24h-payday

Archive

Archive for the ‘American Academy of Pediatrics’ Category

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 , , , , , , , ,

Why Pediatricians Fear Waterbirth – Barbara Harper Reviews the Research on Waterbirth Safety

March 27th, 2014 by avatar

By Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE

On March 20th, 2014, the American Academy of Pediatrics Committee on Fetus and Newborn and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice released a joint clinical report entitled Immersion in Water During Labor and Delivery in the journal Pediatrics.  While not substantially different than previous statements released by the AAP, quite a stir was created.  Today, Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE, of Waterbirth International provides a research summary that supports waterbirth as a safe and reasonable option for mothers and babies.  Barbara Harper has been researching and teaching about safe waterbirth protocols for several decades and is considered an expert on the practice.  I am glad Barbara was able to share her knowledge with Science & Sensibility readers all the way from China, where she just finished another waterbirth workshop for Chinese hospital programs. – Sharon Muza, Community Manager, Science & Sensibility

In a candle lit room in Santa Barbara, California, in October of 1984, my second baby came swimming out of me in a homemade tub at the foot of my bed.  As soon as he was on my chest, I turned to my midwife and exclaimed, “We have got to tell women how easy this is!”

Earlier that month I sat in my obstetrician’s office with my husband discussing our plans, which had changed from an unmedicated hospital birth to a home waterbirth.  The OB shook with anger and accused me of potential child abuse, stating that if I did anything so selfish, stupid and reprehensible he would have no choice but to report me to the Department of Child Welfare.  I never stepped foot in his office again, but I did call his office and share the news of my successful home waterbirth.

Before setting up my homemade 300 gallon tub, I had researched through medical libraries for any published data on waterbirth, but could not find a single article, until a librarian called me and said she was mailing an article that came in from a French medical journal.  The only problem was that it was quite old. It had been published in 1803!  The next article would not come out until 1983, the very year that I was searching.[i]

The objections to waterbirth have always come from pediatricians, some with vehement opinions similar to those expressed by my former obstetrician.  The current opinion of the American Academy of Pediatrics Committee on Fetus and Newborn is nothing new.  It was issued in 2005, restated in November 2012 and it is showing up again now.  There are many obstetricians and pediatricians who are perplexed and angered over the issuing of this statement.  Especially, doctors like Duncan Neilson of the Legacy Health Systems in Portland, Oregon. [ii]  Dr. Neilson is chair of the Perinatology Department and VP of both Women’s Services and Surgical Services at the Legacy Emanuel Hospital in downtown Portland.

In 2006, Dr. Neilson did an independent review of all the literature on waterbirth, including in obstetric, nursing, midwifery and pediatric journals. He concluded, “there is no credible evidence that waterbirth is a potential harm for either mothers or babies.” He reported that the majority of the waterbirth studies have been done and published in Europe with large numbers in retrospective analyses.[iii], [iv], [v], [vi] What has been published in the US is largely anecdotal and has involved very small numbers of case reports from home birth or birth center transfers into NICU. [vii], [viii], [ix] Dr. Neilson even pointed out that Jerold Lucy, M.D., the editor of the American Journal of Pediatrics put the following commentary in a sidebar in a 2002 issue of this respected research journal, “I’ve always considered underwater birth a bad joke, useless and a fad, which was so idiotic that it would go away. It hasn’t! It should!” [x]

The publication of such prejudicial statements makes it difficult for pediatricians to look at the European research without skepticism. Dr. Neilson concluded that American doctors were not getting the complete picture.  After this comprehensive review of waterbirth literature, Dr. Neilson believed that waterbirth is a safe birth option that provides other positive obstetric outcomes. He helped set up a Legacy research committee and the parameters for waterbirth selection were created, using current recommended selection criteria followed by other Portland hospitals offering waterbirth.

Upon Dr. Neilson’s recommendations, the entire Legacy system has adopted waterbirth. The most recent hospital to begin waterbirth was Good Samaritan in Portland, which conducted their first waterbirth in February of 2014.

Women seeking waterbirth and undisturbed birth have usually considered the consequences of interference with the birth process on the development, neurology and epigenetics of the baby.  The goal of the pediatrician and the goal of mothers who choose undisturbed birth is really exactly the same.  The use of warm water immersion aids and assists the mother in feeling calm, relaxed, nurtured, protected, and in control, with the ability to easily move as her body and her baby dictate.  From the mother’s perspective, using water becomes the best way to enhance the natural process without any evidence of increased risk.  A joint statement of the Royal College of Obstetricians, the Royal College of Midwives and the National Childbirth Trust in 2006 agreed.  They sat down together to explore what would increase the normalcy of birth without increasing risk and the very first agreement was that access to water for labor and birth would accomplish that task.[xi]

Framework for Maternity Services Protocol

The UK National Health Service and the National Childbirth Trusts formed a Framework for Maternity Services that includes the following statements:

  • Women have a choice of methods of pain relief during labour, including non pharmacological options.
  • All staff must have up-to-date skills and knowledge to support women who choose to labour without pharmacological intervention, including the use of birthing pools.
  • Wherever possible women should be allowed access to a birthing pool in all facilities, with staff competent in facilitating waterbirths.

There is a concerted effort to educate midwives and physicians in all hospitals in the UK on the proper uses of birthing pools and safe waterbirth practices. [xii]

The baby benefits equally from an unmedicated mother who labors in water and has a full complement of natural brain oxytocin, endorphins and catecholamines flowing through her blood supply. The mother’s relaxed state aids his physiologic imperative to be born.  The descent and birth of the baby is easier when the mother can move into any upright position where she can control her own perineum, ease the baby out and allow the baby to express its primitive reflexes without anyone actually touching the baby’s head.  The birth process is restored to its essential mammalian nature.

The true belief in the safety of waterbirth is a complete understanding of the mechanisms which prevent the baby from initiating respirations while it is still submerged in the water as the head is born and then after the full body has been expelled.  When Paul Johnson, M.D., of Oxford University, explained these mechanisms at the First World Congress on Waterbirth at Wimbledon Hall, in 1995, there was a collective nod of understanding from more than 1100 participants.  With this information, more waterbirth practices were established all over the UK and Europe.  Dr. Johnson went on to publish his explanations in the British Medical Journal in 1996.[xiii]

Johnson’s 1996 review of respiratory physiology suggests that, in a non-stressed fetus, it is unlikely that breathing will commence in the short time that the baby’s head is underwater. Johnson sees no reason to prevent this option being offered to women.

A Cochrane Review[xiv] of women laboring in water or having a waterbirth gives no evidence of increased adverse affects to the fetus, neonate, or woman.

American Academy of Pediatrics’ Misleading Committee Commentary

Despite this review, the 2005 American Academy of Pediatrics committee on Fetus and Newborn commentary raised concerns regarding the safety of hospital waterbirth. The committee commentary was not a study itself, but rather an opinion generated upon the review of research.

A review of the commentary and the sources cited, revealed irregularities. The commentary often paraphrased text from the references, redacted crucial words and sentences from the texts, and sometimes re-interpreted the authors’ conclusions.  Anecdotal case studies were referenced without being part of an empirical study.

Example:

Committee text: “All mothers used water immersion during labor, but only a limited and unspecified number of births occurred under water.” 2 infants required positive pressure support, but little additional data were provided.

From cited reference: 100 births occurred under water. Only 2 infants out of 100 needed suction of the upper respiratory tract and a short period of manual ventilatory support. [xv]

Committee text: “Alderdice et al performed a retrospective survey of 4494 underwater deliveries by midwives in England and Wales. They reported 12 stillbirths or neonatal deaths”

From cited reference: “Twelve babies who died after their mothers laboured or gave birth in water, or both, in 1992 and 1993 were reported. None of these cases was reported to be directly related to labour or birth in water.”[xvi]

Committee text: “In a subsequent survey of 4032 underwater births in England and Wales, the perinatal mortality rate was 1.2 per 1000 live births (95% confidence interval: 0.4–2.9) and the rate of admission to a special care nursery was 8.4 per 1000 live births (95% CI: 5.8–11.8) The author of this survey suggested that these rates may be higher than expected for a term, low-risk, vaginally delivered population.”

From cited reference: “4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (THEY LEFT OUT THE 2ND CI 5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water….”

The reference also provides that the UK perinatal mortality and special care admission rates for conventional birth ranged from 0.8 to 4.6/1000 for perinatal mortality, and 9.2 to 64/1000 for special care admission—significantly higher than those utilizing waterbirth.

Nowhere in the cited reference can the statement be found that “these rates may be higher than expected for a term, low-risk, vaginally delivered population.” In fact, the study results reflect no effect on fetal outcomes and certainly not an increase in fetal mortality and special-care admissions.[xvii]

Finally, the committee commentary acknowledges the findings of the Geissbühler study[xviii]:

“A prospective observational study compared underwater birth with births using Maia-birthing stools and beds. Although underwater birth was associated with a decreased need for episiotomies and pain medication as well as higher APGAR scores and less cord blood acidosis in newborns, the birthing method was determined by maternal preference, and potential confounding variables were not analyzed.”

The committee does not elaborate on which confounding variables they feel are of concern. It appears this supportive study was automatically discredited without a reason.

While the American Academy of Pediatrics is committed to patient safety and evidence-based medicine, this commentary’s conclusions that hospital waterbirths are of greater risk than other hospital birth options for low risk and carefully screened patients are completely unfounded.

Waterbirth Studies

In 1998, I copied all the medical journal articles about waterbirth that had been published to date and sent the labeled and categorized studies to the Practice Committee of ACOG.  In the cover letter accompanying the rather weighty binders, I asked the Committee if they would review the literature and issue an opinion about actual birth in water.  The letter that arrived a few months later from Stanley Zinberg, MD, then head of the Practice Committee, stated, “until there are randomized controlled trials of large numbers of women undergoing birth in water, published in peer reviewed journals in the US, the committee is not able to issue an opinion.”

Randomized studies of waterbirth are difficult to design and implement for one major reason: women want to choose their own method of delivery and should be able to change their mind at any point of labor. Because of this, it is difficult to design a randomized controlled study without crossover between control and study group. A 2005 randomized trial which was set up in a Shanghai, China hospital was abandoned because the hospital director realized after only 45 births that the study was unethical.  The original goal was to study 500 births, but the results of those first 45 were so good they abandoned the research project, yet continued their commitment to offering waterbirth to any woman who wanted one.  The latest communication from the Changning Hospital in Shanghai indicates that they have facilitated well over 5000 waterbirths since then.

Randomized controlled trials may be few, however, many retrospective and prospective case-controlled studies have been performed, primarily in European countries with a long history of waterbirth. In reviewing published studies, a comparison of the safety of waterbirth to conventional births among low-risk patients can be made. The evidence reveals the option of waterbirth is safe and, looking at certain parameters, has superior outcomes.

European Research

Highlights of the literature:

  • APGAR scores were found to be unaffected by water birth.[xix] One study found a decrease in 1-minute APGAR scores exclusively in a subgroup of women who were in water after membranes were ruptured longer than 24 hours.[xx]
  • A consensus of researchers found that waterbirth had either no effect or reduced cesarean section and operative delivery rates.[xxi]
  • No studies have found an effect on rates of maternal or fetal infection.[xxii]
  • Statistically, waterbirth leads to increased relaxation and maternal satisfaction, decreased perineal trauma, decreased pain and use of pharmaceuticals, and decreased labor time.[xxiii]

Cochrane Collaboration Findings

A Cochrane Collaboration review of waterbirth in three randomized controlled studies (RCTs) show no research that demonstrates adverse effects to the fetus or neonate.[xxiv] Other studies that were not RCTs were included in the conclusion:

“There is no evidence of increased adverse affects to the fetus or neonate or woman from laboring in water or waterbirth. However, the studies are variable and considerable heterogeneity was detected for some outcomes. Further research is needed.”

Conclusion

Waterbirth is an option for birth all over the world. World-renowned hospitals, as well as small hospitals and birthing centers, offer waterbirth as an option to low risk patients. Though some members of the American Academy of Pediatrics and American College of Obstetricians and Gynecologists feel otherwise, the Cochrane Review and many other studies find no data that supports safety concerns over waterbirth.

Women increasingly are seeking settings for birth and providers that honor their ability to birth without intervention. Waterbirth increases their chances of attaining the goal of a calm intervention free birth.

Physicians and midwives are skilled providers who are being trained in waterbirth techniques, safety concerns, the ability to handle complications and infection control procedures.

Carefully managed, waterbirth is both an attractive and low-risk birth option that can provide healthy patients with non-pharmacological options in hospital facilities while not compromising their safety.

In contrast to Dr. Lucy’s statement, waterbirth is not a fad and it is not going away, especially when it is mandated as an available option for all women in the UK and practiced worldwide in over ninety countries. The first hospital that began a waterbirth practice in 1991, Monadnock Community Hospital in Peterborough, New Hampshire, is still offering this service to low risk women 23 years later.  They have been joined since then by just under 10% of all US hospitals including large teaching universities and the majority of all free standing birth centers.  Hospitals have invested in equipment, staff training and are collating data to present to the medical community.  Dr. Duncan Neilson in Portland, Oregon is working on a summary of the data on over 800 waterbirths at only one hospital in the Legacy Health System.

I have dedicated my entire life to changing the way we welcome babies into the world since that October night in 1984, when I told my midwife that we have to tell women about the wonders of waterbirth. Since that night, I have traversed the planet to 55 countries and helped hundreds of hospitals start waterbirth practices.  Birth in water is safe, economical, effective and is here to stay, despite the AAP’s recent statement.

References


[i] Odent, M.,1983. The Lancet, December 24/31, p 1476

[ii] Medical Plaza Bldg. 300 N. Graham St., Suite 100 Portland, OR 97227, (503) 413-3622 dneilson@lhs.org

[iii] Alderdice, F., R., Mary, Marchant, S., Ashiurst, H., Hughes, P., Gerridge, G., and Garcia, J. (April 1995). Labour and birth in water in England and Wales. British Journal of Medicine, 310: 837.

[iv] Geissbuehler, V., Stein, S., & Eberhard, J. (2004). Waterbirths compared with landbirths: An observational study of nine years. Journal of Perinatal Medicine, 32, 308-314

[v] Gilbert, Ruth E., Tookey, Pat A. (1999) Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal ;319:483-487 (21 August)

[vi] Zanetti-Dallenback, R., Lapaire, O., Maertens, A., Frei, F., Holzgreve, W., & Hoslit, I. (2006). Waterbirth:, more than a trendy alternative: A prospective, observational study. Archives of Gynecology and Obstetrics, 274, 355-365

[vii] Bowden, K., Kessler, D., Pinette, M., Wilson, D Underwater Birth: Missing the Evidence or Missing the Point? Pediatrics, Oct 2003; 112: 972 – 973.

[viii] Nguyen S, Kuschel C, Reele R, Spooner C. Water birth—a near –drowning experience. Pediatrics. 2002; 110:411-413

[ix] Schroeter, K., (2004). Waterbirths: A naked emperor (commentary) American Journal of Pediatrics, 114 (3) Sept, 855-858

[x] Neilson, Duncan  Presentation at the Gentle Birth World Congress, Portland, Oregon, Setpember 27, 2007

[xi] RCOG/The Royal College of Midwives (2006) Joint Statement no 1: Immersion in Water During Labour and Birth. London: RCOG

[xii] Johnson P (1996) Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynaecology 103(3): 202-8

[xiii] ibid

[xiv] Cluett, E.R., Burns, E. Water in Labor and Birth(review) Cochrane Database of Systematic Reviews 2012, Issue 2 Art. No.: CD000111.DOI: 10:1002/14651858.CD000111.pub3

[xv] Odent, M.,1983. The Lancet, December 24/31, p 1476

[xvi] Alderdice, F. et.al.1995. British Journal of Midwifery 3(7), 375-382

[xvii] ibid

[xviii] Geissbühler V, Eberhard J, 2000

[xix] Aird, et al, 1997; Cammu, et al, 1994; Eriksson, et al, 1996; Lenstrup et al, 1987; Ohlsson et al, 2001, Otigbah et al, 2000; Rush, et al, 1996, Waldenstrom & Nilsson, 1992.

[xx] Waldenstrom & Nillson, 1992

[xxi] Aird, Luckas, Buckett, & Bousfield, 1997; Cammu et al, 1994; Cluett, Pickering, Getliffe, & St. George, 2004; Eckert, Turnbull, & MacLennon, 2001; Lenstrup, et al, 1987, Ohlsson, et al, 2001, Rush, et al, 1996)

[xxii] Cammu, Clasen, Wettere, & Derde, 1994; Eriksson, Lafors, Mattson, & Fall, 1996; Eldering, 2005; Lenstrup, Schantz, Feder, Rosene, & Hertel, 1987; Geissbuhler & Eberhard, 2000; Rush, et al, 1996; Schorn, McAllister, & Blanco, 1993, Thöni A, Mussner K, Ploner F, 2010; Waldenstrom & Nilsson, 1992.

[xxiii] Mackey,2001; Benfield et al, 2001

[xxiv] Cluett, E.R., Burns, E. 2012

About Barbara Harper

© Barbara Harper

© Barbara Harper

Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE,  loves babies and has been a childbirth reform activist since her first day at nursing school over 42 years ago. She is an internationally recognized expert on waterbirth, a published author and she founded Waterbirth International in 1988, with one goal in mind – to insure that waterbirth is an available option for all women. During the past four decades, Barbara has worked as a pediatric nurse, a childbirth educator, home birth midwife, midwifery and doula instructor and has used her vast experience to develop unique seminars which she teaches within hospitals, nursing schools, midwifery and medical schools and community groups worldwide. She was recognized in 2002 by Lamaze International for her contributions in promoting normal birth on an international level. Her best selling book and DVD, ‘Gentle Birth Choices’ book has been translated into 9 languages so far. Her next book ‘Birth, Bath & Beyond: A Practical Guide for Parents and Providers,’ will be ready for publication at the end of 2014. Barbara has dedicated her life to changing the way we welcome babies into the world. She considers her greatest achievement, though, her three adult children, two of whom were born at home in water. She lives in Boca Raton, Florida, where she is active in her Jewish community as a volunteer and as a local midwifery and doula mentor and teacher. Barbara can be reached through her website, Waterbirth International.

ACOG, American Academy of Pediatrics, Babies, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Midwifery, New Research, Newborns, Research, Second Stage, Uncategorized , , , , , , , ,

MANA Response to Recent AAP Home Birth Statement: High-quality out-of-hospital newborn and postpartum care is standard for midwives

May 2nd, 2013 by avatar

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

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

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

 

© http://flic.kr/p/8d52Qc

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

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

Certified Professional Midwives are skilled maternity care providers

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

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

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

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

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

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

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

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

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

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

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

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

An opportunity for collaboration and integrated care 

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

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

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

About Geradine Simkins

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

ACOG, American Academy of Pediatrics, Babies, Delayed Cord Clamping, Home Birth, informed Consent, Maternity Care, Midwifery, Transforming Maternity Care , , , , , , , , , ,

The I-Baby: A Baby’s Brain On Technology

April 11th, 2013 by avatar

Regular contributor Kathy Morelli takes a look at babies and media and technology exposure.  If you are working with expectant families or with families parenting young children, you have an opportunity to share the impact of media on developing brains.  Take a moment to read today’s post and share how you bring up this topic with the families you work with. – Sharon Muza, Community Manager, Science & Sensibility. 

http://flic.kr/p/DVbyu

Today’s babies are definitely digital natives! They grow up in a world saturated by media. The research about the effects of media on child development is in its infancy (no pun intended). 

On one hand, some research suggests when the developing brain is over-exposed to multi-tasking, attentional and learning difficulties can result. On the other hand, other research contradicts this finding. Additionally, there are lots of claims from DVD and TV producers that using their media enhances learning and social growth. 

What’s a parent to believe?

First Off: Parent with Awareness and Moderation

Put some perspective on this issue by reframing parenting around media issues as similar to parenting around other issues. 

Parenting with awareness and moderation through the infant years, around any topic, depends on three important tips.     

Tip One: Parent, Heal Thyself 

Encourage parents to be aware of their own emotional reactions to their baby. Have them own their emotions as their own, not their baby’s.

If the parents themselves have felt abandoned as a child, they may need to do their own hard emotional work, centering on their reactions to their baby’s dependency needs. Feelings around their own issues persist no matter what media is in use in the house. Parents should recognize them as their own feelings and work to own them. 

Tip Two: The Baby is an Individual  

All the statistics and information in the world doesn’t change the fact that each baby is an individual, with individual needs.

All babies need one-on-one attention from their caregivers, but some need more than others. Some babies cry more than others, some have colic, some are calmer and quieter than others. And learning occurs differently in each individual.

Have the parents look for clues. If their baby needs more attention than they think he needs, remember he is an individual and cannot be compared to other babies in their life. If their baby has a negative reaction to some type of media, have the parents either reduce its use or don’t use it at all. It might be a signal that he needs more interactive attention from the parent.  If the baby seems confused, frightened or agitated by some imagery or sounds from media, don’t force him to watch it. Cut it out of the home’s media diet. 

Tip Three: Baby, It’s YOU

There is no substitute for the parents. Have parents plan to spend meaningful time with their baby. A baby’s healthy development depends on attentive, personal, touchable, multisensorial, fully embodied experiences.

Newborn Baby’s Brain – Not So High Tech

First, an infant’s growth is intertwined on all levels; physical, mental and emotional growth are all related. In other words, brain development, movement, emotional development, and language are all inter-related and unfold together, at a biologically prescribed pace.   

Second, in the first three years of life, there are multiple critical periods (windows of opportunity) when a baby must be exposed to particular life experiences in order to learn particular skills. If these windows are missed, it’s extremely hard (or impossible) to learn the skill at a later time in life. The windows of opportunity are biologically based on brain development (Zero to Three, 2012). 

For example, vision and language are two skills dependent on critical windows of time. Acquisition of binocular vision and depth perception depends on a normal early experience with vision in the first few weeks of life.  Language skills must be acquired before five years of age, or there is little chance of developing language later in life (Zero to Three, 2012).  

Third, babies are born with immature brains. Experts estimate in order for the human brain to be fully developed at birth, the gestational period should be 18 months.  But human babies come out in nine months in order to compensate for the size of the human female pelvis (Christakis, 2009).  

Many baby experts refer to the first three months of life as the “fourth trimester” (Karp, 2003).  In the fourth trimester, a baby is still very fetus-like.  At at the beginning of life, a baby’s brain is only a quarter of its adult size and will grow about 20% in just the first three months of life. Her brain structures are in place, but are waiting to grow, based on her experiences. (Stamm, 2007). 

Think of the huge differences between a four day old baby and a four month old baby. That four month old child is cooing and smiling right at their parents, enticing them to connect! That newborn is depending on the parents to connect with her to help her grow (Marvin & Britner, 2008).      

The time between birth and two years old is naturally and biologically a period of extraordinary growth. An infant’s brain naturally grows based on genetics and interactive experience (Zero to Three, 2012; AAP, 2011; Stamm, 2007) 

The Infant Brain – How Babies Learn  

Babies Learn by Social Interaction:  Popular hype says any type of stimulation helps the infant brain grow and learn. But the consensus of child development specialists everywhere is  normal infant development depends on normal social stimulation  involving all the senses (touch, sound, sight, smell) (Vygotsky, 1978; as cited in Fenstermacher et al, 2010).   

What is normal social stimulation with all the senses?

It is responsive care by the parents (caregivers) using all the senses, including skin to skin contact, movement (swaying, walking, gentle dancing), holding, feeding, cuddling, talking,  loving direct eye contact, smiles, gentle play, comforting, and mature acceptance and modulation of your baby’s changing feeling states (angry, happy, sad) (Cozolino, 2006; Wallin, 2007). 

Emotional Attachment Style is Learned: A baby’s emotional template is encoded neurologically based on her earliest experiences with her parents and other caregivers. The biological attachment sequence enacts no matter what type of care a baby receives.

A good quality, secure attachment is created by good quality and consistent interactions between baby and parents. The human brain is plastic, so the attachment template is continuously updated and developed throughout life, but it is much easier on a person to begin life with healthy connectivity patterns, than to correct them as they go along (Wallin, 2007).        

Neglect & Abuse Affect Brain Growth: Research shows children growing up in neglectful and abusive homes, who are rarely spoken to, who do not have the opportunity to explore, may fail to develop the neuronal pathways necessary to learning (Zero to Three, 2012).

No Media vs Hey, It’s Educational!   

Parents of the under two set are understandably concerned by the conflicting messages out there about screen time.

American Academy of Pediatrics (AAP, 2011) strongly discourages any media consumption by children younger than two.

The AAP’s policy statement is based on research findings that media time tends to elbow out time spent in unstructured, creative play time and interactive activities with a parent or caregiver.  High quality, multi-sensorial interactions with a consistent caregiver are essential for healthy child development.

Yet, media is an integral part of our culture. On the average, 100% of children under two watch 1 – 2 hours of media every day and 14% watch over 2 hours a day (AAP, 2011).  40% of all children younger than two years live in households where the TV is on all day long as background noise (Courage & Setcliff, 2009). 

So what’s a parent to believe?

Does media consumption hurt babies?

Many parents say they are comfortable with allowing their under 12 month babies to watch educational media. There are a lot of educational firms pushing DVDs for the under 12 month old set, claiming learning enhancement and improvement for school readiness.

Are their claims substantiated by research?

The Research

What follows are some key points from the research about media consumption, learning and attentional effects on the developing brain.

Media, the Developing Brain and Attentional Difficulties

In 2004, Dimitri Christakis, MD, MPH of the University of Washington, reviewed data from an existing study. He found an association between children under three who watch on average more than two hours a day of television and attentional difficulties. In 2007, further studies by Christakis and his colleague, Fred Zimmerman, found the attentional difficulties were more precisely linked to program content. That is, cartoons and fast paced media seem to be linked to attentional difficulties, but not educational and appropriately paced programs. Christakis theorizes that over-stimulation of the developing brain with flashing and changing sights and sounds might be harmful to the developing brain (Christakis and Zimmerman, 2007; Christakis, 2009; Zimmerman et al, 2009).

On the other hand, there are researchers such as Tara Stevens and Miriam Muslow (2006) who feel the evidence linking media usage and attentional difficulties is highly correlational and Christakis and Zimmerman did not properly account for other factors in their information. Clearly, there is a need for the National Institute of Health to fund a large scale study to see if and how the digital native brain is affected by media saturation.   

How Babies Learn from the Screen 

Video Deficit Effect: Research about screen learning versus live learning indicates infants learn less from video than from live interactions; this is called the “video deficit effect.” The video deficit effect persists to about three years of age (Barr, Muentener, & Garcia, 2007; Zack et al, 2009).

The video deficit effect is mitigated by repetitive viewings, media content design and the context in which the media is used (Barr, 2010).

Repetition: So, babies under 12 months will retain behavior after seeing it performed once by a live model. But it takes repeated viewings for a baby to learn the same behavior from a screen.   

Content design: Retention of information is also enhanced in the under 12 month set by story content. If the story lines are simple, in sequence, and uninterrupted by multiple story lines or commercials, retention is enhanced. (think Teletubbies).

Context: In addition, if the media is in the context of a family situation, that is, if there is an appropriate adult moderator present, to discuss, distract and limit screen use, retention is enhanced and deleterious effects are reduced (Christakis, 2009).

Individual learning differences: In addition, there are differences in how and how fast individual babies learn. In general, at about the age of 12 months, a child becomes capable of seeing something on a screen and then performing it himself. But there are individual variations, and these variations persist into toddlerhood (Barr, 2007).     

But, as discussed above, child development specialists agree infants primarily learn via social-interactional-sensorial methods.

Educational Claims

Let’s take a look at the claims made by current educational DVDs targeted at infants.

In 2010, Susan Fenstermacher and her colleagues conducted an overview of 58 popular DVDs (culled from a total of 218 made between Fall 2007 and Spring 2008) marketed as educational to parents for their infants. A total of 17% of 686 claims made by the producers were that the DVDs provide socio-emotional educational content. However, the researchers found that only 4% of all the scenes were socio-interactional in content and these scenes were not of high quality.

In general, producers of DVDs do not use research-based child development learning principles, despite their claims. Of course this may be changing as these producers begin to use child development experts as content consultants.  

Language Development and Media

Language: Research shows babies learn language from being directly spoken to by their caregivers. Babies don’t learn language from the television or from observing conversations between adults, they need direct attention.

Matthew LaPierre and his colleagues (2012) found that children from eight months to eight years are exposed to over 4 hours of TV a day. This can be reduced by not having a TV in the child’s room.

Studies have shown that having the television on at home all day as background noise causes language delays and reduced interaction between parents and children (Kirkorian et al, 2012; LaPierre, Piotrowski & Linebarger, 2012).

Profoundly, a study of 1000 infants found that babies who watched over 2 hours of DVDs a day had poorer language assessments than babies who did not watch DVDs. Specifically, for each hour of watching a DVD, a baby knew 6 – 8 words less than babies who did not watch DVDs (Christakis & Zimmerman, 2007).

On the other hand, in 2010, Allen and Scofield found that 2 year olds can learn simple words from very simplified content, from a video.  They found the Blues Clues format was good for this.

Again, the research is not yet complete, but still points to the benefits of parental awareness and judicious use of media.   

Reality vs Fantasy in the Young Mind

Remember babies brain structures are not yet developed. The lower brain centers, the emotional centers, with structures such as the amygdala, are fully formed at birth. The amygdala is in charge of emotional designation. But the neo-cortex, the logic center is not fully formed until the early twenties (Cozolino,2006). Thus, the capacity to differentiate between fantasy and reality is limited in babies, toddlers and children. Babies are wired to empathize with the emotions of the people around them and have the capacity to do so. And remember that babies do retain information from repeated viewings.

For an example of how differently children view reality than adults, studies show children believe that many planes hit the World Trade Center, not just two, as the event was shown over and over again on TV.

So keep in mind babies/toddlers and adults have a different understanding about fantasy and reality as applied to what is viewed on the screen and they also can “catch” emotions from the people around them and from the screen. 

Five Tips for Parents: Media & Infants 

So, when it comes to media consumption, think about parenting a young baby with awareness and moderation. Some age appropriate media is ok, and its ok to for parents to take breaks with a TV show, but don’t let it edge out stroller walks, hikes in a baby back pack in the woods, and bonding time. 

Tip One: There is no substitute for the parent.

Studies indicate using media over 2 hours a day steals precious interactional learning time from the baby.  Encourage parents to help their baby grow by being present with her.

Tip Two: Like any parenting decision that needs to be made, make the decision from a place of awareness and in moderation.

Tip Three:   Be aware of how much your TV is on.

Again, research has found that children in the US are exposed to over 4 hours of TV a day. Reduce this time limiting the number of TV’s in the home, and not putting a TV or computer in the child’s bedroom.

Tip Four: Those educational DVDs? Well, research shows they make a lot of claims and the content is not based on research.   

Since some studies have implicated attentional and language deficits in babies who view more than two hours of media per day, limit the amount of media with your infant. A baby’s primitive brain learns socially and with many senses involved: touch, smell, sight, sound. A baby’s early interactions and experiences are encoded in the brain and have lasting effects. Choose media that has child development consultants working on the production.  

Tip Five: Think twice about exposing your young baby/toddler to violent imagery on the screen. Remember repetitive showings increase retention, babies are naturally wired to empathize with emotions and studies show that children have a different perception of reality and fantasy than adults.

Five positive ways for parents to interact with their babies: 

  • Consistently interact with a baby using prolonged eye contact, gentle skin to skin touching and smiling
  • Actively watching appropriate media with a baby is a way for parents to get a needed sitting rest and also enhances learning and mitigates negative effects
  • Baby massage is a wonderful tool for parents. Studies show it reduces anxiety and depression in both parents and babies (Field, Hernandez-Reif, M. and Diego,  2006)
  • Teach her to regulate her emotional states by appropriately soothing her when necessary. She is learning how to accept and tolerate her own emotional states from parents, so remain calm and consistent.
  • Remind parents that they don’t need to be perfect, they just need to be good enough!

 References 

American Academy of Pediatrics, Council on Communication and Media (2012). Policy Statement: Media Use by Children Younger Than 2 Years. May 15, 2012 from  http://pediatrics.aappublications.org/content/128/5/1040.full.html

Barr, R, Muentener, P, and Garcia, A. (2007). Age related changes in deferred imitation from television by 6-18-month-olds.  Developmental Science,10(6), 910-922.  

Christakis, D (2009). The effects of infant media usage: what do we know and what should we learn? Acta Pædiatrica, 98, 8–16.

Christakis, D. and Zimmerman, F. (2007). Associations between content types of early media exposure and subsequent attentional problems. Pediatrics, 120(5), 986 -992. doi: 10.1542/peds.2006-3322

Courage, M. and Setliff, (2009). Debating the impact of television and video material on very young children: Attention, learning, and the developing brain. Society for Research in Child Development, 3(1), 72-78.

Cozolino, L. (2006). The neuroscience of human relationships. New York: W.W. Norton & Company. 

Fenstermacher, S. K., Barr, R., Brey, E., Pempek, T. A., Ryan, M., Calvert, S. L. and Linebarger, D. (2010). Interactional quality depicted in infant and toddler videos: where are the interactions?. Infant & Child Development, 19(6), 594-612. doi:10.1002/icd.714

Field, T., Hernandez-Reif, M., & Diego, M. (2006). Newborns of depressed mothers who received moderate versus light pressure massage during pregnancy. Infant Behavior and Development, 29, 54-58.

Kirkorian, H. L., Pempek, T. A., Murphy, L. A., Schmidt, M. E., & Anderson, D. R. (2009). The Impact of Background Television on Parent–Child Interaction. Child Development, 80(5), 1350-1359. doi:10.1111/j.1467-8624.2009.01337.x. 

LaPierre, M., Piotrowski, J., and Linebarger, D. (2012).  American children exposed to high amounts of harmful TV. Unpublished paper presented at International Communication Association’s annual conference (Phoenix, AZ, May 24-28, 2012).

Marvin, R.S. & Britner, P.A. (2008). Normative Development: The ontogeny of attachment. In J. Cassidy & P.R. Shaw (Eds),  Handbook of Attachment, (pp. 269-294). New York: The Guilford Press.

Stamm, J. (2007). Bright from the start. New York: Penguin Books.

Stevens, T. and Mulsow, M. (2006). There is no meaningful relationship between television exposure and symptoms of attention-deficit/hyperactivity disorder. Pediatrics, 117(3), 665-672. Retrieved May 21, 2012 from http://pediatrics.aappublications.org/content/117/3/665.full.html

Wallin,D.J. (2007).  Attachment in psychotherapy. New York: The Guilford Press.

Zack, E., Barr, R., Gerhardstein, P., Dickerson, K., and Meltzoff, A.N. (2009). Infant imitation from television using novel touchscreen technology. British Journal of Developmental Psychology, 27, 13–26.

Zero to Three (2012). General brain development. Retrieved May 15, 2012 from  http://main.zerotothree.org/site/PageServer?pagename=ter_key_brainFAQ#bybirthZimmerman, F. J., Gilkerson, J., Richards, J. A., Christakis, D. A., Dongxin, X., Gray, S., & Yapanel, U. (2009). Teaching by Listening: The Importance of Adult-Child Conversations to Language Development. Pediatrics124(1), 342-349. doi:10.1542/peds.2008-2267 

American Academy of Pediatrics, Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Parenting an Infant , , , , , , ,

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!   

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 , , , , , , , , , , ,