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Elisabeth Bing, Mother of Lamaze, Remembered for Humanizing Childbirth

May 18th, 2015 by avatar

“I hope I have made women aware that they have choices, they can get to know their body and trust their body.”

 

Elisabeth Bing, 1914-2015, Co-Founder of Lamaze International

elisabethbingElisabeth Bing, known as the “mother of Lamaze” passed away on Friday, May 15th, 2015 in her home in New York City, NY a few weeks shy of her 101st  birthday.  Elisabeth, along with Marjorie Karmel, founded Lamaze International (then known as The American Society for Psychoprophylaxis in Obstetrics/Lamaze, or ASPO/Lamaze) 55 years ago.  Her legacy lives on, not only in the numerous books she authored, (Six Practical Lessons for an Easier Childbirth, her most well known book, first published in 1967) but in each one of us, especially Lamaze Certified Childbirth Educators, who have been helping women and families for decades to be “aware that they have choices, they can get to know their body and trust their body.”

There are many resources (see links below) written that document Elisabeth’s life, her journey from Germany, to England and then finally the USA, where she established a groundbreaking childbirth education program at Mt. Sinai Hospital in Manhattan.  I didn’t want to rewrite what has already been documented.  I encourage you to read them as they are both fascinating and factual, documenting the magnificent achievements of a life committed to improving birth for women and babies.

Teaching in Studio, 1978 © Lamaze

 

I wanted to share information about Elisabeth that has not already been shared. I never had the honor of meeting Elisabeth Bing, nor hearing her speak, so I wanted to ask some of the women and leaders of Lamaze International to share what Elisabeth was like from their own personal experiences with this icon of childbirth education. I wanted to know how she influenced their lives and their careers, and to learn more about who she was and what she was like.  I also wanted to share this information with you.  Please join me in, as these women share their thoughts and memories.

Judith Lothian, PhD, RN, LCCE, FACCE, Chairperson of the Lamaze Certification Council Governing Body, Associate Editor of the Journal of Perinatal Education and co-author of The Official Lamaze Guide: Giving Birth with Confidence

Mary Jo Podgurski, RNC, EdD, LCCE, FACCE, Past President of Lamaze International

Robin Elise Weiss, PhD, MPH, LCCE, FACCE, author and current Lamaze International President

Linda Harmon, MPH, Executive Director of Lamaze International

Sharon Muza: Do you remember the first time you met Elisabeth? Can you share the details of that meeting and your first impressions?

Linda Harmon: I met Elisabeth for the first time at the annual conference over twenty years ago. I was meeting the “mother of Lamaze”. She was gracious and warm, and took the time and interest to get to know me personally. It was always special to have a few moments with Elisabeth at the conference for many years after our first meeting all those years ago.

© Librado Romero/The New York Times

© Librado Romero/The New York Times

Robin Elise Weiss: The first time I actually saw Elisabeth in person was at a conference in Chicago. I was coming down the escalator and I looked over at the fountain and she caught my eye. She was sitting there with Sheila Kitzinger, and all I could think was “Wow what an amazing woman. And two great legends sitting together just as simple as could be, not even understanding the impact that they’ve had on my life.

Mary Jo Podgurski: I’d always admired Elisabeth from afar, hanging onto her every word during her talks and taking an occasional picture with her at a conference. I clearly recall when we first spent time together. I was elected to the Lamaze board in 1994. Elisabeth asked me to meet with her. She engaged me in conversation about so many things – my passion for working with teens, my personal belief system, my family, my values, my experiences with birthing women, my own births – I realized I was being vetted. She was wise, she listened to hear, and she was visionary. She became my mentor. In time we became close personal friends.

Judith Lothian: I met Elisabeth in 1973. She interviewed me in her apartment…where she died…for the NYC Lamaze teacher training program. I was nervous. She was gracious and kind. I took the seminar later that year. In that same apartment. A group of about 8. It was wonderful. Take aways? They were the foundation for my career and life as a childbirth educator. “The breathing works because women make it their own in labor” There was nothing rigid about the way she taught the principles of the then “psychoprophylaxis”. And then began a 20 year journey where Elisabeth mentored me…she had me take over the teacher training program in NYC and then said “It’s time you went on to DC to the national organization”. I never would have done either without her literally telling me to do it. A wonderful mentor.

Dr. Marshall Klauss, Elisabeth Bing, Linda Harmon (L-R)

Dr. Marshall Klauss, Elisabeth Bing, Linda Harmon (L-R) 1996 © Lamaze

SM: When did you last meet/see/communicate with Elisabeth? Can you share those details?

JL: We did a video for the 50th anniversary of Lamaze. I spent a day with Elisabeth in her apartment. We shared memories and had tea together and she watched the taping and participated. It was an incredible day.

REW: One of the last times that I saw Elizabeth she was actually swimming in the ocean at the Fort Lauderdale Lamaze conference. All I could think was I hope I have that much spunk when I’m 90 years old.

LH: I remember visiting Elisabeth in her New York apartment when Lamaze had the opportunity to do a quick Lamaze lesson on the Regis and Kelly show. I got the grand tour which included her ground floor studio where she taught Lamaze classes for many years.

MJP: The last time we saw one another was her 100th birthday celebration in her apartment in NYC – July 8th, 2014. We last spoke at Christmas, 2014, when I sent her my usual present, a dozen red roses. She never failed to call and thank me, and then she always sent a thank you note. I treasure her notes. When I was in New York I always went to see her. I remember walking into her apartment about two years ago. When I entered, she looked up and said, “It’s my friend Mary Jo!”

Elisabeth with son Peter © Lamaze

Elisabeth with son Peter © Lamaze

SM: How would you describe Elisabeth’s personality and character?

MJP: Independent. Wise. Fiercely loyal. Kind. Intellectual. Curious. Gentle. Visionary. Strong-willed.

REW: I saw her as an amazing combination of feisty and sweet. She wouldn’t take no for an answer but you always left with a positive impression. She always made me feel like I was the only person she was talking to or cared about in the moment.

JL: Strong. Wise. Generous and kind.

SM: How do you think Elisabeth would want to be remembered?

LH: For starting what was at the time a radical consumer movement to improve birth for women and their partners, a legacy that has stood the test of time and continues to be relevant and important 55 years later.

MJP: As an advocate for birth and for women. As a musician and writer. As a mother. As a friend

JL: As someone who helped women give birth easily and simply.

SM: Of all the contributions Elisabeth has made to childbirth, both here in the USA, and abroad, what do you think is her greatest legacy?

MJP: Elisabeth modeled independence, strength and true advocacy. She empowered women. We (CBEs) are her legacy.

JL: Beginning, really, the movement to change birth in the US. She was at the forefront and gave women with her “Six Practical Lessons” a way to do it. Simply and easily. It may seem rigid and simplistic today but it worked then.

REW: Her greatest legacy will be the fact that women now have choices that were once not even considered possible. Many women do not know her name, but have her to thank for the options that they now have in childbirth.

SM: What advice would Elisabeth give to today’s pregnant person about their upcoming labor and birth?

MJP: One of the last things I remember her saying at a conference presentation was ‘Now, let’s take on the insurance companies’. I think Elisabeth would empower a pregnant person by sharing knowledge, speaking truth to power, and modeling courage. I think she’d say that the woman’s body knew how to give birth.

REW: Know your options. Fight for what works for you and your family.

SM: Do you have a favorite quote or story that Elisabeth said or shared with you and others? What might that be?

JL: Elisabeth in the 1970s was on a radio show with Dr. Bradley. She refused to talk about which “method” of childbirth was better. She said “Anything that helps women have good births is what is important”. I was impressed that she was not pushing Lamaze… but acknowledging women. She was gracious and kind always.

MJP: Once when we were discussing her youth in Germany and her time in England during the Blitz, she told me how she reacted to the bombings. She said that, at first, she went to the shelters with other people when the air raid sirens wailed. In time, she decided not to go. She said she wouldn’t die huddled below ground, but would continue doing whatever she was doing when the raid began. Those words resonated with me then, and echo for me now.  I visited her about six weeks after 9/11. She was calm and unafraid. I spoke with her as soon after the attacks as I could; she expressed no anxiety. Elisabeth showed me how to live with courage and well.

SM: Any other comments that you would like to share?

MJP: I loved Elisabeth Bing as a mentor, a true educator, a strong woman of integrity, but most of all, as my dear friend. I will always love and remember her.

Dr. Mary Jo Podgurski and  Elisabeth Bing 2014 © Podgurski

Dr. Mary Jo Podgurski and Elisabeth Bing 2014 © Podgurski

JL: I found Lamaze (ASPO) because I wanted a natural birth. But then I found Elisabeth when I wanted to teach classes and help women have the wonderful birth experience that I had. I had the privilege of being trained by her…and, contrary to all that is said about early Lamaze, there was nothing rigid about the what she taught or the way she taught. What I learned from Elisabeth was the foundation for all that I have done as a childbirth educator and nursing educator, and as an advocate for safe, health birth.. I am eternally grateful.

_____________________

Elisabeth Bing had a vision that there was a better way to give birth and she made that vision a reality through her books, the organization she founded (Lamaze International), the thousands upon thousands of families she taught, the relationships she forged with medical professionals, and the men and women she mentored, guided, supported and taught who have gone on to become childbirth educators themselves, carrying on the mission and vision. Elisabeth once said, “I hope I have made women aware that they have choices, they can get to know their body and trust their body.” I think, upon reflection, that we can all agree that Elisabeth Bing was beyond successful in this goal, and millions of families are grateful for her work and her effort.  I join Lamaze International and the Lamaze leaders, past and present, Lamaze Board of Directors and Staff, Lamaze Certified Childbirth Educators, readers of this blog and families everywhere in sending our deepest sympathies to Elisabeth’s family on the loss of their mother and family member.  We will forever be deeply indebted to her legacy.

Do you have memories of meeting Elisabeth Bing? Hearing her speak? Reading her books?  Please take a moment to share your thoughts and what her work meant to you in our comments section.  Thank you.

Books authored by Elisabeth Bing (incomplete list)

 

Babies, Childbirth Education, Journal of Perinatal Education, Lamaze International, Lamaze Method, Lamaze News , , , , , ,

Book Review: Birth Ambassadors; Doulas and the Re-Emergence of Woman-Supported Birth in America.

May 7th, 2015 by avatar

By Kim James, BA, BDT(DONA), CD(PALS), ICCE, LCCE

May is International Doula Month and Lamaze International recognizes the importance of labor support. (Note – there are both birth and postpartum doulas who work with families during the childbearing year. We are grateful for the work that they both do.)  In fact, our third Healthy Birth Practice specifically addresses doulas and support people as an effective component of safe and healthy birth. The American College of Obstetricians and Gynecologists (ACOG) in their 2014 Safe Prevention of the Primary Cesarean Obstetric Care Consensus Statement stated “published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”  Childbirth educators and health care providers have ample opportunity to inform parents about the benefits of a doula when they are meeting with families and patients.  

In mid-2014, sociologist Christine Morton, Ph.D. with Elayne G. Clift, MA, wrote a book, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America examining doulas from both an historical perspective as well as an assessment of the role of the doula in current American society . Kim James, LCCE and certified DONA birth doula, reviews this book and shares her perspective and take-aways with readers of this blog.

This book would make a great read for a book club book for birth professionals, and Kim generously shares some discussion questions at the end of today’s post to facilitate your discussion, should you wish to participate.  Alternately, if you have read the book, please feel free to respond in our comments section. 

Science & Sensibility and Lamaze International want to thank all the doulas who work tirelessly to support families as they birth their babies and transition to parenthood. Happy International Doula Month. – Sharon Muza, Science & Sensibility Community Manager. 

idm15 lamazeBirth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, written by Christine Morton, Ph.D. with Elayne G. Clift, MAis a thorough and compelling documentary of the history of doula support, the current dilemmas and issues facing the doula occupation, what drives doulas to pursue this work and how the work of doula support might fit into the future as the United States strains to find better ways of providing quality improvements in maternity care. For doula trainers and doulas looking to pursue this work in a professional manner, Birth Ambassadors is critical, mandatory reading. (For trainers and doulas interested in how to use this book to critically assess your work, please see the discussion questions below this article).

But what about for childbirth educators? What in it for them?

While the history is fascinating, it’s the critical sociological analysis of the current dilemmas and issues facing the doula occupation that childbirth educators’ need to thoroughly understand, especially Lamaze certified childbirth educators.

Lamaze International’s third Healthy Care Practice, ‘Bring a Loved One, Friend or Doula for Continuous Support’, outlines why continuous support is important and how a doula performs their work:

  • Continuous support can help alleviate fear and worry.
  • A doula’s intuitive sense and training mean emotional and physical needs are met with timely, individualized care.
  • Greater emotional and physical comfort may encourage the most efficient and healthy labor progress.

While most childbirth educators are aware of the intended benefits of doula care, not all are aware of the dilemmas doulas face in performing their work and the institutional and cultural issues that prevent doulas from having the greatest beneficial impact. Lamaze certified childbirth educators must have a firm understanding of these dilemmas so as not to ‘over-promise’ what the third Lamaze Healthy Care Practice is intended to deliver.

I want to highlight three dilemmas facing doulas that childbirth educators should be aware of and what they can do to educate parents who want doula-supported birth experiences:

Kim James' well read Birth  Ambassadors

Kim James’ well read Birth Ambassadors

First dilemma

The ecological fallacy of applying aggregate results of research that show doula efficacy to an individual family’s outcome. The cultural and institutional context of most US hospital births limit the doula’s efficacy, often by prohibiting truly continuous support and refusing to recognize a doula’s unique scope of practice. Childbirth educators should lead discussions with parents about what hospitals and which care providers in their areas are most and least supportive of doula care. Childbirth educators are instrumental in helping parents understand the questions they can ask during hospital tours and prenatal visits to find out if their chosen place of birth and attendant understand and support doulas attending families at births.

Second dilemma

The frequent contradiction between a doula’s personal values (often a deep belief in the optimality of the midwifery model of care, natural, drug-free childbirth or specific parenting practices) and her obligation to provide unconditional support for parents’ birth and parenting choices. Childbirth educators must help parents clarify their values around birth and parenting so that parents can find the support people who suit them best. Not every doula will be the best support for every parent.

Third dilemma

No occupation-wide standard for training or certification. The competing tensions within doula organizations between increased professionalization and maintaining low barriers to entry for all people to become doulas remain unresolved. While the majority of doulas are well-trained through recognized, long-standing organizations, some will only have received light, if any, training possibly through correspondence and online courses. Not every doula’s skill set is the same. Not every doula will practice within a scope of practice that is evidence based. Not every doula will pledge to follow a recognized code of ethics backed by an organization with an active grievance policy. Childbirth educators who make referrals to families asking for doulas should always make referrals to doulas who are well-trained, consistently receive excellent feedback from the families they serve and most importantly practice in a manner that is consistent with the evidence based third Lamaze Healthy Care Practice.

As a current Lamaze certified childbirth educator and professionally-working certified doula, I found my own experiences reflected in this book. While at times uncomfortable to confront the dilemmas and issues our occupation faces, Birth Ambassadors is well worth reading for the history and reflections for the future. It will give childbirth educators who are not currently practicing doulas good data on what the real impact of doula support means for the families that hire them.

Book club discussion questions

When Birth Ambassadors was newly released, I hosted a book club-style discussion group with several local doulas to discuss this book’s implications for our current and future work. Here are the big questions that came up for our group representing doulas who were well-established in their practices, those who were just starting out and both certified and non-certified doulas.

  • When is your personal bias stronger than your ability to offer unconditional support? (Reference: page 195).
  • Analyze this: “Doulas advocate evidence-based care for physiologic birth, yet are not trained clinically to recognize or treat women when their pregnancies and labors become non-normal”. (Reference: page 37).
  • The original purpose of the first doula organizations was to provide moral support for each other. What do we need from our organizations now? (Reference: page 90)
  • Do we have the training to be professionally non-judgmental? (Reference: page 196).
  • Doula neutrality –When do you abandon it? How do you maintain it? (Reference: page 261).
  • What are the current debates around our standard of practice and code of ethics? (Reference: page 81).
  • Outcome-based care vs emotional companionship: What are you drawn to in this work? (Reference: page 260)
  • Are you comfortable with the “outsider-within” role? Does attract or repel you? (Reference: page 36)

How do you talk about doulas in your childbirth classes?  In your midwifery or obstetrical practice?  Have you read Birth Ambassadors?  What were your big take-aways?  Have you shared Lamaze International’s “Who Says Three’s a Crowd?” infographic with the families you work with?

Note: Christine Morton is a member of Lamaze International’s Board of Directors.

About Kim James 

Kim James HeadshotKim James BA, BDT(DONA), CD(PALS), ICCE, LCCE, is an ICEA and Lamaze certified childbirth educator teaching at Parent Trust for Washington Children/Great Starts where she sits on the Education Committee. She owns and operates www.DoulaMatch.net and is a DONA International and PALS Doulas certified birth doula as well as a DONA-approved birth doula trainer working at the Simkin Center/Bastyr University. Kim also volunteers her time on the Lamaze International membership committee and serves as Washington State DONA SPAR. Her daughters are 9 and 16 years old.  Kim and her family live in Seattle, Washington.

Babies, Book Reviews, Childbirth Education, Doula Care, Guest Posts, Healthy Birth Practices, Lamaze International, Newborns , , , , , ,

BABE Series: Cesarean Section Role Play Helps Prepare Families

April 30th, 2015 by avatar

apron and babyToday, in our monthly series “Brilliant Activities for Birth Educators” (BABE), I would like to share one of the activities that I do in my Lamaze class to help families feel prepared for a cesarean section. Most families in my classes are planning a vaginal birth, but it never hurts to be prepared should plans change.  One in three pregnant people will birth by cesarean in the USA.  April is Cesarean Awareness Month and that is why I am sharing this activity at this time.

Objectives

My objectives for this specific activity are threefold – 1) to share how the procedure is done 2) to offer different options that might be available for the family to request (skin to skin in the OR, delayed newborn procedures, etc., and 3) brainstorm the role of the support person during a cesarean and what kind of support the pregnant person will find comforting and helpful.

This role play is done in the fifth week of a seven week series. We have just covered variations in labor (induction, augmentation, EFM, AROM, pain medications, assisted second stage and more). They have heard about the hard and soft reasons for a cesarean and now I hope that they will understand the procedure and the choices and options they might have at the time.

Supplies for the activity and the setup

  • Cesarean apron
  • surgical masks
  • drape
  • soft baby
  • hair nets
  • scrubs
  • surgical clothing
  • laminated labels for each role
  • optional – IV bag, BP cuff, EKG leads, etc
up close cesarean apron

Up close of four zippers on cesarean apron

My main prop in this activity is a “cesarean apron” handmade by Kris Avery, a fellow LCCE here in Washington State. The apron has breasts, a belly button and some pubic hair painted on it, but what makes it special is a series of zippers that correspond to the different layers of a person’s body that will be cut during the cesarean procedure. Each zipper is sewn into a different layer and opens to reveal the layer underneath. The skin is represented by the apron, and then there is a layer of fat (yellow felt) that zips open, revealing the uterus (red felt). There are no muscles to “open” because as we know, the abdominal muscles are retracted and not cut. Finally, underneath the uterus, is the amniotic sac, represented by a thin white nylon material.

I ask a partner to come with me out of sight of the class and place the cesarean apron on them. All the zippers are closed. I place a soft baby doll (I use the baby from IKEA) underneath the apron with the head positioned right near the inner zipper.  Sometimes I place the baby in the breech position and plan on having the bum be removed first. When the partner is ready, we walk together back into the classroom and I ask them to lay on a table, where I have placed a pillow.

How I conduct the role play

I invite two class members to come up and hold a drape at chest level, just like it might be positioned in the OR.  I hand out laminated cards to all the other class members. Each card has the role of someone who might be in the OR during a cesarean section – surgeon, baby nurse, anesthesiologist, surgical tech, respiratory therapist, and so on.   I ask the pregnant person who is partnered with my “cesarean person” to play the role of “partner.”  I invite the partner to get into the white “moon suit” that is normally provided to family members during a cesarean.  I hand out hair nets, scrubs, face masks, surgical gowns, to all those who will be in the OR and everyone suits up.  I position all the “actors” in the appropriate spot.  Some go by a pretend “baby warmer” and others stand around the birthing person while others go where they might be in the real operating room. I talk about how hard it is to tell who is in the room and what their role is, when everyone is wearing scrubs/gowns/hats/masks and suggest that they ask people to introduce themselves.  I discuss strategies that the birthing person can use if they are temporarily separated from their support person.  I bring the support person over and seat them at the head of the OR table near the “anesthesiologist” and discuss how they cannot see over the drape for both the patient and the partner. The partner can stand up at the time of birth if they wish, or together they could ask for the drape to be dropped at that moment.  I ask the pregnant person how they are feeling as the surgery is about to begin.FullSizeRender

I walk everyone through the procedure step by step and describe what is happening.  I share what noises they might hear, and what sensations the pregnant person might “feel.”  (Tugging, pressure, pulling, but no pain.)  I try and give a sense of how long it takes for each part of the operation, (prep, incision to baby, closure)  I ask the surgeons to begin to open the zippers, and talk about each layer that they come to.  Finally the surgeons are through the amniotic sac and they reach in and remove the baby’s head through the opening. It is a somewhat tight fit and we discuss how that might benefit the baby.

The baby is delivered, shown to the parents and taken over to the “warmer” where the baby team is waiting.  I encourage partner to go over and see the baby, initiate talking to the baby and start sharing information with the birthing person – what the baby looks like, how s/he is doing, and so on.

cesarean apronWe go on to discuss how the partner can facilitate having the baby brought over to the birthing person ASAP, skin-to-skin, what might need to happen if baby is moved to the special care nursery, and more.  Throughout all of this, the class participants are role-playing through all of the likely activities and people are stepping up to help the family to have a positive experience, within the scope of their assigned role.  The surgeons close (zip up) the different layers and close the outer zipper on the skin.

I am leaving out much of the detail, as I am confident that you can fill in the activities that happen when a person is prepped, taken to the OR, has the cesarean surgery and is then taken to recover.  My hope is to have parents aware of some of the major points of the overall procedure.

Processing the activity

The class members take off the “costumes” and return to their seats.  I feel it is very important to debrief this activity.  It can be overwhelming to some. We debrief further, discussing any observations they had, how they felt as our role play was happening. I ask what are the values that are important to them and their family, if a cesarean should be needed.  A discussion also takes place about what a cesarean recovery plan might look like and how the family’s needs might change if they do not have a vaginal birth.

How is this activity received?

IMG_0116During the activity, class members are usually very engaged and creative in answering questions, acting out their “roles” and brainstorming solutions to the situations I present.  The real magic happens when we debrief.  I can see the wheels turning as families articulate what they will want and need should they have a cesarean birth.  They learn that they have a voice and can share what is important with their medical team.

Time and time again, I receive emails and and notes from class members who ended up having a cesarean. They share how “accurate” our role play was and how it helped them to understand the steps involved with their cesarean.  They were able to speak up in regards to their preferences and felt like their class preparation helped to reduce their stress and anxiety.

Summary

This activity takes time and I often wonder if I should replace it with something much shorter that covers the same topic.  But, I continue to do this role play activity because I see how it really helps families to understand how to play an active role in the birth of their baby, even if it is by cesarean section.

Other resources that I share with the class are the following links:

How might you make a “cesarean apron” that you could use for this activity?  Do you have ideas on how you could modify this activity for your classes?  What other things do you do to help your families to be prepared for a cesarean birth?  I would love to learn how you cover this important topic.  Please share your ideas in the comments section below.

 

Babies, Cesarean Birth, Childbirth Education, Medical Interventions, Newborns, Push for Your Baby, Series: BABE - Brilliant Activities for Birth Educators , , , ,

The Healthy Birth: Dyad or Triad? Exploring Birth and the Microbiome

April 28th, 2015 by avatar

By Anne Estes, PhD, Illustrated by Cara Gibson, PhD

There has been much discussion and burgeoning research on how the mode of birth affects the microbiome of the infant (and later on the adult).  It is becoming clear that how babies are born impacts the type of bacteria that take up residence in and on our bodies. Today, I would like to welcome researcher and writer Anne Estes, PhD, and researcher and illustrator Cara Gibson, PhD to Science & Sensibility.  Anne shares information on the research into a newborn’s (and later on the adult) microbiome and how it can be affected by the location of birth, the type of birth and the interventions that occur during birth.  Learn more about what this new field of research is telling us about the importance of the microbiome. Stay tuned for a future interview by Anne, with some of the research scientists attempting to supplement the microbiome of infants delivered by planned Cesareans. – Sharon Muza, Science & Sensibility Community Manager

Birth plans often change. Neither my husband nor I anticipated the series of interventions with my first daughter’s birth. In the end, though we had the most important outcome – a healthy mom and baby dyad. How did these interventions influence the health of the third, silent, and invisible member of my daughter’s birth that I hadn’t included in her birth plan – her microbiome?

The helpful and harmful bacteria, viruses, and fungi that live in and on every environment, both living and nonliving, are the microbiome of that environment. The bacterial component of the microbiome is best understood to date and will be this post’s focus. An organism’s microbiome influences the development and health of those animals and plants, whereas the microbiome of soil and buildings influence organisms that reside in those non-living environments. Our helpful microbes provide services that range from vitamin synthesis and food degradation to preventing attacks by pathogens. However, in the last few centuries of human-microbe interactions, changes in our birth and medical practices and living conditions may have altered the acquisition of our microbial communities. Our altered microbiomes, especially in the industrialized world, may help explain the increase in allergies, asthma, diabetes, gastrointestinal diseases, and mental disorders, such as depression, anxiety, and autism.

Humans as ecosystems for microbes

To a bacterium, you are a planet made up of several different ecosystems. From the dry, UV-intense “deserts” of your skin to the warm, wet, nutrient-rich “lakes” of your mouth, specific bacteria live in different regions on a person, just as specific vertebrate animals live in different ecosystems on the Earth. As ecosystems of the human environment change during development, pregnancy, or with changing diets, which bacterial species remain or how these microbial species function may shift is slowly becoming understood. How do we first acquire these microbes? Previous posts here and other blogs have done excellent reviews of the human microbiome and birth, so my post will serve to provide updates and pose new questions for consideration.

Fig1_MapLadies6

 

The source of the infant microbiome

The infant microbiome is acquired during birth [1, 2], from first foods [3-5], and the environment [6], and may also be partially colonized in utero [7]. The Fig2_MicrobirthVagvC5microbiome of infants born vaginally most closely represents the microbiome of the mother’s vagina and feces [1], and is rich in beneficial bacteria such as Bifidobacterium longum subsp. infantis and Bacteroidetes [8, 9]. In contrast, the microbiome of infants born via planned Cesarean is more similar to that of the mother’s skin and hospital environment [1]. The microbiomes of planned Cesarean-born infants are more likely to have hospital-acquired pathogens such as Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and pathogenic Es. coli [1] and lack beneficial Bacteroidetes and Bi. longum subsp. infantis [10]. However, when beneficial Bifidobacterium were occasionally present in Cesarean-born infants, pathogenic Es. coli and C. difficile were not found [11] suggesting that one benefit of Bifidobacterium, especially Bi. longum subsp. infantis, may be outcompeting these potential pathogens.

Influence of birth mode on microbiome transmission

Repeatedly, studies in different countries, ethnic groups, ages, and health status have suggested that planned Cesarean-born infants are more likely to have more health issues and a different microbiome, as compared to vaginally born infants [2, 10, 12-14]. These differences in community composition can even be seen in adulthood [15]. A new Canadian study finds that the microbiome of infants born via unplanned Cesarean had increased bacterial richness and diversity, more similar to that of vaginally born infants than planned Cesarean [10]. Unfortunately, this was only a small study where fewer than ten mother-infant pairs were examined. Several variables such as length of time in labor or how far labor progressed, antibiotic use, natural vs. artificial rupture of membranes, and/or other interventions that may influence the microbiome were also not examined [10]. However, it does suggest that the process of labor, perhaps the hormonal or other physiological changes, may influence the microbiome. Additionally, some maternal bacteria may be transmitted when membranes rupture during labor [10]. Are bacteria “eavesdropping” on the chemical changes in the human to prepare themselves for transmission to the baby? Do these maternal hormone changes lead to increased vaginal or gut epithelial sloughing to transmit more or specific bacteria? Certainly, studies with larger sample sizes that can help control for these variables along with experimental studies on model animals are warranted.

Influence of birth place on microbiome transmission

Infants also acquire a proportion of their microbiome from their physical, inanimate surroundings. What proportion of the microbiome and which bacteria are acquired most likely depends on how many and what kinds of bacteria are acquired in utero, through birth method, and first foods. Since Cesarean delivered infants seem to be exposed to a lower density of maternal bacteria than vaginally delivered babies, the former may be more likely to acquire bacteria from their environment. However, this hypothesis has not been examined.

Fig3_Locations4

Just as living organisms are a microbial environment, so are non-living structures such as buildings. Scientists at several universities working together on The Microbiology of the Built Environment Project funded by the Sloan Foundation are comparing the microbes of homes and hospitals. They have found that buildings are quickly colonized by the microbes of the people living in them [16]. Such rapid colonization specific to the individual being housed is even seen in infants in the neonatal intensive care unit (NICU) [17, 18] . One group is surveying the microbiome of a hospital over time, as it is being built and then occupied. Hospital-acquired infections are an increasing concern for all patients, especially newborns. Infants born by Cesarean have an increased rate of MRSA, C. difficile, and other opportunistic pathogens [1]. However, different hospitals and even wards within a hospital might be expected to have disparate levels of pathogens depending on how prevalent the disease is within the hospital patients and staff. Whether freestanding birth centers, operating rooms dedicated to labor-and-delivery only, and mixed-use operating rooms have dissimilar microbiomes has yet to be investigated. Infants born in private homes would be exposed to the same microbiomes of members of the household.

Influence of first foods on microbiome transmission

First foods are a third source of the infant microbiome. Breastfed infants have two “moms:” their human mother and their Milk-Oriented Microbiota (MOM). The MOM are a diverse group of about 200 species of beneficial bacteria transmitted via breast milk and fed by the breast milk sugars. Fig4_MicrobirthBreastvBottle5The average breastfed baby receives between 1 and 10 million bacteria daily from their mother’s milk – quite the bacterial soup [5]! The bacterial diversity and concentrations of specific bacteria change dramatically between colostrum and mature milk with colostrum having over 1,000 different bacterial types [4]. The milk microbiome is a unique assemblage of bacteria, different from human skin, gut, oral, vaginal, and other specific site microbiomes [4]. Although only ten women were followed, it is intriguing that the milk microbiome of women delivering via planned Cesarean at birth, one month, and six months post-birth, was more similar to their gut microbiome than the breast milk of mothers who delivered vaginally [4]. Milk of mothers undergoing unplanned Cesarean and vaginally delivering mothers were most similar [4]. Breast milk also includes the food, or prebiotics, for the developing infant microbiome. Sugars found in breast milk, the human milk oligosaccharides (HMOs), differ in sugar types and concentrations between pre-term and full term birth, vaginally delivering and planned Cesarean births (reviewed in [19]), and even between mothers with different types of “secretor” genes [20]. These HMOs are digested by the microbes, not the infant. Additionally, the changes in sugar types and concentrations seem to influence bacterial diversity, keeping strains of Bifidobacterium longum subsp infantis in highest abundance in the first few months of life [19]. How the presence of different microbes influences the developing infant immune system has yet to be determined.

Formula-fed babies have a more diverse and rich microbiome than breast-fed babies, with lower numbers of Bifidobacterium and higher abundances of Peptostreptococcaceae, which includes C. difficile [10, 21]. Gut bacterial diversity is essential in increasing the ability of adults to digest a wide variety of foods. However, bacterial diversity may be detrimental in the infant stage when the immune system is developing and learning to distinguish between microbes that are friends and those that are foes. Breast milk sugars may mediate the relative abundances of different bacterial species [22]. Through studies like the Milk Bioactives Program at University of California at Davis, more is learned about the interaction between breast milk sugars and specific bacteria that can lead to better probiotic and prebiotic formulas and improve infant health.

Influence of in utero environment on microbiome transmission

Many other factors surrounding birth may influence the infant microbiome. High levels of reported maternal stress and high cortisol concentrations during pregnancy, correlated with lower relative abundances of beneficial Lactobacillus and Bifidobacterium sp. and higher abundances of Proteobacteria, such as Enterobacter and Escherichia. Infants of these highly stressed mothers had increased reports of gastrointestinal symptoms and allergic reactions, though these issues were reported by caregivers, not physicians, which may confound the findings [23]. A separate study found infants whose gestation lengths were less than 38 weeks had microbiome communities that were low in Bifidobacterium and took three to six months to reach a normal Bifidiobacterium-rich community as compared to infants born at 40 or more weeks [9]. Finally, the use of antibiotics during pregnancy [12] may also lead to infant health issues.

Do birth interventions change the microbiome?

The potential “eavesdropping” of bacteria on human hormones during pregnancy and labor lead me to wonder how the use of synthetic hormones such as Pitocin, especially during stalled labor, might influence the microbiome and overall infant health. There are so many variables to the birth process that many of these questions could only be answered with extremely detailed data of tens of thousands of mother-infant-microbiome triads over time. The influence of interventions such as epidurals, frequency of cervical checks, vaginal preparation with betadine, enemas, and other procedures used during labor and delivery also have not been extensively examined. In general, any procedure that “sterilizes” or cleans the vaginal and rectal area would most likely decrease the transmission of the mother’s microbial community. Whether cervical checks introduce skin or environmental microbes to the infant should also be considered. Finally, what effect does postponing baby’s first bath until 24 or 48 hours after birth have on microbial colonization? What role does the vernix have in facilitating the colonization of the infant’s microbiome?

From lab bench to birth room

Antibiotics, Cesarean delivery, and other interventions are valuable and life-saving for many women and infants; however, as they have become more commonly used we have seen an increase in many long-term diseases and disorders. Recent microbiome research suggests that we should consider birth as delivering and nurturing a healthy triad – mom, infant, and microbiome. Currently, studies are being conducted to swab Cesarean delivered infants with vaginal secretions immediately after birth. Should fecal microbiome members also be considered? If hormone surges are important for the microbiome transmission during labor and in breast milk, as the unplanned Cesarean data suggest, how could the natural hormone surges of labor be mimicked for planned Cesarean? When antibiotics are needed for mother or infant, how best can we quickly repopulate the disturbance to the native microbiome?

Humans, and all organisms, are planets with diverse ecosystems. In sequencing of the human genome, we learned that diseases rarely correlated to specific human genes. Most likely instead of focusing on only the human or only the microbes, we should be examining the intersection between human genomics and microbiome structure and function to best understand health and disease of human-microbe ecosystems. Both human genomics and microbiome work are in their infancy (pun intended). Researchers examine correlations to develop testable hypotheses that can be examined in non-human animal models. Yet many of the microbes of interest are currently unable to be cultivated for direct testing or probiotic use. At this time, directly translating research findings to the delivery room is difficult, but I hope that this post will stimulate thought and conversations about the silent, invisible, yet important third member of human birth and life.

References

  1. Dominguez-Bello, M. G., E. K. Costello, M. Contreras, M. Magris, G. Hidalgo, N. Fierer, and R. Knight. 2010. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proceedings of the National Academy of Sciences 107:11971-11975.
  2. Mueller, N. T., E. Bakacs, J. Combellick, Z. Grigoryan, and M. G. Dominguez-Bello. 2015. The infant microbiome development: mom matters. Trends in Molecular Medicine 21:109-117.
  3. Zivkovic, A. M., J. B. German, C. B. Lebrilla, and D. A. Mills. 2011. Human milk glycobiome and its impact on the infant gastrointestinal microbiota. Proceedings of the National Academy of Sciences 108:4653-4658.
  4. Cabrera-Rubio, R., M. C. Collado, K. Laitinen, S. Salminen, E. Isolauri, and A. Mira. 2012. The human milk microbiome changes over lactation and is shaped by maternal weight and mode of delivery. The American Journal of Clinical Nutrition 96:544-551.
  5. Fernández, L., S. Langa, V. Martín, A. Maldonado, E. Jiménez, R. Martín, and J. M. Rodríguez. 2013. The human milk microbiota: Origin and potential roles in health and disease. Pharmacological Research 69:1-10.
  6. Thompson, A. L., A. Monteagudo-Mera, M. B. Cadenas, M. L. Lampl, and M. A. Azcarate-Peril. 2015. Milk- and solid-feeding practices and daycare attendance are associated with differences in bacterial diversity, predominant communities, and metabolic and immune function of the infant gut microbiome. Frontiers in Cellular and Infection Microbiology 5.
  7. Prince, A. L., D. M. Chu, M. D. Seferovic, K. M. Antony, J. Ma, and K. M. Aagaard. 2015. The Perinatal Microbiome and Pregnancy: Moving Beyond the Vaginal Microbiome. Cold Spring Harbor Perspectives in Medicine.
  8. Jost, T., C. Lacroix, C. P. Braegger, and C. Chassard. 2012. New Insights in Gut Microbiota Establishment in Healthy Breast Fed Neonates. PLoS ONE 7:e44595.
  9. Dogra, S., O. Sakwinska, S.-E. Soh, C. Ngom-Bru, W. M. Brück, B. Berger, H. Brüssow, Y. S. Lee, F. Yap, Y.-S. Chong, et al. 2015. Dynamics of Infant Gut Microbiota Are Influenced by Delivery Mode and Gestational Duration and Are Associated with Subsequent Adiposity. mBio 6.
  10. Azad, M. B., T. Konya, H. Maughan, D. S. Guttman, C. J. Field, R. S. Chari, M. R. Sears, A. B. Becker, J. A. Scott, and A. L. Kozyrskyj. 2013. Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. Canadian Medical Association Journal 185:385-394.
  11. Musilova, S., V. Rada, E. Vlkova, V. Bunesova, and J. Nevoral. 2015. Colonisation of the gut by bifidobacteria is much more common in vaginal deliveries than Caesarean sections. Acta Paediatrica 104:e184-e186.
  12. Mueller, N. T., R. Whyatt, L. Hoepner, S. Oberfield, M. G. Dominguez-Bello, E. M. Widen, A. Hassoun, F. Perera, and A. Rundle. 2014. Prenatal exposure to antibiotics, cesarean section and risk of childhood obesity. Int J Obes.
  13. Neu, J., and J. Rushing. 2011. Cesarean versus Vaginal Delivery: Long term infant outcomes and the Hygiene Hypothesis. Clinics in perinatology 38:321-331.
  14. van Nimwegen, F. A., J. Penders, E. E. Stobberingh, D. S. Postma, G. H. Koppelman, M. Kerkhof, N. E. Reijmerink, E. Dompeling, P. A. van den Brandt, I. Ferreira, et al. 2011. Mode and place of delivery, gastrointestinal microbiota, and their influence on asthma and atopy. J Allergy Clin Immunol 128:948-55 e1-3.
  15. Goedert, J. J., X. Hua, G. Yu, and J. Shi. 2014. Diversity and Composition of the Adult Fecal Microbiome Associated with History of Cesarean Birth or Appendectomy: Analysis of the American Gut Project. EBioMedicine 1:167-172.
  16. Lax, S., D. P. Smith, J. Hampton-Marcell, S. M. Owens, K. M. Handley, N. M. Scott, S. M. Gibbons, P. Larsen, B. D. Shogan, S. Weiss, et al. 2014. Longitudinal analysis of microbial interaction between humans and the indoor environment. Science 345:1048-1052.
  17. Brooks, B., B. Firek, C. Miller, I. Sharon, B. Thomas, R. Baker, M. Morowitz, and J. Banfield. 2014. Microbes in the neonatal intensive care unit resemble those found in the gut of premature infants. Microbiome 2:1.
  18. Raveh-Sadka, T., B. C. Thomas, A. Singh, B. Firek, B. Brooks, C. J. Castelle, I. Sharon, R. Baker, M. Good, M. J. Morowitz, et al. 2015. Gut bacteria are rarely shared by co-hospitalized premature infants, regardless of necrotizing enterocolitis development, vol. 4.
  19. Smilowitz, J. T., C. B. Lebrilla, D. A. Mills, J. B. German, and S. L. Freeman. 2014. Breast Milk Oligosaccharides: Structure-Function Relationships in the Neonate. Annual Review of Nutrition 34:143-169.
  20. Lewis, Z., S. Totten, J. Smilowitz, M. Popovic, E. Parker, D. Lemay, M. Van Tassell, M. Miller, Y.-S. Jin, J. German, et al. 2015. Maternal fucosyltransferase 2 status affects the gut bifidobacterial communities of breastfed infants. Microbiome 3:13.
  21. Bezirtzoglou, E., A. Tsiotsias, and G. W. Welling. 2011. Microbiota profile in feces of breast- and formula-fed newborns by using fluorescence in situ hybridization (FISH). Anaerobe 17:478-482.
  22. Guaraldi, F., and G. Salvatori. 2012. Effect of Breast and Formula Feeding on Gut Microbiota Shaping in Newborns. Frontiers in Cellular and Infection Microbiology 2:94.
  23. Zijlmans, M. A. C., K. Korpela, J. M. Riksen-Walraven, W. M. de Vos, and C. de Weerth. 2015. Maternal prenatal stress is associated with the infant intestinal microbiota. Psychoneuroendocrinology 53:233-245.

About Anne Estes

AnneMEstes_headshot 2015Anne M. Estes, PhD is a postdoctoral fellow at the Institute for Genome Sciences in Baltimore, MD. She is interested in how microbes and their host organisms work together throughout host development. Anne blogs about the importance of microbes, especially during pregnancy, birth, first foods, and early childhood at Mostly Microbes.

 

 

About Cara Gibson

cara gibson head shot 2015Cara Gibson, BSc (Hon), MS, PhD was trained as an entomologist (insect scientist) and her interests include ecology, biodiversity, and interactions with microbial symbionts. She has worked as a field ecologist, research scientist, educator, outreach coordinator, and scientific illustrator. Dr. Gibson would like to help bridge the gap between current practices and new research to improve women’s health and birth outcomes. Contact Cara at caramgibson at gmail dot com for illustration inquiries / permissions.

 

 

 

 

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, New Research, Newborns , , , , , ,

World Health Organization: Provide Cesareans for Women in Need, Don’t Focus on Specific Rate

April 21st, 2015 by avatar
© Patti Ramos Photography

© Patti Ramos Photography

As we have mentioned earlier this month, when Jen Kamel discussed placenta accreta as a downstream risk factor of the increasing cesarean rate, April is Cesarean Awareness Month and the World Health Organization (WHO) has come out with a new statement (WHO Statement on Caesarean Section Rates) that discourages identifying a “cesarean target rate” but rather encourages the use of cesarean surgery worldwide only when appropriate to protect the health of mother and baby. The goal should be that every cesarean performed is done out of true medical necessity and the decision to do so should be based on individual circumstances evaluated at the time for each mother/baby dyad.

Since 1985,  it has been stated that a safe and appropriate cesarean target rate was between 10-15%.  It was believed that if the cesarean rate exceeded that target rate, the mortality and morbidity for both mothers and babies would rise as a result of potentially unnecessary surgeries being performed.  Everyone recognizes that a cesarean birth can save the life of a mother and/or a baby.  But it needs to be acknowledged that there are no benefits to mothers and babies when a cesarean is done when it is not required.  WHO has decided to revisit the decades old suggested target rate as the number of cesarean surgeries being performed are increasing all around the world.  In the USA, in 2013, 1,284,339 cesarean surgeries were performed.  32.7% of all babies born in the USA that year were delivered by surgery.

There are both short term and long term risks to mothers, babies and future pregnancies every time a cesarean is performed.  These risks are even more elevated in areas where women have limited access to appropriate obstetrical care.

The WHO strived to identify an ideal cesarean rate for each country or population as well as a worldwide country level analysis.  The cesarean rate at the population level is determined by two items – 1) the level of access to cesareans and 2) the use of the intervention, both appropriate and inappropriately. Governments and agencies can use this information to allocate funding and resources.  Cesareans are costly to perform and doing more than necessary puts undue financial hardship on resources that may already be stretched too thin in many places around the world.

After conducting a systematic review – the team tasked with determining the population based cesarean rate determined that indeed, when cesareans are performed up to a rate of approximately 10-15%, maternal, neonatal and infant mortality and morbidity is reduced.  When the cesarean rate starts to increase above this level, mortality rates are not improved. When socioeconomic factors were included in the analysis, the relationship between lower mortality rates and an increasing cesarean rate disappeared.  In locations where cesarean rates were below 10%, as the rate increased, there was a decrease in mortality in both mothers and babies.  When the rate was between 10-30%, they did not see a continued decrease in mother or newborn mortality rates. The team also acknowledged that once the cesarean rate increased to 30% or above, the link between newborn and maternal mortality becomes difficult to assess.

In countries that struggle with resources, staffing and access to care, the common complications of surgery, such as infection, make cesarean surgery even more complicated and even dangerous for those women who give birth this way.

The team also struggled with analyzing the morbidity rate due to the lack of available data.  They did acknowledge that while the social and psychological impact of cesarean sections were not analyzed, potential impacts could be found in the maternal–infant relationship, women’s psychological health, women’s ability to successfully initiate breastfeeding and pediatric outcomes.  More research is needed.

WHO Cesarean Rate Conclusions

© WHO

 

The WHO team also felt it is important to establish, recognize and apply a universal classification system for cesareans that can be applied at the hospital level and allow comparisons to take place between different facilities and the unique populations that they serve. Once established, rates and systems could be compared between geographic regions, countries, different facilities and on a global level and the data analyzed effectively to help identify where change can be effective at reducing poor outcomes.

robson high res 2

© WHO – click image for full size version

After reviewing the different classification systems currently available, they determined that universal use of the Robson classification would best meet the needs of both international and local analysis.  The Robson classification system is named after Dr. Michael Robson, who in 2001 developed this system to classify women based on their obstetric characteristics for the purpose of research analysis.  This allows for comparisons to be made regarding cesarean section rates with few confounding factors.  Every woman will be clearly classified into one of the ten known groups when admitted for delivery. The WHO team states that the Robson classification system “is simple, robust, reproducible, clinically relevant, and prospective.”

The WHO team believes that using the Robson classification will aid in data analysis on many levels and the information obtained from these analyses be public information.  This information can be used to help facilities to optimize the use of cesarean section in the specific groups that will benefit from intervention.  It will also help determine the effectiveness of different strategies that are currently being used to reduce this intervention when not necessary.

Cesarean sections can be a life-saving tool under certain circumstances.  When cesareans are performed when not medically necessary, there are both long term and short term risks to both mothers and babies, including increased mortality and morbidity and risks to future pregnancies.  This becomes especially significant in areas of low resources and scare obstetric care.  Better data is needed to help reduce the cesarean rate in locations where it is unnecessarily high and to be able to direct resources where they are needed and can improve outcomes.  The World Health Organization hopes that this data becomes available so that more accurate research can be conducted and the reduction in mortality and morbidity for mothers and babies can be reduced.

Are you sharing with your classes, clients and families the importance of having a cesarean only when medically necessary?  While April may be Cesarean Awareness Month, we need to be diligent all year long to prevent cesareans that are not needed.

Lamaze International has created and made available three infographics that can help families learn more about cesareans and VBACs.

Screenshot 2015-04-20 19.52.53

What’s the Deal with Cesareans?

Avoiding the First Cesarean

VBAC, Yes, It’s an Option! (NEW!)

You can download and print these and other Lamaze International infographics from this page here.

Share what you are doing to honor Cesarean Awareness Month in your professional practice in our comments section below.

 

 

 

Babies, Cesarean Birth, Childbirth Education, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, Medical Interventions, Newborns, Research, Systematic Review , , , , , ,