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Report Finds Widespread Global Mistreatment of Women during Childbirth

July 2nd, 2015 by avatar
© Pawan Kumar

© Pawan Kumar

The journal PLOS Medicine published a research review yesterday, “The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Method Systematic Review” (Bohren, et al, 2015).  Reading this report was both disturbing and extremely sad to me. Respectful care is a part of the United Nations Millennium Development Goal Target 5A: Improve Maternal Health. – which set a goal of reducing the maternal mortality ratio (the number of deaths among women caused by pregnancy- or childbirth-related complications (maternal deaths) per 100,000 live births) by 75% from 1990 to 2015.  The target rate had been 95 pregnancy or childbirth related deaths per 100,000 women but the current rate is sitting at 210/100,000, which is just a 45% drop.  99% of all maternal deaths occur in low-income and middle-income countries, where resources are limited and access to safe, acceptable, good quality sexual and reproductive health care, including maternity care, is not available to many women during their childbearing year. The most common cause of these maternal deaths are postpartum hemorrhage, postpartum infection, obstructed labors and blood pressure issues – all conditions considered very preventable or treatable with access to quality care and trained birth attendants.

Analysis of reports examined in this paper indicate that “many women globally experience poor treatment during childbirth, including abusive, neglectful, or disrespectful care.” This treatment can further complicate the situation downstream, by creating a disincentive for women to seek care from these facilities and providers in future pregnancies.

The reports and studies that were reviewed to create this report obtained their information from direct observation, interviews with women under care,  and were self-reported by the mothers.  Follow-up surveys were also conducted.

From the qualitative research, investigators were able to classify the mistreatment  into seven categories:

  1. physical abuse
  2. sexual abuse
  3. verbal abuse
  4. stigma and discrimination
  5. failure to meet professional standards of care
  6. poor rapport between women and providers
  7. health system conditions and constraints

The quantitative research revealed two themes: sexual abuse and the performance of unconsented surgical operations.

World Bank Photo Collection http://flickr.com/photos/worldbank/7556637184 shared under a Creative Commons (BY-NC-ND) license

It is no surprise that women’s experiences were negatively impacted by the mistreatment they received during their maternity care treatment period.  Some of the treatment was one on one – from the care provider to the mother, while other inappropriate treatment was on a facility level.

Investigation of the treatment of women during pregnancy and childbirth was conducted because it is known that care by a qualified attendant can significantly impact maternal mortality, but if women are disinclined to seek out appropriate care due to a fear of mistreatment, help is not available or utilized and mortality rates rise.  Removing this obstacle is key to reducing maternal deaths.

Prior experiences and perceptions of mistreatment, low expectations of the care provided at facilities, and poor reputations of facilities in the community have eroded many women’s trust in the health system and have impacted their decision to deliver in health facilities in the future, particularly in low- and middle-income countries Some women may consider childbirth in facilities as a last resort, prioritizing the culturally appropriate and supportive care received from traditional providers in their homes over medical intervention. These women may desire home births where they can deliver in a preferred position, are able to cry out without fear of punishment, receive no surgical intervention, and are not physically restrained. – Bohren, et al.

Women who are mistreated during childbirth obviously reflects a quality of care issue, but also a larger scale- a fundamental human rights issue.  International standards are clear that this is not acceptable.  The researchers encourage the use of their finding to assist in the development of measurement tools that can be used to inform policies, standards and improvement programs.

We must seek to find a process by which women and health care providers engage to promote and protect women’s participation in safe and positive childbirth experiences. A woman’s autonomy and dignity during childbirth must be respected, and her health care providers should promote positive birth experiences through respectful, dignified, supportive care, as well as by ensuring high-quality clinical care. – Bohren, et al.

I encourage you to read the study for a thorough review of the research findings.  The information is difficult to fully take in. Additionally, a companion paper  – “Mistreatment of Women in Childbith: Time for Action on this Important Dimension of Violence against Women” provides further information.  The New York Times covered this topic in their June 30th Health Section. The World Health Organization also covered this report and has a statement on this issue, endorsed by over 80 organizations, including Lamaze International.  The WHO also has a list of videos on the topic of abuse and mistreatment of women during pregnancy and childbirth that can be found here.

References

Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. (2015) The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med 12(6): e1001847. doi:10.1371/journal.pmed.1001847

Jewkes R, Penn-Kekana L (2015) Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women. PLoS Med 12(6): e1001849. doi:10.1371/journal.pmed.1001849

Do No Harm, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, New Research, News about Pregnancy, Research , , , , , ,

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 for transgender and gender non-conforming parents who breastfeed, chestfeed, or feed their expressed milk to their babies. The effective treatment of breastfeeding/chestfeeding parents with postpartum depression will also need to include responding to whether and how they are experiencing gender dysphoria during lactation.

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 , , , , , , , ,

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 non-living, 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 “desert” of your skin to the warm, wet, nutrient-rich “lake” of your mouth, specific bacteria live in different regions on a person, just as specific vertebrate animals live in different ecosystems on the Earth (Figure 1, left and center). 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 microbiome 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] (Figure 2, left). 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] (Figure 2, right). 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.

Fig2_MicrobirthVagvC5

 

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] (Figure 3).

Fig3_Locations4

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

Fig4_MicrobirthBreastvBottle5First foods are another influence on the infant microbiome. Breastfed infants have two “moms:” their human mother and their Milk-Oriented Microbiota (MOM) (Figure 4, left). The MOM are beneficial, protective bacteria in the infant’s gut that thrive when fed the sugars in breast milk [19]. Although human milk oligosaccharides (HMOs) are the third most abundant component of breast milk, the infant cannot digest these sugars. Instead, HMOs are a natural prebiotic or “bacterial food”. Various HMO sugar types and concentrations influence bacterial diversity, keeping strains of Bifidobacterium longum subsp infantis in highest abundance in the first few months of life and preventing pathogens from binding to the gut [20]. HMOs vary between pre-term and full term birth, vaginal deliveries and planned Cesarean births (reviewed in [20]), and even between mothers with different types of “secretor” genes [21]. Does this HMO variability serve to maintain and enhance some of the differences in bacterial communities between individuals? In addition to the MOM, a diversity and abundance of bacteria are found in breast milk. The average breastfed baby is exposed to between 1 and 10 million bacteria daily from their mother’s milk [5]! The breast milk microbiome is a unique assemblage of bacteria, distinct from human skin, gut, oral, vaginal, and other specific body site microbiomes [4]. Like other components of breast milk, the bacterial community changes dramatically between colostrum and mature milk with colostrum being the most diverse with over 1,000 different bacterial types [4]. Although only ten women were followed, it is intriguing that the breast 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 moms undergoing unplanned Cesarean and vaginally delivering mothers were most similar [4]. How the presence of different microbes influences the developing human infant immune system has yet to be determined. Additionally, does the breast milk bacteria colonize the infant gut or are they digested? Could breast milk bacteria change how the MOM infant gut microbiome works as they pass through the gut, as one probiotic does in elderly patients [22]?

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, 23] (Figure 4, right). 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 [24]. 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 [25]. A separate study found infants whose gestation lengths were less than 38 weeks had microbiome communities that were low in Bifidobacterium and took 3 to 6 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 led 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, episiotomies, 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. Zivkovic, A. M., Z. T. Lewis, J. B. German, and D. A. Mills. 2013. Establishment of a Milk-Oriented Microbiota (MOM) in Early Life: How Babies Meet Their Moms. Functional Food Reviews 5:3-12.
  20. 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.
  21. 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.
  22. Eloe-Fadrosh, E. A., A. Brady, J. Crabtree, E. F. Drabek, B. Ma, A. Mahurkar, J. Ravel, M. Haverkamp, A.-M. Fiorino, C. Botelho, et al. 2015. Functional Dynamics of the Gut Microbiome in Elderly People during Probiotic Consumption. mBio 6.
  23. 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.
  24. 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.
  25. 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 , , , , , ,

Exclusive Q&A with Rebecca Dekker – What Does the Evidence Say about Induction for Going Past your Due Date?

April 15th, 2015 by avatar

What does the evidence say about dueToday on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review –  Induction for Going Past your Due Date: What does the Evidence Say?  I had an opportunity to preview the article and ask Rebecca some questions about her most recent project on due dates. I would like to share our conversation here on Science & Sensibility with all of you. Rebecca’s website has become a very useful tool for both professionals and consumers to read about current best practice.Consumers can gather information on the common issues that they maybe dealing with during their pregnancies. Professionals can find resources and information to share with students and clients.  How do you cover the topic of inductions at term for due date?  After reading today’s S&S post and Rebecca’s research post, do you think you might share additional information or change what you discuss?  Let us know in the comments section.- Sharon Muza, Community Manager, Science & Sensibility.

Note: if the Evidence Based Birth post is not up yet, try again in a bit, it should be momentarily.

Sharon Muza: Why did you decide to tackle the topic of due dates as your next research project and blog post?

Rebecca Dekker: Last year, I polled my audience as to what they would like me to write about next. They overwhelmingly said that they wanted an Evidence Based Birth article about Advanced Maternal Age (AMA), or pregnancy over the age of 35. As I started reviewing the research on AMA, it became abundantly clear to me that I had to first publish an article all about the evidence on due dates. This article on induction for due dates creates a solid foundation on which my readers can learn about induction versus waiting for spontaneous labor in pregnant women who are over the age of 35.

SM: When you started to dig into the research, were there any findings that surprised you, or that you didn’t expect?

RD: There were two topics that I really had to dig into in order to thoroughly understand.

The first is the topic on stillbirth rates. I began to understand that it’s really important to know which mathematical formula researchers used to calculate stillbirth rates by gestational age. It was interesting to read through the old research studies and letters to the editors where researchers argued about which math formulas were best. In the end, I had to draw up diagrams of the different formulas (you can see those diagrams in the article) for the formulas to make sense in my head, and once I did, the issue made perfect sense!

Before 1987 (and even after 1987, in some cases) researchers really DID use the wrong formulas, and it’s kind of funny to think that for so many years, they used the wrong math! In general, I thought the research studies on stillbirth rates by gestational age were really interesting…it raised questions for me that I couldn’t answer, like why are the stillbirth rates so different at different times and in different countries? Also, it was really clear from the research that stillbirth rates are drastically different depending on whether you are looking at samples that include or don’t include babies who are growth-restricted.

The other big breakthrough or “ah ha” moment I had was when I finally realized the true meaning of the Hannah (1992) Post-Term study. There was such a huge paradox in their findings… why did they find that the expectant management group had HIGHER Cesarean rates, when clinicians instinctively know that inductions have higher Cesarean rates compared to spontaneous labor? Since all of the meta-analyses rely heavily on the Hannah study, I knew I needed to figure this problem out.

There are a couple different theories in the literature as to why there were higher C-section rates in the expectant management group in Hannah’s study. One theory is that the induction group had Prostaglandins to ripen the cervix, while the expectant management group did not. However, in a secondary data analysis published by Hannah et al. in 1996, they found that this probably played just a minor role.

Another theory is that as women go further along in their pregnancy, physicians get more nervous about the risk of stillbirth, and so they may be quicker to recommend a Cesarean in a woman who is past 42 or 43 weeks, compared to one who is just at 41 weeks. This theory has been proposed by several different researchers in the literature, and there is probably some merit to it.

But in the end, I found out exactly why the C-section rates are higher in the expectant management group in the Hannah Post Term study (and thus in every meta-analysis that has ever been done on this topic). Don’t you want to know why? I finally found the evidence in Hannah’s 1996 article called “Putting the merits of a policy of induction of labor into perspective.” The data that I was looking for were not in the original Hannah study… they were in this commentary that was published several years later.

dekker headshotThe reason that Cesarean rates were higher in the expectant management group in the Hannah study is because the women who were randomly assigned to wait for spontaneous labor, but actually ended up with inductions, had Cesarean rates that were nearly double of those among women who had spontaneous labor. Some of these inductions were medically indicated, and some of them were requested by the mother. In any case, this explains the paradox. It’s not spontaneous labor that leads to higher Cesarean rates with expectant management… the higher Cesarean rates come from women who wait for spontaneous labor but end up having inductions instead. 

So the good news is that if you choose “expectant management” at 41-42 weeks (which is a term that I really dislike, because it implies that you’re “managing” women, but I digress), your chances of a Cesarean are pretty low if you go into spontaneous labor. But if you end up being one of the women who waits and then later on chooses to have an induction, or ends up with a medically indicated induction, then your chances of a Cesarean are much higher than if you had just had an elective induction at 41 weeks.

SM: What information do you recommend that childbirth educators share to help families make informed decisions about inductions and actions to take as a due date comes and then even goes, and they are still pregnant.

RD: First of all, I think it’s important for all of us to dispel the myth of the 40 week due date. There really is no such thing as a due date. There is a range of time in which most women will go into labor on their own. About half of women will go into labor by 40 weeks and 5 days if you’re a first-time mom (or 40 weeks and 3 days if you’ve given birth before), and the other half will go into labor after that.

The other thing that it is important for childbirth educators to do is to encourage families—early in pregnancy—to talk with their health care provider about when they recommend induction, and why.

There are some health care providers who believe strongly that induction at 39, 40, 41, or 42 weeks reduces the risk of stillbirth and other poor outcomes. There are parents who have the same preference. Then there are other health care providers who believe strongly that induction for going past your due date is a bad thing, and shouldn’t be attempted unless there are clear medical reasons for the induction. And there are parents who will tend to share that same preference. Either way, parents need accurate information about the benefits and risks of waiting versus elective induction at 41-42 weeks—because both are valid options.

But it’s probably best to avoid a mismatch between parents and providers. If parents believes strongly that they want to wait for spontaneous labor, and they understand the risks, but they have a care provider who believes strongly in elective induction at 41 weeks, then they will run into problems when they reach 41 or 42 weeks and their care provider disagrees with their decision.

Clearly, there are benefits to experiencing spontaneous labor and avoiding unnecessary interventions. But at the same time there is a rise in the relative risk of stillbirth starting at about 39 weeks, depending on which study you are looking at. However, the overall risk is still low up until 42 weeks. At 42 weeks, the risk of stillbirth rises to about 1 in 1,000 in babies who are not growth-restricted. The risk may be higher in some women who have additional risk factors for stillbirth. Women who experience post-term pregnancy (past 42 weeks) are more likely to experience infections and Cesareans, and their infants are more likely to experience meconium aspiration syndrome, NICU admissions, and low Apgar scores.

SM: Would you recommend that families have conversations about how their due date is being calculated, at the first prenatal with their health care providers. What should that conversation include?

RD: I would recommend asking these questions:

  • What is the estimated date range that I might expect to give birth—not based on Naegele’s rule, but based on more current research about the average length of a pregnancy?
  • Did you use my Last Menstrual Period or an early ultrasound to determine my baby’s gestational age?
  • Has my due date been changed in my chart at any point in my pregnancy? If so, why?

SM: The concept of being “overdue” if still pregnant at the due date is firmly ingrained in our culture. What do you think needs to happen both socially and practically to change the way we think about the “due date?”

RD: We need to start telling everyone, “There is no such thing as a due date.” To help women deal with the social pressure they may experience at the end of pregnancy, I’ve created several Facebook profile photos that they can use as their Facebook profile when they get close to their traditional “due date.” To download those photos, visit www.evidendebasedbirth.com/duedates

SM: How available and widely used are first trimester ultrasounds? If first trimester ultrasounds were done as the standard of care in all pregnancies, would it result in more accurate due dates and better outcomes? Do you think there should be a shift to that method of EDD estimation?

RD: I think the option of having a first trimester ultrasound definitely needs to be part of the conversation between a woman and her care provider, especially because it has implications for the number of women who will be induced for “post-term.” I could not find any data on the percentage of women who have an ultrasound before 20 weeks, but in my geographic area it seems to be nearly 100%, anecdotally.

If your estimated due date is based on your LMP, you have a 10% chance of reaching the post-term period, but if it’s based on an early ultrasound, you only have a 3% chance of reaching 42 weeks.

One strange thing that I noted is that ACOG still prefers the LMP date over an early ultrasound date. They have specific guidelines in their practice bulletin about when you need to switch from the LMP date to an ultrasound date, but the default date is still the LMP. I found that rather odd, since research is very clear that ultrasound data is more accurate than the LMP, for a host of reasons!

Before I published the due dates article, I reached out to Tara Elrod, a Certified Direct Entry Midwife in Alaska, to get her expert feedback as a home birth midwife. She raised an excellent point:

“It is of significant interest to me as a licensed midwife practicing solely in the Out-of-Hospital setting that ultrasounds done in early pregnancy are more accurate than using LMP. If early ultrasound dating was achieved, it’s thought that this would ultimately equate to less women being induced for post-term pregnancy. This is significant to midwives such as myself due to the scope-of-care regulation of not providing care beyond 42 weeks. While an initial- and perhaps arguably by some ‘elective’ ultrasound-  may not be a popular choice in the midwife clientele population, a thoughtful risk versus benefit consideration should occur, as to assess the circumstance of “risking out” of care for suspected post-dates. [In my licensing state, my scope of care is limited to 37+0 weeks to 42+0 weeks, with the occasional patient reaching 42 weeks and therefore subsequently “risking out,” necessitating a transfer of care.]” ~Tara Elrod, CDM

SM: What do you think the economic cost of inductions for due dates is? The social costs? What benefits might we see if we relied on a better system for determining due dates and when to take action based on being postdates?

RD: There are economic costs to both elective inductions and waiting for labor to start on its own. The Hannah Post-Term trial investigators actually published a paper that looked at the cost effectiveness of their intervention, and they found that induction was cheaper than expectant management. This was primarily because with expectant management, there were extra costs related to fetal monitoring (non stress tests, amniotic fluid measurements, etc.) and the increased number of Cesareans in the expectant management group.

But there are many unanswered questions about the cost-effectiveness of elective induction of labor versus waiting for labor to begin (with fetal monitoring), so I’m afraid I can’t make any definitive statements or projections about the economic and social costs of elective inductions. Here is a study that may be of interest to some with further information on this topic.

I do know that in a healthy, low-risk population, birth centers in the National Birth Center Study II provided excellent care at a very low cost with women who had spontaneous births all the way up to 42 weeks. I would love to see researchers analyze maternal and neonatal outcomes in women stratified by gestational age in the Perinatal Data Registry with the American Association of Birth Centers.

 SM: I very much look forward to all your research posts and appreciate the work  and effort you put into doing them. What is on your radar for your next piece?

RD: The next piece will be Advanced Maternal Age!! After that, I will probably be polling my audience to see what they want, but I’m interested in tackling some topics related to pain control (epidurals and nitrous oxide) or maybe episiotomies.

SM: Is there anything else that you want to share about this post or other topics?

RD: No, I would just like to give a big thank you to everyone who helped in some way or another on this article!! There was a great interdisciplinary team who helped ensure that the due dates article passed scrutiny—we had an obstetrician, family physician, nurse midwife, several PhD-prepared researchers, and a certified direct entry midwife all provide expert review before the article was published. I am so thankful to all of them.

References

Hannah, M. E., C. Huh, et al. (1996). “Postterm pregnancy: putting the merits of a policy of induction of labor into perspective.” Birth 23(1): 13-19.

Hannah, M. E., W. J. Hannah, et al. (1992). “Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group.” N Engl J Med 326(24): 1587-1592.

 

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, informed Consent, Maternal Quality Improvement, Maternity Care, New Research, Research , , , , ,

Birth By The Numbers Releases New Video – Myth and Reality Concerning US Cesareans

March 19th, 2015 by avatar

birth by numbers header

I have been a huge fan of Dr. Eugene Declercq and his team over at Birth by the Numbers ever since I watched the original Birth by the Numbers bonus segment that was found on the Orgasmic Birth DVD I purchased back in 2008.  I was on the board of REACHE when we brought Dr. Declercq to Seattle to speak at our regional childbirth conference in 2010 and since then have heard him present at various conferences around the country, including most recently at the 2014 Lamaze International/DONA International Confluence, where Dr. Declercq was a keynote speaker.  I enjoy listening to him just as much now as I did back in 2008.  You  may also be familiar with Dr. Declercq’s work as part of the Listening to Mothers research team that has brought us three very valuable studies.

Birth by the Numbers has grown into a valuable and up to date website for the birth professional and the consumer, filled to the brim with useful information, videos, slide presentations and blog posts.  This past Tuesday, the newest video was released on the website: Birth By The Numbers: Part II – Myth and Reality Concerning US Cesareans and is embedded here for you to watch.  We shared Part I in a blog post last fall.


Also available for public use is a slide presentation located in the the “Teaching Tools” section of the Birth by the Numbers website designed to provide additional information, maps, data and resources for this new Myths and Reality Concerning Cesareans video. Included in this slideshow are notes and updates to help you understand the slides and share with others.  This material is freely given for your use.

© Birth by the Numbers

© Birth by the Numbers

This video explores how cesareans impact maternity care systems in the USA.  After watching the video and reviewing the slides, here are some of my top takeaways.

1.  The common reasons given for the nearly 33% cesarean rate in the USA (bigger babies, older mothers, more mothers with obesity, diabetes and hypertension, more multiples and maternal request) just don’t hold water when examined closer.

2. Many women feel pressure from their healthcare provider to have a cesarean, either prenatally or in labor.

3. The leading indicators for cesareans are labor arrest (34%) and nonreassuring fetal heart tracings (23%).

4. The rise in cesareans is not a result of a different indications.  Dr. Declercq quotes a 20 year old article’s title that could still grace the front pages today. “The Rise in Cesarean Section Rate: the same indications – but a lower threshold.”

5. When examining the distribution of cesarean births by states over time, it is clear that those states with the highest cesarean birth rate decades ago, still remain in those spots today.

6. “We are talking about cultural phenomena when we are talking about cesareans, not just medical phenomena.”

7. First time, low risk mothers who birthed at term and experienced labor had a 5% cesarean rate if they went into spontaneous labor and did not receive an epidural.  If they were induced and received an epidural, the cesarean rate was 31%.

8. The United States has the lowest VBAC rate of any industrialized country in the world.

© Birth by the Numbers

© Birth by the Numbers

While the video is rich (and heavy) in data laden charts and diagrams, the message, though not new, is clear.  The US maternity care system is in crisis.  We have to right the ship, and get back on course for healthier and safer births for pregnant people and babies. Take a look at this new video, and think about what messages you can share with the families you work with and in the classes you teach, to help consumers make informed choices about the care they receive during the childbearing year.

Please watch the video, visit the website to view the slides and let me know here in the comments section what you are going to use from this information to improve birth.

Babies, Cesarean Birth, Childbirth Education, informed Consent, Maternal Obesity, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research , , , ,

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