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Book Review: “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers”

May 28th, 2015 by avatar

By Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

monograph cover_tn_kenKathleen Kendall-Tackett, Ph.D, author, IBCLC, researcher, internationally acclaimed speaker and occasional contributor to our blog, has written a new book – “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers,” that tries to lay to rest the myth that receiving help for a postpartum mood disorder and breastfeeding are not compatible.  I asked Cynthia Good Mojab to share her expert review of the book to commemorate the end of Perinatal Mood Disorders Awareness Month.  Cynthia is the perfect person for this task as she wears the hat of both a lactation consultant and a clinical counselor.  As birth professionals who work with families throughout the childbearing year, we have a sincere responsibility to provide information and screening resources so that families can be evaluated and directed to receive help that continues to support the breastfeeding dyad if breastfeeding is the parent’s desire.  Read Cynthia’s review and consider what you can do to increase awareness of perinatal mood disorders and offer your clients and students the best evidence based information available about how treatment options and breastfeeding are not mutually exclusive. – Sharon Muza, Community Manager, Science & Sensibility

Globally, the prevalence of postpartum depression is as high as 82.1% when measured using self-report questionnaires and as high as 26.3% when measured using structured clinical interviews (Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). These high rates mean that a significant proportion of families navigate breastfeeding in the context of postpartum depression.

As a perinatal mental health care provider and an IBCLC, I am frequently contacted by parents who found me after having been unable to access breastfeeding-compatible mental health care for postpartum depression (Good Mojab, 2014). They report feeling as though they are caught between a rock and a hard place: they’ve been diagnosed with postpartum depression and have been told by their primary care provider and/or their mental health care provider that they must wean in order to treat their depression. Sometimes they are even told that breastfeeding is causing their depression. Not only is that not true, but the relationship between infant feeding and postpartum depression is actually quite complex (Nonacs, 2014). While breastfeeding problems increase the risk of postpartum depression, breastfeeding itself is protective (Kendall-Tacket, n.d.). And research shows that infant-feeding intentions matter: breastfeeding mothers who are unable to accomplish their breastfeeding goals are two-and-a-half times more likely to develop postpartum depression (Borra et al., 2015). These research findings match what I see in my private practice: the partial or complete loss of a parent’s desired experience of breastfeeding can precipitate deep grief and worsen or precede the onset of postpartum depression.

Fortunately, there are many breastfeeding-compatible treatments for postpartum depression which health care providers and mental health care providers can use to effectively treat the vast majority of their clients. Dr. Kathleen Kendall-Tackett’s new book, “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers,” presents an up-to-date overview of the related research in an outline format that is quick and easy to read. She presents a compelling case for ensuring that families coping with breastfeeding problems receive additional lactation support and that breastfeeding parents coping with postpartum depression have access to treatment that is compatible with the continuation of breastfeeding.

In the first chapter, Kendall-Tackett introduces the rationale for screening for, referring for, and treating postpartum depression: postpartum depression is common in new parents and untreated postpartum depression has significant, immediate, and long-term negative consequences for both parent and child. She then presents research showing that breastfeeding does not cause depression (as some health care providers falsely believe); rather, breastfeeding serves to protect the dyad from the deleterious consequences of postpartum depression via its dampening of the stress response and via its facilitation of ongoing engagement between parent and baby. (When we shift our culturally based reference frame in recognition that breastfeeding is the biological norm for humans, we can see that this research also shows that formula feeding increases the risk of deleterious consequences from postpartum depression through increasing the stress response and potentially lessening ongoing engagement between parent and baby.) The substantial evidence base for why the effective treatment of postpartum depression is so critical—briefly introduced in chapter 1—is presented in more detail in chapter 3. Psychological disorders that often co-occur with postpartum depression, such as posttraumatic stress disorder, bipolar disorder, eating disorders, and obsessive-compulsive disorder, are then described. Chapter 5 reviews the complex causes of postpartum depression, including inflammation, fatigue and sleep disturbance, pain, traumatic birth experiences, infant characteristics such as illness and prematurity, and maternal characteristics, life history, psychiatric history, and social context.baby breastfeeding

Chapter 6 emphasizes the importance of screening for postpartum depression. Kendall-Tackett wisely advocates that validated screening tools be used (rather than relying merely on casual observation) and that screening occur in a variety of care settings—prenatal, hospital, home, and pediatric office visits. The recommendation for prenatal screening is very important. Depression during pregnancy is common (11% to 23% of pregnant women experience depression), is a risk factor for adverse reproductive outcomes such as preterm delivery, and is among the strongest predictors of postpartum depression (Gaynes, et al., 2005; Yonkers, et al., 2009; Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). Kendall-Tackett describes three reliable screening tools—two of which (the Patient Health Questionnaire-2 and the Edinburgh Postnatal Depression Scale) are in the public domain. This excellent chapter would be improved further with information about how to implement perinatal mental health screening in various settings, including the need to build a breastfeeding-friendly referral network prior to initiating screening and the need to develop or obtain materials (e.g., brochures, handouts, posters, resource lists, referral lists) that provide anticipatory guidance and help parents more easily access information, support, and treatment for postpartum depression (Good Mojab, 2015).

In chapter 7, Kendall-Tackett presents the development of a breastfeeding-friendly treatment plan as being grounded in the facilitation of informed decision making—something perinatal care providers are ethically obligated to do. Informed decision making requires that parents be offered evidence-based information that will allow them to weigh the risks and benefits of a variety of treatment options. This final chapter presents such information in the form of a succinct review of the available research on treatments that have been shown to be effective in treating depression, including: 1) “alternative” treatments (i.e., long-chain omega-3 fatty acids, exercise, S-Adenosyl-L-Methionine, and bright light therapy), 2) psychotherapeutic treatments (i.e., cognitive behavioral therapy and interpersonal therapy), 3) herbal medications (i.e., St. John’s Wort); and 4) anti-depressant medications. The reader is referred to the Infant Risk Center for up-to-date information about the use of particular anti-depressant medications during breastfeeding. Additionally, Medications and Mothers’ Milk: A Manual of Lactational Pharmacology is listed among the references. The LactMed app, though not mentioned in the book, is another useful resource for facilitating informed decision making regarding the use of drugs and supplements during breastfeeding.

The appendices are helpful for readers who have not yet begun to screen for perinatal depression and are looking for appropriate screening tools. Included are the Postpartum Depression Predictors Inventory—which can be used to identify risk factors for postpartum depression—and the Edinburgh Postnatal Depression Scale—which is well-validated as a screening tool for perinatal depression in mothers, in many cultures and languages, and in fathers. (A gender/prenatal/postpartum inclusive version of the EPDS is available here.) Because postpartum depression often includes symptoms of anxiety and/or co-occurs with an anxiety disorder, the appendices would have been improved by including the well-validated Generalized Anxiety Disorder 7-item (GAD-7) Scale, which is also in the public domain.

Scattered throughout the book are links to video clips that provide information on topics such as how breastfeeding protects maternal mental health and how breastfeeding ameliorates the negative effects of sexual assault. Readers with an auditory learning style will especially appreciate this access to online interviews and mini-presentations. Unfortunately, the dark gray links on a light gray background can sometimes be hard to read, leaving the reader to wonder “is that character a capital I, a lowercase L, or a numeric 1?” But, the video resources are worth the trial and error needed to open a couple of the links. Those with access to a smartphone with a QR code reader or barcode scanner can simply scan the code for each video clip to open the links, which greatly simplifies the process.

While the title of the book, “A Breastfeeding-Friendly Approach to Postpartum Depression,” is gender neutral, readers should know that the book is focused on cisgender mothers and uses cisnormative language. Certainly, there is a dearth of research on transgender and gender non-conforming parents which makes it difficult to write an evidence-based book addressing their needs in the context of breastfeeding/chestfeeding and postpartum depression. Nonetheless, we can infer that the high rate of clinical depression (44.1%) among transgender individuals means that transgender parents are at high risk for postpartum depression. And, the fact that transgender individuals experience “gender insensitivity, displays of discomfort, denied services, substandard care, verbal abuse, and forced care” in health care settings (Bockting, et al., 2013) means that transgender parents are also at high risk of being unable to access effective mental health care, much less breastfeeding/chestfeeding-compatible mental health care. Perinatal care providers need to be aware of these higher risks and learn how to bring their services into compliance with the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (Bockting, et al., 2011). The lactation-friendly treatment options for postpartum depression that are reviewed in the book are likely to also be effective in transgender and gender non-conforming parents who breastfeed, chestfeed, or feed their expressed milk to their babies.”

Although written for health care providers, “A Breastfeeding-Friendly Approach to Postpartum Depression” will also be useful for childbirth educators, doulas, lay supporters, lactation specialists, and perinatal mental health care providers as they strive to do their part to offer families evidence-based anticipatory guidance about postpartum depression and its treatment options, advocate for more lactation support for families coping with breastfeeding difficulties, screen for postpartum depression, refer to and effectively collaborate with other breastfeeding-friendly perinatal care providers, and provide services that avoid iatrogenically increasing the risk of negative health, developmental, and mental health consequences for parents and babies through the unnecessary undermining of breastfeeding. The more widely Dr. Kendall-Tackett’s powerful little book is read and applied in practice, the more breastfeeding families will have access to breastfeeding-compatible treatment that truly meets their needs in the context of postpartum depression.

References

Bockting, W., Miner, M., Swinburne, R., Hamilton, A., and Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health, 103:943–951. Accessed: May 23, 2015. Url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698807/pdf/AJPH.2013.301241.pdf

Borra, C., Iacovou, M., and Sevilla, A. (2015). New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health Journal, 19:897–907. Url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353856/pdf/10995_2014_Article_1591.pdf

Coleman, E., Bockting, W., Botzer, M., et al. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13:165–232. Accessed May 23, 2015. Url: http://www.wpath.org/uploaded_files/140/files/IJT%20soc,%20v7.pdf

Gaynes, B., Gavin, N., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., Brody, S., Miller, W., et al. (2005). Perinatal depression: Prevalence, screening accuracy and screening outcomes;Evid Rep Technol Assess (Summ). 119:1–8.

Good Mojab, C. (2014). Mental Health Care for Postpartum Depression During Breastfeeding. Lynnwood, WA: LifeCircle Counseling and Consulting, LLC. Accessed May 23, 2015. Url: http://lifecirclecc.com/yahoo_site_admin/assets/docs/MentalHealthCarePPDBfd2014.pdf

Good Mojab, C. (2015). The Basics of Perinatal Screening. Accessed May 23, 2015. Url: http://www.lifecirclecc.com/professionals/perinatal_screening

Hale, T. and Rowe, H. (2014). Medications and Mothers’ Milk: A Manual of Lactational Pharmacology. Amarillo, TX: Hale Publishing.

Kendall-Tackett, K. (n.d). Why Breastfeeding and Omega-3s Help Prevent Depression in Pregnant and Postpartum Women. Accessed May 23, 2015. Url: http://www.uppitysciencechick.com/why_bfand_omega_3s.pdf

Kosenko, K., Rintamaki, L., Raney, S., and Maness, K. (2013). Transgender patient perceptions of stigma in health care contexts. Med Care, 51(9):819-22.

Nonacs, R. (2014). Breastfeeding and Postpartum Depression: Further Insights Into a Complicated Relationship. Massachusetts General Hospital Center for Women’s Mental Health. Accessed: May 23, 2015. Url: http://womensmentalhealth.org/posts/breastfeeding-postpartum-depression-insights-complicated-relationship/

Norhayati, M., Nik Hazlina, N., Asrenee, A., & Wan Emilin, W. (2014). Magnitude and risk factors for postpartum symptoms: A literature review. Journal of Affective Disorders, 175C, 34-52.

Yonkers, K. Wisner, K., Stewart, D. Oberlander, T., Dell, D., Stotland, N., Ramin, S., et al. (2009). The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 114(3):703–713. Accessed: May 28, 2015. Url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094693/pdf/nihms293837.pdf 

About Cynthia Good Mojab

cynthia good mojab headshot 2015Cynthia Good Mojab, MS Clinical Psychology, is a Clinical Counselor, International Board Certified Lactation Consultant, author, award-winning researcher, and internationally recognized speaker. She is the Director of LifeCircle Counseling and Consulting, LLC where she specializes in providing perinatal mental health care, including breastfeeding-compatible treatment for postpartum depression. Cynthia is Certified in Acute Traumatic Stress Management and is a member of the American Academy of Experts in Traumatic Stress and the National Center for Crisis Management. Her areas of focus include perinatal loss, grief, depression, anxiety, and trauma; lactational psychology; cultural competence; and social justice. She has authored, contributed to, and provided editorial review of numerous publications. Cynthia can be reached through her website.

 

Babies, Book Reviews, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Newborns, Perinatal Mood Disorders, Postpartum Depression, Uncategorized , , , , , , , ,

Celebrate International Day of the Midwife! ACOG Calls for Universal ICM Standards

May 5th, 2015 by avatar

Lamaze and Midwives IDM 2015Lamaze International and Science & Sensibility join with other partners around the world to celebrate International Day of the Midwife.  This global celebration is observed every year on May 5th and was officially recognized by the International Confederation of Midwives in 1992. (Read Judith Lothian’s report from the 2014 ICM Congress here.) This year’s theme is “The World Needs Midwives Today More Than Ever.”

Key midwifery concepts and model of care

Key midwifery concepts as defined by the International Confederation of Midwives describe the unique role that midwives have in providing care to women and families:

  • partnership with women to promote self-care and the health of mothers, infants, and families;
  • respect for human dignity and for women as persons with full human rights;
  • advocacy for women so that their voices are heard and their health care choices are respected;
  • cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
  • a focus on health promotion and disease prevention that views pregnancy as a normal life event;
  • advocacy for normal physiologic labour and birth to enhance best outcomes for mothers and infants.  (Fullerton, Thompson & Severino, 2011).

ACOG advocates universal standards

http://www.flickr.com/photos/eyeliam/

http://www.flickr.com/photos/eyeliam/

On April 20, 2015, the American College of Obstetricians and Gynecologists (ACOG) endorsed the International Confederation of Midwives education and training standards and suggested that this criteria be adopted as the minimum requirements for midwifery licensure in the United States.  ACOG “advocates for implementation of the ICM standards in every state to assure all women access to safe, qualified, highly skilled providers.” In the same document, ACOG calls for a single midwife credential.  Currently, in the USA there are certified nurse midwives (CNM), Certified Midwives (CM) and Certified Professional Midwives (CPM) and they all have different core competencies and educational requirements.  You can read the entire ACOG statement here.  This document is meant to accompany their Levels of Maternal Care statement that I wrote about in a previous blog post.  Both of these recent statements signify a recognition that families have choices about the type of health care provider they receive their maternity care from and that more and more families every year are choosing midwifery.

Five interesting facts about midwifery

  1. There are approximately 26,000 midwives in the USA.  This number includes Certified Nurse Midwives, Certified Midwives and Certified Professional Midwives.
  2. Midwives practice and catch babies in hospitals, birth centers and in families’ homes.
  3. Midwives who are educated and regulated to international standards can provide 87% of the essential care needed for women and newborns. (UNFPA, 2014)
  4. 11.3% of all babies born in the USA in 2013 were caught by midwives (Martin, Hamilton, Osterman, et al. 2015)
  5. Approximately 0.6% of all midwives in the USA are male. (Pinkerton, Schorn, 2008)

Summary

How are you celebrating International Day of the Midwife in your community and in your classes?  Have you reached out to the midwives in your community and let them know that they are appreciated?  Take a moment to do so and join Lamaze International in thanking midwives for helping families have safe and healthy  births.

References

Fullerton, J. T., Thompson, J. B., & Severino, R. (2011). The International Confederation of Midwives essential competencies for basic midwifery practice. An update study: 2009–2010. Midwifery, 27(4), 399-408.

Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2013. National vital statistics reports; vol 64 no 1. Hyattsville, MD: National Center for Health Statistics. 2015.

Pilkenton, D., & Schorn, M. N. (2008). Midwifery: a career for men in nursing.Men in Nursing Journal, 3(1), 32.

UNFPA. The State of the World’s Midwifery 2014. A Universal Pathway. A Woman’s Right to Health. United Nations Population Fund, New York; 2014

Breastfeeding, Home Birth, Midwifery, Uncategorized , , , , , , , , ,

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 , , , , , ,

Remembering Sheila Kitzinger – An Amazing Advocate for Women, Babies and Families

April 13th, 2015 by avatar

“Sheila Kitzinger is a giant upon whose shoulders we will stand on as we continue our important work for women and their babies. She will be sorely missed.” – Judith Lothian

SheilaKitzinger85Birthday_lSheila Kitzinger passed away on April 12th at her home in Oxfordshire, England after a short illness  Ms. Kitzinger was 86 years old. My eldest son, the father of four, forwarded me the BBC announcement. It shouldn’t have been a shock because I had heard she was very ill. But it is. We have lost a birth advocate who “rocked the boat” and taught the rest of us how to do it.

Kitzinger was an anthropologist and childbirth educator. As a childbirth educator, she pushed educators to go beyond just sharing knowledge, beyond just educating women about birth. She believed that we needed to confront the system in which birth takes place, to advocate in powerful ways so that women could give birth without being traumatized physically or emotionally. She wrote more than 25 books, an endless number of articles in scholarly journals, including her wonderful “Letter from Europe” column in Birth, and a steady stream of newspaper and magazine articles and letters to the editors. Her latest book, A Passion for Birth: My Life; Anthropology, Family, and Feminismher memoirs, will be published in the UK in June.

Sheila came to New York City in the 1970s several times. I was a young mother and new childbirth educator who knew nothing about Kitzinger before I heard her speak. Her passion, her knowledge, and her genuine interest in everyone she met inspired and motivated me, really all of us, to meet the challenges (and they were substantial) that we faced back then. I have spent the last 40 years reading literally everything Sheila Kitzinger has written. Many of those books and articles I have read over and over again, always learning something new. I consider Sheila Kitzinger one of my most important mentors, although we only spoke at length on four occasions in all those years.rediscovering birth kitzinger

With a handful of others, Kitzinger turned the world of birth upside down. Although we still have a long way to go, Sheila Kitzinger’s work has made contributions that simply cannot be measured. Kitzinger’s work going back to the 1970s on episiotomy and the value and importance of home birth were the start of what would become prolific contributions. Her books for women on pregnancy and childbirth, breastfeeding, sex and pregnancy, and the sexuality of birth and breastfeeding can’t be beat. Her work on post traumatic birth in the Uk was groundbreaking. Her books on the politics of birth, the culture of birth, becoming a mother, and becoming a grandmother are major contributions to the literature. Rediscovering Birth is a personal favorite. If that book doesn’t inspire women to think differently about birth, I don’t know what can!

sheila kitzinger 2The article that made the biggest difference in my life was “Should Childbirth Educators Rock the Boat?” published in Birth in 1993. At the time I was new to the Board of Directors of Lamaze International (then ASPO Lamaze) and was soon to become President of the organization. Kitzinger wrote powerfully of the need for childbirth educators to not just teach women about birth but to advocate within the system for change, to take strong stands in support of normal physiologic birth, home birth, and humane, empowering childbirth. Her call to action drove my own work within Lamaze. The result was a philosophy of birth that was courageous and groundbreaking and has driven the work of the organization since then. Advocacy is a competency of a Lamaze Certified Childbirth Educator and the mission of the organization clearly identifies the role of advocacy. Lamaze International’s six evidence based Healthy Birth Practices “rock the boat” of the standardized childbirth education class that creates good patients and hospitals that claim to provide safe care to women and babies. When The Official Lamaze Guide: Giving Birth with Confidence was first published in 2005, Sheila reviewed the book. In her review she wrote, “…It’s humane, funny, tender, down-to-earth and joyful. Essential reading for all pregnant women who seek autonomy in childbirth.” I wanted to tell her – “Without your passion and inspiration that book might not have been written.”

There are a number of other bits of wisdom from Kitzinger that I often quote. They have made a difference to me and, I suspect, to everyone who knows Sheila’s work.

  • What breastfeeding mothers need most is a healthy dose of confidence
  • Home birth should be a safe, accessible option for women
  • Touch in childbirth has changed from warm, human touch to the disconnected touch of intravenous, fetal monitors, blood pressure cuffs
  • Women know how to give birth
  • The clock is perhaps the most destructive piece of modern technology

Kitzinger gave me a healthy dose of confidence in myself and in the importance of what we do in small and big ways as we go about the work of changing the world of birth. She convinced me that talking about birth and writing about birth, even if only to the choir, makes a difference. We know we’re not alone and we become more passionate and more committed. We develop the courage to “rock the boat”.

Sheila Kitzinger is a giant upon whose shoulders we will stand on as we continue our important work for women and their babies. She will be sorely missed. May she rest in peace. Our deepest sympathies go out to her family and friends.

Do you have a memory or story to share about Sheila Kitzinger?  How has she or her work impacted you personally or professionally?  Share your stories in our comments section. – SM

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

Babies, Breastfeeding, Childbirth Education, Guest Posts, Healthy Birth Practices, Home Birth, Infant Attachment, Lamaze International, Maternity Care, Midwifery, Newborns , , , ,

New Webinar for Birth Pros: “Making It Work! – Breastfeeding Tips for the Working Mom”

March 24th, 2015 by avatar
breastfeeding working mother

flickr.com/photos/jennysbradford/4356862824

I often share in childbirth classes that breastfeeding can be the next big challenge after birth.  As a childbirth educator, I weave breastfeeding information throughout my class series. By the time the “breastfeeding” part of the class happens towards the end of the series, the families are eager and ready to learn how to be as prepared as possible to feed their baby, without actually having baby there yet to “practice” with.

I provide additional follow up resources for the families as well, including where to get help locally with breastfeeding issues, what current best practice says on a variety of breastfeeding topics and useful videos like effective hand expression.  Returning to work and breastfeeding is one topic that I feel is important to cover, but often gets short shrift due to lack of time. Families don’t even have their babies in their arms yet, and the “return to work” point still seems very far off, and I have a lot of information to share in a short class time. In some areas, there are specific classes that families can attend that specialize in the “breastfeeding for the working parent” topic, but not many families can locate or take advantage of this type of class.

I would love to be able to support my families long after their childbirth education class is over with information they can use and apply for the working/breastfeeding parent, and that is why I am planning on attending Lamaze International’s free (non-Lamaze members $20) 60 minute webinar “Making It Work! Breastfeeding Tips for the Working Mom” offered on March 26th at 1:00 PM EST.

It is well documented that exclusive breastfeeding rates drop significantly when women return to work or school.  There are many barriers to overcome and prenatal information and support can help families to prepare for the time when babies are being cared for by others and still being breastfed.  This online webinar is appropriate for doulas, childbirth educators, lactation consultants, nursing staff, physicians and midwives.

The webinar is being presented by Patty Nilsen, RN, BSN, BA, IBCLC, ANLC.  Patty is an Outpatient Lactation Consultant for Mount Carmel East, West & St. Ann’s Hospitals in Columbus, Ohio, where she provides daily private outpatient lactation consultation for women experiencing challenges and in need of encouragement with breastfeeding, leads weekly breastfeeding support groups, and answers over 300 breastfeeding helpline calls per month.  Patty has learned many innovative tips for returning to work and breastfeeding from the thousands of mothers she has worked with over the years and is eager to share them in this webinar.

© womenshealth.gov

© womenshealth.gov

The webinar is open to all, and Lamaze International members are able to attend at no cost.  Non-members will pay $20 at registration to participate.  Additionally, this workshop has been approved for continuing nursing education hours which  are accepted by DONA, Lamaze, ICEA and other birth professional organizations. The cost for receiving continuing education hours for Lamaze members is $35 and for non-members is $55, (which includes the cost of the webinar). As mentioned above, Lamaze members attend for free, if they are not enrolled for the contact hours.  Contact hours are awarded after completing the webinar and a post-webinar evaluation. CERPS are pending.

You can register for the webinar (select contact hours or no-contact hours) at this link – and then prepare to join on Thursday at 1:oo PM EST.  After the webinar, come back and share your top takeaways and how you are going to use this information to support families in your area with other Science & Sensibility readers.

Babies, Breastfeeding, Childbirth Education, Lamaze International, Webinars , , , , , , ,