Committee. We were told that the Practice Committee would review the contents of our letters at their meeting in mid-June, and that was the last update that we have received.

SM: What is the difference between an “Opinion Statement” and other types of policy recommendations or guidelines that these organizations release? Does it carry as much weight as practice bulletins?

RD: That’s an interesting question. At the very top of the Opinion Statement, there are two sentences that read: “This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.” But, as you will see, some hospitals do see this statement as dictating an exclusive course of treatment, and others don’t.

I have heard that “opinions” do not carry as much weight as “practice bulletins,” but it really depends on who the audience is and who is listening. In other words, some hospitals may take the Opinion Statement word-for-word and feel that they must follow it to the letter, and other hospitals may ignore it. A lot of it probably depends on the advice of their risk management lawyers.

For example, a nurse midwife at a hospital in Illinois sent me a letter that their risk-management attorneys had put together to advise them on this issue. (She had the attorney’s permission to share the letter with me). These lawyers basically said that when a committee of two highly-respected organizations says that the practice of waterbirth should be considered an experimental procedure, both health care providers and hospitals are “charged with a duty to heed that statement,” unless they find research evidence that waterbirth has benefits for the mother or fetus, and that the evidence can override the Committee’s conclusions.

On the other hand, another risk management lawyer for a large hospital system told me that of course hospitals are not under any obligation to follow an ACOG/AAP Opinion Statement. It’s simply just that—an opinion.

So as to how much weight the Opinion Statement carries—I guess it is really dependent on who is reading it!

SM: How would you suggest a well-designed research study be conducted to examine the efficacy and safety of waterbirth? Or would you say that satisfactory research already exists.

RD: First of all, I want to say that I’m really looking forward to the publication of the American Association of Birth Centers (AABC) data on nearly 4,000 waterbirths that occurred in birth centers in the U.S., to see what kind of methods they used. From what I hear, they had really fantastic outcomes.

And it’s also really exciting that anyone can join the AABC research registry, whether you practice in a hospital, birth center, or at home. The more people who join the registry, the bigger the data set will be for future research and analysis. Visit the AABC PDR website to find out more.

I think it’s pretty clear that a randomized trial would be difficult to do, because we would need at least 2,000 women in the overall sample in order to tell differences in rare outcomes. So instead we need well-designed observational studies.

My dream study on waterbirth would be this: A large, prospective, multi-center registry that follows women who are interested in waterbirth and compares three groups: 1) women who have a waterbirth, 2) women who want a waterbirth and are eligible for a waterbirth but the tub is not available—so they had a conventional land birth, 3) women who labored in water but got out of the tub for the birth. The researchers would measure an extensive list of both maternal and fetal outcomes.

It would also be interesting to do an additional analysis to compare women from group 2 who had an epidural with women from group 1 who had a waterbirth. To my knowledge, only one study has specifically compared women who had waterbirths with women who had epidurals. Since these are two very different forms of pain relief, it would be nice to have a side-by-side comparison to help inform mothers’ decision making.

SM: What was the most surprising finding to you in researching your article on the evidence on water birth safety?

RD: I guess I was most surprised by how poorly the ACOG/AAP literature review was done in their Opinion Statement. During my initial read of it, I instantly recognized multiple scientific problems.

A glance at the references they cited was so surprising to me—when discussing the fetal risks of waterbirth, they referenced a laboratory study of pregnant rats that were randomized to exercise swimming in cold or warm water! There weren’t even any rat waterbirths! It was both hilarious and sad, at the same time! And it’s not like you have to read the entire rat article to figure out that they were talking about pregnant rats—it was right there in their list of references, in the title of the article, “Effect of water temperature on exercise-induced maternal hyperthermia on fetal development in rats.”

These kind of mistakes were very surprising, and incredibly disappointing. I expect a lot higher standards from such important professional organizations. These organizations have a huge influence on the care of women in the U.S., and even around the world, as other countries look to their recommendations for guidance. The fact that they were making a sweeping statement about the availability of a pain relief option during labor, based on an ill-researched and substandard literature review—was very surprising indeed.

SM: What was the most interesting fact you discovered during your research?

RD: With all this talk from ACOG and the AAP about how there are “no maternal benefits,” I was fascinated as I dug into the research to almost immediately find that waterbirth has a strong negative effect on the use of episiotomy during childbirth.

Every single study on this topic has shown that waterbirth drastically reduces and in some cases completely eliminates the use of episiotomy. Many women are eager to avoid episiotomies, and to have intact perineums, and waterbirth is associated with both lower episiotomy rates and higher intact perineum rates. That is a substantial maternal benefit. It’s kind of sad to see leading professional organizations not even give the slightest nod to waterbirth’s ability to keep women’s perineums intact.

In fact, I’m puzzled as to why keeping women’s perineums intact and uncut is not perceived as a benefit by anyone other than the women themselves. And here is the heart of declaring waterbirth as “not having enough benefits” to justify its use: Who decides the benefits? Who decides what a benefit is, if not the person benefitting? Who should be weighing the potential harms and the potential benefits of waterbirth, and making an informed decision about their options? Should it be the mother? Or should it be the obstetrician?

SM: What can families do if they want waterbirth to be an option in their local hospital or birth center and it has been taken away or not even ever been offered before?

RD: That’s a hard question. It’s a big problem.

Basically what it boils down to is this—there are a lot of restraining forces that keep waterbirth from being a pain relief option for many women. But there are also some positive driving forces. According to change theory, if you want to see a behavior change at the healthcare organization level, it is a matter of decreasing the restraining forces, while increasing the driving forces. Debunking the ACOG/AAP Opinion Statement is an important piece of decreasing restraining forces. On the other side, increasing consumer pressure can help drive positive change.

SM: Do you think that consumers will be responding with their health dollars in changing providers and facilities in order to have a waterbirth?

RD: I think that if a hospital offered waterbirth as an option to low-risk women, that this could be a huge marketing tool and would put that hospital at an advantage in their community, especially if the other hospitals did not offer waterbirth.

SM: The ACOG/AAP opinion sounded very reactionary, but to what I am not sure. What do you think are the biggest concerns these organizations have and why was this topic even addressed? Weren’t things sailing along smoothly in the many facilities already offering a water birth option?

RD: I don’t know if you saw the interview with Medscape, but one of the authors of the Opinion Statement suggested that they were partially motivated to come out with this statement because of the increase in home birth, and they perceive that women are having a lot of waterbirths at home.

I also wonder if they are hoping to leverage their influence as the FDA considers regulation of birthing pools. You may remember that in 2012, the FDA temporarily prohibited birthing pools from coming into the U.S. Then the FDA held a big meeting with the different midwifery and physician organizations. At that meeting, AAP and ACOG had a united front against waterbirth. So I guess it’s no surprise for them to come out with a joint opinion statement shortly afterwards.

My sincere hope is that the FDA is able to recognize the seriously flawed methods of the literature review in this Opinion Statement, before they come out with any new regulations.

SM: How should childbirth educators be addressing the topic of waterbirth and waterbirth options in our classes in light of the recent ACOG/AAP Opinion Statement and what you have written about in your research review on the Evidence on Water Birth Safety?

RD: It’s not an easy subject. There are both pros and cons to waterbirth, and it’s important for women to discuss waterbirth with their providers so that they can make an informed decision. At the same time, there are a lot of obstetricians who cannot or will not support waterbirth because of ACOG’s position. So if a woman is really interested in waterbirth, she will need to a) find a supportive care provider, b) find a birth setting that encourages and supports waterbirth.

You can’t really have a waterbirth with an unwilling provider or unwilling facility. Well, let me take that back… you can have an “accidental” waterbirth… but unplanned waterbirths have not been included in the research studies on waterbirth, so the evidence on the safety of waterbirth does not generalize to unplanned waterbirths. Also, you have to ask yourself, is your care provider knowledgeable and capable of facilitating a waterbirth? It might not be safe to try to have an “accidental” waterbirth if your care provider and setting have no idea how to handle one. Do they follow infection control policies? Do they know how to handle a shoulder dystocia in the water?

SM: What kind of response do you think there will be from medical organizations and facilities as well as consumers about your research findings?

RD: I hope that it is positive! I would love to see some media coverage of this issue. I hope that the Evidence Based Birth® article inspires discussion among care providers and women, and among colleagues at medical organizations, about the quality of evidence in guidelines, and their role in providing quality information to help guide informed decision-making.

SM: Based on your research, you conclude that the evidence does not support universal bans on waterbirth. Is there anything you would suggest be done or changed to improve waterbirth outcomes for mothers or babies?

RD: The conclusion that I came to in my article—that waterbirth should not be “banned,” is basically what several other respected organization have already said. The American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives have all said basically the same thing.

How can we improve waterbirth outcomes? I think continuing to be involved in clinical research studies (such as the AABC registry) is an important way to advance the science and provide evidence on which we can base practice and make more informed decisions with. Also, conducting clinical audits (tracking outcomes) in facilities that provide waterbirth would be important for quality control.

SM: Let’s look into the future. What is next on your plate to write about?

RD: I recently had a writing retreat with several amazing clinicians and researchers who flew from across the country to conduct literature reviews with me. We made an awesome team!! The topics that we have started looking at are: induction for post-dates, induction for ruptured membranes, and evidence-based care for women of advanced maternal age. I can’t decide which one we will publish first! The Evidence Based Birth readers have requested AMA next, but the induction for ruptured membranes article is probably further along than that one. We shall see!!

SM: Is there anything else you would like to share with Science & Sensibility readers on this topic?

RD: Thanks for being so patient with me! I know a lot of people were eagerly awaiting this article, and I wish it could have come out sooner, but these kinds of reviews take a lot of time. Time is my most precious commodity right now!

Has the recent Opinion Statement released by ACOG/AAP impacted birth options in your communities?  Do you discuss this with your clients, students and patients?  What has been the reaction of the families you work with? Let us know below in the comments section! – SM.

ACOG, American Academy of Pediatrics, Babies, Childbirth Education, Evidence Based Medicine, Home Birth, informed Consent, Maternity Care, New Research, Newborns, Research , , , , , , , ,

Evidence for the Vitamin K Shot in Newborns – Exclusive Q&A with Rebecca Dekker on her New Research

March 18th, 2014 by avatar

 Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just published a new article, “Evidence for the Vitamin K Shot in Newborns that examines Vitamin K deficiency bleeding (VKDB)- a rare but serious consequence of insufficient Vitamin K in a newborn or infant that can be prevented by administering an injection of Vitamin K at birth.  I had the opportunity to ask Rebecca some questions about her research into the evidence and some of her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Note:  Evidence Based Birth website may be temporarily unavailable due to high volume loads on their server.  Please be patient with the site, I know the EBB team is working on it.

Sharon Muza: Why was the topic of Vitamin K an important one for you to cover and why now?

Rebecca Dekker: Well, I try to pick my articles based on what my audience wants me to cover. I heard over and over again that people were confused and concerned about Vitamin K. A lot of parents told me they weren’t sure if they should consent to the injection or not. There was just so much confusion, and even I didn’t understand what the Vitamin K shot was all about. I didn’t know what I was going to do at the birth of my own child last December. It seemed like there was a need for an evidence-based blog article to clear up all the confusion once and for all.

So as usual, I dove in head first into the research, with no up-front biases one way or the other. I just wanted to get to the bottom of this mess!

SM: Were you surprised by what the current research showed about the rates of VKDB, and the apparent significant protection offered by the Vitamin K shot?

RD: I knew that Vitamin K deficiency bleeding (VKDB) was rare, but I didn’t realize—until I started reading the research—how effective the shot is at basically eliminating this life-threatening problem.

I was surprised by how low the rates of VKDB are in European studies, and by how VKDB is more common in Asian populations. I was also surprised by the fact that we don’t track VKDB in the U.S. and we have no idea how many infants in the U.S. would develop VKDB if we stopped giving the shot.

The number of infants in Tennessee last year who developed VKDB is very concerning to me. They had 5 cases of life-threatening VKDB in Nashville during an 8 month period—7 if you count the infants who were found to have severe Vitamin K deficiencies but didn’t bleed. None of these infants received Vitamin K, mostly because their parents thought it was unnecessary and weren’t accurately informed about the risks of declining the shot.

So the Tennessee situation makes me worry that maybe there is something about our diets in America, or our genetics, that makes us at higher risk for VKDB if we decline the Vitamin K shot for our newborns. But we don’t know our underlying risk, because we don’t track these numbers on a nationwide scale.

SM: What was the most surprising finding to you in writing this article?

RD: That the research on Vitamin K for newborns goes back as far as the 1930’s and 1940’s… that we have literally eight or nine decades of research backing up the use of Vitamin K for newborns. I was under the impression that we were using the shot without any supporting evidence. That turned out not to be the case.

I even forked out the money to buy the landmark 1944 study in which a Swedish researcher gave Vitamin K to more than 13,000 newborns. He observed a drastic decrease in deaths from bleeding during the first week of life. I am usually able to read all of my articles through my various subscriptions, but this article was so old the only way I could read it was to buy it. It was pretty eye-opening. There was some really good research going on back then on Vitamin K. About 15 years later, the American Academy of Pediatrics finally recommended giving Vitamin K at birth. We know that it takes about 15 years for research to make its way into practice. It looks like the same was true back then.

But there is this misconception that “Vitamin K doesn’t have any evidence supporting its use,” and I found that belief is totally untrue. There is a lot of evidence out there. People have just forgotten about it or not realized it was there.

SM: What was the most interesting finding to you in writing this article?

RD: That the two main risk factors for late Vitamin K deficiency bleeding (the most dangerous kind of VKDB that usually involves brain bleeding) are exclusive breastfeeding and not giving the Vitamin K shot.

Parents who have been declining the shot are the ones who are probably exclusively breastfeeding. So their infants are at highest risk for VKDB.

SM: What do you think is the biggest misconception around the Vitamin K shot?

RD: How do I choose which one? There are so many misconceptions and myths. I’ve heard them all. The scary thing is, I’ve heard these misconceptions from doulas and childbirth educators—the very people that parents are often getting their information from. I’ve heard: “You don’t need Vitamin K if you aren’t going to circumcise.” “Getting the shot isn’t necessary.” “Getting the shot causes childhood cancer.” “Getting the shot is unnatural and it’s full of toxins that will harm your baby.” “You don’t need the shot as long as you have delayed cord clamping.” “You don’t need the shot if you had a gentle birth.”

Informed consent and refusal isn’t truly informed if you’re giving parents inaccurate information.

SM: What do you think are the sources of information that families are using to make the Vitamin K decision and where are they getting this information from? Do you think families trust the evidence around this?

RD: This is what I did—I googled “Vitamin K for newborns” and read some of the blog articles that pop up on the front page of results. It is truly alarming the things that parents are reading. “Vitamin K leads to a 1 in 500 chance of leukemia.” “Vitamin K is full of toxins.” Most of the articles on the front page of results are written by people who have no healthcare or research background and did not do any reference checking to see if what they were saying was accurate. It’s appalling to me that some bloggers are putting such bad information out there.

If parents don’t trust the evidence, it may be because they have read so many of these bad articles that it’s hard to overcome the bias against Vitamin K. All I can say is, given the number of bad articles on the internet about Vitamin K, I can totally understand the confusion people have.

I mean, even I was confused before I started diving into the research! I truly went into this experience with no pre-existing biases. I just wanted to figure out the truth. If even I—the founder of Evidence Based Birth—didn’t know all the facts about Vitamin K, then I think that’s a pretty good sign that most other people don’t know the facts, either!

To help remedy the amount of misinformation out there, I’d like for the new Evidence Based Birth article to make it towards the top of the Google results so that parents can read evidence-based information on Vitamin K and check out the references for themselves.

SM: In your article, you state “The official cause of classical VKDB is listed as “unknown,” but breastfeeding and poor feeding (<100 mL milk/day) are major risk factors.” – Why, if breastmilk offers little to no protection against VKBD, is “poor feeding” seen as a risk factor?  What should it matter?

RD: Poor feeding is a risk factor for classical VKDB, which happens in the first week of life. There are limited amounts of Vitamin K in breastmilk overall, but there is more Vitamin K in colostrum than in mature milk. So infants who don’t receive enough milk in those first few days may be at higher risk. This connection was first observed by Dr. Townsend in Boston in the 1890’s. He figured out that he could help some infants with early bleeding by getting them to a wet nurse. These infants weren’t getting enough milk from their biological mothers, for whatever reasons.

SM: Are families in the USA receiving proper informed consent around the issue of Vitamin K and the risks and benefits of the different options available to their children at birth (injection, oral,  or declination of both?)

RD: I’m not sure, but my gut reaction is that I don’t think parents are giving informed consent. In my case, when my first child received the shot, I wasn’t even told that she got it! They just did it in the nursery when they separated me from my daughter after birth. It would have been nice to receive some education on it and be given the chance to consent. Maybe if healthcare providers had been properly consenting parents all along, we wouldn’t have so much misinformation out there! By taking parents out of the equation and doing the shot in the nursery without their knowledge, that certainly doesn’t help educate the public!

I don’t think we are doing a very good job with the parents who decline the shot, either. If you read the part of my article where I wrote about the epidemic in Nashville, all of the parents refused the shot, but none of the parents gave informed refusal. All of them had been given inaccurate information about the shot, so they couldn’t make a truly informed decision. Can you imagine what it must be like for the people who gave them the inaccurate information? That would be so terrible to know that your misinformation may have led to the parents making the choice that they did. 

SM: What should the information look like during the consent process so that families can make informed decisions about having their newborns receive Vitamin K in injection or oral form.

RD: I think the CDC has a really great handout that can be used for informed consent. If parents want more detailed information and references, or if they have concerns that the CDC handout doesn’t answer, then the Evidence Based Birth blog article covers most of the research out there. 

Also, here is a link to a peer-reviewed manuscript that is free full-text, and although it is written at a higher level, it does a good job addressing the myths about the Vitamin K shot.

SM: Are you aware of any adverse effects from either the injection or the oral administration of Vitamin K, other than bruising, pain and bleeding at the injection site if an injection pathway is chosen?

RD: Not if given via the intramuscular method. Some bloggers out there look at the medication information sheet and immediately start pointing out some scary sounding side effects. It’s important to realize that those side effects refer to intravenous administration. Giving a medication intravenously (IV) is a whole different ballgame than giving an intramuscular shot (IM). In general, medications have the potential to be a lot more dangerous if they are given IV—because when medications are given IV they go straight to the heart and all throughout the circulation in potent quantities. For newborns, the Vitamin K is given IM, not IV, which is a much safer method of giving medications in general.

SM: In a childbirth education class, with limited time and a lot of material to cover, what message do you think educators should be sharing about the Vitamin K options.

RD: If I had to sum it up in a minute or less, I would share that babies are born with limited amounts of Vitamin K, and Vitamin K is necessary for clotting. Although bleeding from not having enough Vitamin K is rare, when it happens it can be deadly and strike without warning, and half of all cases involve bleeding in the baby’s brain.

Breastfed babies are at higher risk for Vitamin K bleeding because there are very low levels of Vitamin K in breastmilk. Giving a breastfed infant a Vitamin K shot virtually eliminates the chance of life-threatening Vitamin K deficiency bleeding. The only known adverse effects of the shot are pain, bleeding, and bruising at the site of the injection.

Right now there is no FDA-approved version of oral Vitamin K, although you can buy a non-regulated Vitamin K supplement online. A regimen of three doses of oral Vitamin K1 at birth, 1 week, and 1 month reduces the risk of bleeding. Although oral Vitamin K1 is better than nothing, it is not 100% effective. It is important for parents to administer all 3 doses in order for this regimen to help lower the risk of late Vitamin K deficiency bleeding.

If parents want to use the oral method, or decline the Vitamin K altogether, I would encourage them to do their research and talk with their healthcare provider so that they truly understand the risks of declining the injection. I would tell them to take caution when reading materials online because there is a lot of misinformation out there and you don’t want them making important healthcare decisions based on faulty information.

 SM: How should a childbirth educator (or other professional who works with birthing women) respond when asked  by parents “Why does breastmilk, the perfect food for babies, not offer the protection that babies need? It doesn’t make sense?”

RD: Breastmilk is the perfect food for babies! But for some reason—we don’t know why—Vitamin K doesn’t do a very good job of going from the mom to the baby through breastmilk. Our diets today are probably low in Vitamin K (green leafy vegetables), which doesn’t help matters, either.

It’s possible that maybe there is some reason we don’t know of that could explain why Vitamin K doesn’t cross the placenta or get into breastmilk very well. Maybe the same mechanism that keeps Vitamin K out of breastmilk is protecting our babies from some other environmental toxin. Who knows?

If it helps, look at it this way—don’t blame it on the breastmilk! Blame it on the Vitamin K! That pesky little molecule doesn’t do a good job of getting from one place to the other. So we have to give our infants a little boost at the beginning of life to help them out until they start eating Vitamin K on their own at around 6 months.

SM: If formula feeding is protective, because of the addition of Vitamin K in the formula, why wouldn’t oral dosing of Vitamin K be effective for the exclusively breastfed infant  – is it just a compliance issue?

RD: Part of the failure of oral Vitamin K is compliance—not all parents will give the full regimen of oral doses, no matter how well-intentioned they are. But research from Germany shows that half of the cases of late VKDB occur in infants who completed all 3 doses. It’s thought that maybe some infants don’t absorb the Vitamin K as well orally. Vitamin K is a fat-soluble vitamin, and it needs to be eaten with fatty foods or fatty acids in order for it to be absorbed. So maybe some of those infants had the Vitamin K on an empty stomach. Or maybe they spit it up!

SM: Do you expect a strong reaction from any particular segment of professionals or consumers about your findings?

RD: No more so than when I published the Group B Strep article!

I anticipate that some people may think that the shot is too painful for newborns, and they may theorize that this pain will cause life-long psychological distress. Unfortunately there really isn’t any evidence to back that claim up, and so I can’t really address this theory. But I have spoken with parents and nurses, and they say that having the baby breastfeed while the shot is administered can drastically reduce the pain of the shot.

I would encourage parents who are worried about pain to weigh these two things: the chance of your infant experiencing temporary pain with an injection, versus the possibility of a brain bleed if you don’t get the shot.

 SM: Any last thoughts that you  would like to share with Science & Sensibility readers on this topic?

RD: You can be a natural-minded parent… interested in natural birth and naturally healthy living, and still consent to your newborn having a shot with a Vitamin K to prevent bleeding. These things are not mutually exclusive. One hundred years ago, infants with Vitamin K deficiency bleeding would have died with no known cause. But today, we have the chance to prevent these deaths and brain injuries using a very simple remedy. The discovery of Vitamin K and its ability to prevent deadly bleeds is a pretty amazing gift. I am thankful to all of the researchers and scientists who used their talents and gifts and got us to this point, where we now have the power to prevent these tragedies 100% of the time.

I want to thank Rebecca Dekker for taking the time to answer my questions  I always look forward to Rebecca’s new articles, and appreciate the effort she puts into preparing them,  Have you had a chance to read Rebecca Dekker’s new post on the Evidence for Vitamin K Shots in Newborns?  Will you be changing what you say to your clients or patients based on what you read or based on this interview with Rebecca?  What are your thoughts on this information?  Are you surprised by anything you learned?  I am very interested in your thoughts – please share in our comments section. – SM

Babies, Childbirth Education, Evidence Based Medicine, informed Consent, New Research, Newborns, Research, Vaccinations , , , , , , , ,

Can Moxibustion Help Turn Breech Babies?

November 5th, 2013 by avatar

By Rebecca Dekker, PhD, RN, APRN

Occasional Science & Sensibility contributor Rebecca Dekker of www.EvidenceBasedBirth.com examines the practice of Moxibustion to help turn breech babies head down.  Rebecca looks at what the current research shows on this ancient treatment for turning babies and shares the results with Science & Sensibility readers in an article that can be easily shared with students, clients and patients. – Sharon Muza, Science & Sensibility Community Manager.

A mother tries moxibustion to turn her breech baby. © EvidenceBased Birth.com

About 3-4% of pregnant women end up with a baby who is in breech (bottom first) position at term. The vast majority of these babies (90%) are born by planned cesarean section. In order to avoid a cesarean section, many women try various ways to turn their babies into a head-down position. I have written in the past about using external cephalic version (ECV), also called the hands-to-belly procedure, for turning breech babies. However, although ECV is safe and frequently effective, it can be uncomfortable and women may want to try different options for turning a breech baby. One potential option is moxibustion.

What is moxibustion?

Moxibustion is a type of Chinese medicine where you burn an herb (Artemesia vulgaria) close to the skin of the fifth toes of both feet. The fifth toe is a traditional acupuncture point called Bladder 67.

How do you use moxibustion?

There is no one recommended way to use moxibustion, but many women burn the moxa sticks close to their toes for about 15-20 minutes, from anywhere to 1-10 times per day, for up to two weeks. This treatment is usually started between 28 and 37 weeks of pregnancy.

How could moxibustion work?

The burning of the moxa stick stimulates heat receptors on the skin of the toe. It is thought that the heat encourages the release of two pregnancy hormones—placental estrogen and prostaglandins—which lead to uterine contractions. These contractions can then stimulate the baby to move (Cardini & Weixin, 1998).

So, does moxibustion work?

In 2012, researchers combined results from eight studies where 1,346 women with breech babies were randomly assigned to moxibustion, no treatment, or an alternative treatment (like acupuncture). The women in these studies lived in Italy, China, and Switzerland (Coyle et al., 2012).

For the women who were assigned to receive moxibustion, some used moxibustion alone, some had moxibustion plus acupuncture, and some used moxibustion plus posture techniques.

When moxibustion alone was compared to no treatment (3 studies, 594 women) there was:

• No difference in the percentage of babies who were breech at birth

• No difference in the need for external cephalic version

• No difference in cesarean section rates

• No difference in the risk of water breaking before labor began

• No difference in Apgar scores at birth

• A 72% decrease in the risk of using oxytocin for women in the moxibustion group who ended up with a vaginal birth

Side effects of the moxibustion included smelling an unpleasant odor, nausea, and abdominal pain from contractions.

When moxibustion alone was compared to acupuncture alone, fewer women in the moxibustion group had breech babies at birth compared to the acupuncture group. However, there were only 25 women in the single study that compared moxibustion alone to acupuncture alone, so this doesn’t really tell us that much.

When moxibustion plus acupuncture was compared to no treatment (1 study, 226 women), women who had moxibustion plus acupuncture had a:

• 27% decrease in the risk of having a breech baby at birth

• 21% decrease in the risk of having a cesarean section

When moxibustion plus acupuncture was compared to acupuncture alone, one study with only 24 women found no difference in the number of women who had breech babies at birth. Because this study was so small, it doesn’t really give us much meaningful information.

When moxibustion plus postural techniques was compared to postural techniques alone (3 studies, 470 women), women in the moxibustion plus postural group had:

• a 74% decrease in the risk of having a breech baby at birth

Are there any limitations to this evidence?

A homemade moxa stick holder helps a mother administer a moxibustion treatment. © EvidenceBasedBirth.com

Overall, the studies that were used in this review were good quality. However, some of the studies were very small, and sometimes researchers did not measure things that we would be interested in—for example, when moxibustion plus postural techniques was compared to postural techniques alone, we have no idea if it made a difference in cesarean section rates or any other health results. Also, all of the researchers used different methods of moxibustion. Some women may have had more frequent or longer sessions, and some women may have been more compliant with the therapy than others.

Is there any other good evidence on moxibustion?

After the review above was published, evidence from a new randomized controlled trial that took place in Spain came out in 2013. In this new study, 406 low-risk pregnant women who had a baby in breech position at 33-35 weeks were randomly assigned to true moxibustion, “fake” moxibustion, or regular care.

What kind of treatments did the women receive?

In the true moxibustion group, the women laid face up, and the hot moxa stick was held near the outside of the little toenail 20 minutes per day for two weeks, changing from one foot to the other when the heat became uncomfortable. The women did the moxibustion at home with the help of a family member. In the fake moxibustion group, the same treatment was carried out, except that the moxa stick was applied to the big toe, which is not a true acupuncture point. Women in all of the groups were educated on how to use a knee-chest posture to try and turn the baby.

Did the moxibustion work?

Women who did moxibustion plus postural techniques were 1.3 times more likely to have a baby in head-down position at birth when compared to both the fake moxibustion and the usual care groups. If you look at the exact numbers, 58% of the women who used moxibustion had a baby who was head-down at birth, compared to 43% of the fake moxibustion group and 45% of the usual care group. The number of women who would need to use moxibustion in order to successfully turn one baby is, on average, eight women.

There was no statistical difference in cesarean section rates among the three groups, but it looked like the numbers were trending in favor of true moxibustion: 51% of the women in the true moxibustion group had cesarean sections, compared to 62% of the fake moxibustion group and 59% of the usual care group.

Were there any safety concerns?

Overall, evidence showed that moxibustion treatment was safe. About 1 out of 3 women reported having contractions during the treatment, but there was no increase in the risk of preterm birth. Some women (14%) said they felt heart palpitations. One woman experienced a burn from the moxibustion. Other complaints from women in all three groups included heartburn, nausea and vomiting (2%), dizziness (1.7%), mild high blood pressure problems (1.7%), stomach pain (1.5%), and baby hiccups (1.2%). However, there were no differences among the three groups in the number of women who had these complaints. There were also no differences in newborn health issues or labor problems among the three groups. All of the babies had good Apgar scores five minutes after birth.

So what’s the bottom line?

• Evidence suggests that moxibustion—when combined with either acupuncture or postural techniques—is safe and increases your chances of turning a breech baby

• We still don’t know for sure which kind of moxibustion method (timing during pregnancy, number of sessions, length of sessions, etc.) works best for turning breech babies. However it appears that using moxibustion twice per day for two weeks (during 33-35 weeks of pregnancy) will work for 1 out of every 8 women.

• If women are interested in using Chinese medicine (moxibustion and acupuncture) to help turn a breech baby, they may want to consult a licensed acupuncturist who specializes in treatment of pregnant women.

Here is a video where an acupuncture physician shows how to use moxibustion to turn a breech baby:

Thank you to Kiné Fischler L.Ac. of Willow Tree Wellness Clinic, who provided feedback on this article.

As a childbirth educator or other birth professional, do you share information on moxibustion as a method that mothers might use to turn a breech baby?  How do you present this information?  How do the families you work with feel after learning about this option? If you did not cover this before, do you feel like you might start to include this information in your classes after reading Rebecca’s information here and on her blog? Are you aware of physicians who also encourage patients to try this treatment?  Please share your experiences in our comments section. I welcome your discussions. – SM

References

Cardini F. & Weixin H. (1998). Moxibustion for correction of breech presentation: A randomized controlled trial. JAMA 280(18), 1580-1584. Free full text: http://jama.jamanetwork.com/article.aspx?articleid=188144

Coyle ME, Smith CA, & Peat B. 2012. Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No: CD003928. http://www.ncbi.nlm.nih.gov/pubmed/22592693

Vas J, Aranda-Regules JM, Modesto M, et al. (2013). Acupuncture Medicine 31: 31-38. http://www.ncbi.nlm.nih.gov/pubmed/23249535

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and the founder and author of EvidenceBasedBirth.com.  Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style. The mission of Evidence Based Birth is to get birth evidence out of medical journals and into the hands of the public. You can follow Rebecca on Facebook, Twitter or follow the Evidence Based Birth newsletter to get free printable handouts and other news.

 

 

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Six Birth Blogs Every Childbirth Educator Should Be Reading

September 17th, 2013 by avatar

Today on Science & Sensibility, I wanted to share with readers some of my favorite birth related blogs, after Science & Sensibility of course! I subscribe to over 400 blogs, on a variety of topics, not just birth. I hope that someone has a larger blog list then I do, otherwise I will start to worry about how this might be an obsession.

I really enjoy reading what experts in the field of maternal and infant health have to say on their blogs and frequently find myself sharing information in my classes and with the families that I work with as well as with other professionals. I appreciate the effort, the research, the time and the energy that goes into making my favorite blogs so rich and useful for me, and so relevant to the work I do as an LCCE. 

Here are six of my favorite blogs, in no particular order:

1. Spinning Babies Blog

Midwife Gail Tully has long been well known for her website, Spinning Babies and her blog is an added bonus!  Gail frequently answers questions from readers, describes some new research she came across or shares a new technique to help babies move easier through the pelvis.  Here you can frequently find a video snippet you can use in your childbirth class, a book review or an inspiring birth story usually related to babies who chose to do things their way, as they work to be born.  

2. Evidence Based Birth

This blog burst onto the scene in mid-2012, and has been a fantastic resource ever since.  Rebecca Dekker, PhD, RN, APRN is an assistant professor of nursing at a research university in the U.S. She teaches pathophysiology and pharmacology, but has a strong personal interest in birth, and hence the blog was created.  The mission of Evidence Based Birth is to “promote evidence-based practice during childbirth by providing research evidence directly to women and families.”  Rebecca takes a look at the big issues (failure to progress, big babies, low AFI, for example) that face women during their pregnancy and birth, and does a thorough job of evaluating all the research and explaining it in a logical, easy to understand post.  Rebecca sums up her posts with recommendations based on the evidence and gives readers the bottom line and take-away.  Additionally, there are “printables” that are concise versions of some of her blog posts that families can print out and take to appointments with their healthcare providers in order to help facilitate discussions about best practice.

3.  VBAC Facts

Jennifer Kamel has created a plethora of useful information on vaginal birth after cesarean (VBAC) facts and statistics.  She founded her blog after doing a huge amount of research on the benefits and risks of VBAC, after her first birth ended in a Cesarean and she prepared for her second.   The amount of information, statistics, research summaries and discussion found on her blog is amazing.  Jen is a “numbers gal” and does a great job of explaining risks and numbers in an easy to understand presentation.  I frequently find myself going to her blog when I want to know the risk of placental complications after a cesarean or to better understand some of the new research and policy statements from ACOG and other professional organizations.  When 1 in 3 women in the US will give birth by Cesarean, it is good to have a resource such as VBACFacts.com to go to that can help me understand and explain options to families birthing after a cesarean.

4. The Well-Rounded Mama

Pamela Vireday has written “The Well-Rounded Mama” blog since 2008 and it has been a valuable resource for women of all sizes, when they are looking for answers and facts about options for birth.  The mission of the blog is “to provide general information about pregnancy, birth, and breastfeeding, to discuss how to improve care for women of size, to raise awareness about the impact of weight stigma and discrimination on people of size, and to promote health by focusing on positive habits instead of numbers on a scale.” Pamela does an awesome job of gathering, explaining and summarizing research, particularly related to women of size, but in all honestly, extremely relevant to all birthing women.  I appreciate her plus size photo galleries of pregnant and breastfeeding women of size. If you might be a  woman who is larger than many of the models in today’s pregnancy magazines, seeing the gallery of women who look beautiful pregnant and breastfeeding, with a wide range of body shapes, can be comforting.  In addition to providing evidence based information,  Pamela answers some of the questions that plus sized mothers might have, but are hesitant to ask their healthcare provider, such as concerns about about whether fetal movement will be noticeable if they are larger sized.  A great blog, with relevant articles for all women!

5. Midwife Thinking

This blog is written by Rachel Reed, an Australian PhD midwife, who enjoys taking a look at the research and sharing her thoughts on how well the research is applied to application.  I enjoy reading her blog for that reason, and often find myself amazed that she chooses to write about the very topics that I wonder about and want to learn more on.  Rachel’s aim is to “stimulate thinking and share knowledge, evidence and views on birth and midwifery. ”  I also appreciate her “Down Under” perspective and celebrating the commonalities of birth across the many miles.  Rachel is not afraid to agree when the science backs up the “less popular” treatment and care amongst childbirth advocates, allowing the evidence to speak for itself and carefully explaining why.   Rachel does a great job of normalizing many of the topics that bog women down during labor and birth, such as the “anterior cervical lip” or “early labor and mixed messages.”  I like to share Rachel’s posts with families who are experiencing the very situation she is writing about.

6. ACOG President’s Blog

Every week, the current president of the American Congress of Obstetricians and Gynecologists (ACOG) writes a blog post on a matter of importance to women.  Not all the posts are on birth related topics, but I find it very interesting to see what Dr. Jeanne A. Conry, M.D. PhD shares with readers.  While some of her blogs are directed at her fellow physicians, many of the posts highlight information and resources directly related to women’s health, especially during the reproductive years.  I enjoy learning more about what Dr. Conry feels is important, and especially what messages and information she is directing to her colleagues. I appreciate her middle of the road approach and look forward to a new post every week.

I hope that you might consider following some of the blogs I mentioned here, if you are not already doing so.  I would also love if you shared your favorite blogs with myself and our Science & Sensibility readers.  I always have room for more good birth related blogs in my blog reader!  What blogs do you read?

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Evidence Based Birth Takes on Group B Strep: An Interview with Rebecca Dekker

April 9th, 2013 by avatar

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!   

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