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New Research: Majority of Preeclampsia-Related Maternal Deaths Deemed Preventable

May 12th, 2015 by avatar

By Eleni Z. Tsigas

Preeclampsia Awareness Month 2015May is Preeclampsia Awareness Month and the journal Obstetrics and Gynecology highlighted some new research published by doctors and researchers at the California Maternal Quality Care Collaborative that demonstrated that the majority of preeclampsia-related deaths could have been prevented.  This is significant because preeclampsia is one of the top perinatal causes of death. Today on Science & Sensibility, Preeclampsia Foundation Executive Director Eleni Z. Tsigas provides an update on this new research and important facts that birth professionals should know.  As childbirth educators, along with teaching families about normal labor and birth, we have an obligation to share information about warning signs and potential complications.  While not as much “fun” as teaching how to cope with a contraction, it is equally important.  Have you checked out the information available at the Preeclampsia Foundation‘s website?  There is a great short video, class tear sheets and even information en español.  How do you teach about preeclampsia to the families that you work with?  Let us know in the comments section. – Sharon Muza, Science & Sensibility Community Manager

Research published in the April 2015 issue of Obstetrics & Gynecology shows that 60 percent of preeclampsia-related maternal deaths were deemed preventable. This large study – Pregnancy-Related Mortality in California: Causes, Characteristics, and Improvement Opportunities – analyzed U.S. pregnancy-related mortality administrative reports and medical records for each maternal death to identify the causes and contributing factors, and improve public health and clinical practices.

Over the last 20 years, a previous decline in maternal deaths has reversed and is cause for concern. The 2009 U.S. pregnancy-related mortality rate was 17.8 deaths per 100,000 live births, up from 7.7 per 100,000 in 1997 and above that of other high-resource countries.

One of every eight U.S. births occurs in California, resulting in more than 500,000 annual deliveries with extensive racial and ethnic diversity. With California’s large population-based sample, this study provides a unique opportunity to compare major causes of pregnancy-related mortality and identify improvement opportunities.

Preeclampsia-related maternal death deemed most preventable

Among the 207 pregnancy-related deaths from 2002 to 2005 studied in California, preeclampsia or eclampsia were identified as one of the five leading causes. The others were cardiovascular disease, hemorrhage, venous thromboembolism, and amniotic fluid embolism.

Of the five leading causes of death, preeclampsia was deemed one of the most preventable – preeclampsia-related deaths had a good-to-strong chance of preventability, estimated at 60%.

Healthcare provider factors were the most common type of contributor, especially delayed response to clinical warning signs followed by ineffective care.

Patients play important role in preventing preeclampsia-related deaths 

The leading patient factors among preeclampsia deaths were delays in seeking care (42%), presumed lack of knowledge regarding the severity of a symptom or condition (39%), and underlying medical condition (39%).

Preeclampsia deaths were most common among foreign-born Hispanic and African American women and associated with early gestational age, consistent with studies demonstrating the increased severity of early-onset preeclampsia.

These findings illustrate the need for public health interventions aimed at helping all women understand and recognize their risks and attain optimal pre-pregnancy health and weight.

It’s worth noting that since the study period, patient awareness has improved, led by several Preeclampsia Foundation education initiatives – currently preeclampsia awareness among pregnant women is 83%, according to a survey conducted last year by BabyCenter®.

The findings also underscore the need for focused approaches to improve care such as hospital-based safety bundles as well as comprehensive programs for patient education, communication, and teamwork development. Read the full report here.

Maternal health improvement initiatives underway 

As these Pregnancy-Related Mortality research findings are announced, several states have already moved forward with maternal health improvement initiatives. Recently the California Maternal Quality Care Collaborative (CMQCC), Hospital Corporation of America, and the American College of Obstetricians and Gynecologists released guidelines and quality improvement toolkits with standardized approaches to recognize and treat severe hypertension, and to increase awareness of atypical clinical presentations and patient education.

CMQCC’s Preeclampsia Toolkit incorporated the Preeclampsia Foundation’s Illustrated Symptoms Tear Pad that effectively informs women who are pregnant or recently gave birth about preeclampsia, which can strike up to six weeks after delivery. Developed by the Preeclampsia Foundation and researchers at Northwestern University Feinberg School of Medicine, the tear pad uses illustrations to describe the symptoms of preeclampsia so they are easily understandable, especially for those with poor health literacy. This toolkit is freely available online and has been downloaded by over 5,100 persons in the United States and more than 60 other countries. It is also being implemented in more than 150 California hospitals as part of the California Partnership for Maternal Safety.

In the year since implementing a Severe Maternal Morbidity Pre- and Post-Toolkit, CMQCC has noted a 34% reduction in maternal adverse outcomes. After implementing Pre- and Post-Hypertension Bundles, the rate of eclampsia has decreased by 31%.

New York joins California in distributing the tear pad throughout the state – as part of a statewide Maternal Preeclampsia Initiative, the New York State Perinatal Quality Collaborative, an initiative of the New York State Department of Health and the New York State Partnership for Patients – has adopted this patient education tool, making it available to all New York birthing facilities.

The Preeclampsia Foundation is proud to play a role in reversing the rate of maternal mortality and severe morbidity; it’s a team effort that requires the combined efforts of public health, clinical and hospital leaders and their institutions, and professional and consumer organizations.

References

Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., & Lawton, E. S. (2015). Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstetrics & Gynecology, 125(4), 938-947.

About Eleni Z. Tsigas

G8FK7644Eleni Z. Tsigas is the Executive Director of the Preeclampsia Foundation. Prior to this position, she served in a variety of volunteer capacities for the organization, including six years on the Board of Directors, two as its chairman. Working with dedicated volunteers, board members and professional staff, Eleni has helped lead the Foundation to its current position as a sustainable, mission-driven, results-oriented organization.

As a preeclampsia survivor herself, Eleni is a relentless champion for the improvement of patient and provider education and practices, for the catalytic role that patients can have to advance the science and status of maternal-infant health, and for the progress that can be realized by building global partnerships to improve patient outcomes.

She has served as a technical advisor to the World Health Organization (WHO) and participated in the Hypertension in Pregnancy Task Force created by the American College of Obstetricians and Gynecologists to develop the national guidelines introduced in 2013, as well as a similar task force for the California Maternal Quality Care Collaborative (CMQCC). Eleni also serves on the National Partnership for Maternal Safety initiative, the Patient Advisory Board of IMPROvED (IMproved PRegnancy Outcomes via Early Detection), Ireland, and the Technical Advisory Group and Knowledge Translation Committee for PRE-EMPT (funded by the Bill & Melinda Gates Foundation). Eleni is frequently engaged as an expert representing the consumer perspective on preeclampsia at national and international meetings, and has been honored to deliver keynote addresses for several professional healthcare providers’ societies.

Eleni has collaborated in numerous research studies, has authored invited chapters and papers in peer-reviewed journals, and is the Principal Investigator for The Preeclampsia Registry.

A veteran of public relations, she has secured media coverage about preeclampsia in national consumer magazines, as well as newspapers, radio and online. Eleni previously spent 8 years executing and managing strategic communications and public relations for technology and biotech companies with Waggener Edstrom Worldwide and for 6 years prior in the television industry.

She is married, and has had two of her three pregnancies seriously impacted by preeclampsia. 

 

Childbirth Education, Guest Posts, Maternal Quality Improvement, Maternity Care, Pre-eclampsia, Research , , , ,

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

May 7th, 2015 by avatar

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

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

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

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

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

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

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

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

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

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

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

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

Kim James' well read Birth  Ambassadors

Kim James’ well read Birth Ambassadors

First dilemma

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

Second dilemma

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

Third dilemma

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

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

Book club discussion questions

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

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

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

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

About Kim James 

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

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

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 , , , ,

Advocacy: Lamaze International Leaders on Capitol Hill

April 7th, 2015 by avatar

By John Richardson, Director, Government Relations, Lamaze International

I am proud of being both a member of Lamaze International and a Lamaze Certified Childbirth Educator for many reasons.  Today’s post by John Richardson, Lamaze International’s Director of Government Relations is just one reason why I am happy to pay my membership dues and be a part of the Lamaze organization.  Lamaze is actively working in both the private sector and with public/governmental leaders to help every family to have access to the resources to have a safe and healthy birth.  Today on the blog, we share about how our Board of Directors met with Congressmen and Congresswomen to share the importance of an evidence based childbirth education class being available to all families.  My certifying organization works hard for me and the families I teach every day.  – Sharon Muza, Science & Sensibility Community Manager.

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Lamaze BoD on Capitol Hill, 2015

Advocacy is a foundational element of the Lamaze International mission to advance safe and healthy pregnancy, birth and early parenting through evidence-based education and advocacy. Assisting women and their families to make informed decisions for childbearing and acting as an advocate to promote, support, and protect safe and healthy birth are two core competencies of a Lamaze Certified Childbirth Educator.

Advocacy comes in many different forms. The new Lamaze Strategic Framework specifically calls for taking advocacy efforts to the next level, focusing on government and legislative advocacy — leveraging strategic partnerships to advocate for perinatal/childbirth education coverage under the Affordable Care Act (ACA) and partnering with insurance companies, including the Centers for Medicaid and Medicare Services (CMS), to become part of the “bundled care” system. (Bundled care payment programs refer to the concept of grouping together the multiple services associated with a certain health “episode” versus the current fee for service system where each service associated with a condition is charged separately, and is one of the ACA’s many attempts to incentivize health care providers to be more cost efficient.)

BoD President Robin Elise Weiss and BOD Christine Morton

BoD President Robin Elise Weiss and BOD Christine Morton

Over the years, Lamaze has been involved in a variety of coalition and advocacy efforts related to improving access to high-quality maternity care that includes evidence based childbirth education by qualified educators and the promotion of breastfeeding within the health care industry. These efforts will continue with Lamaze taking its message directly to Capitol Hill to have a stronger voice with federal policymakers on behalf of the organization, its members, and the women and families that Lamaze serves. We want to let Congress know that Lamaze International provides gold standard childbirth education which can play an important role in promoting healthier outcomes for mother and baby and reducing healthcare costs and burdens on the healthcare system.

What does advocacy look like?

Advocacy campaigns at the federal level in the United States are typically a set of actions targeted to create support for a specific policy or proposal. The goals of an advocacy campaign may include drafting and passing a new law, drafting and passing amendments to existing laws, commenting on regulation, or influencing public perception and awareness of a particular issue.

Why is advocacy important for Lamaze?

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Board member Alice Turner

The delivery of health care is one of the most regulated industries in the United States. State and federal regulations often define whether services are covered by insurance, which practitioners are allowed to deliver services, the manner in which services are delivered, and how much individual practitioners and health care organizations are reimbursed. Naturally, there are a lot of people and organizations invested in steering and influencing these policies. There are literally thousands of issues and groups vying for policymakers’ attention. For Lamaze, it is critical to engage directly in advocacy activities so that policymakers become aware of the issues that are important to our organization and make them priorities.

There have been several recent successful advocacy initiatives to improve care for pregnant and postpartum women. For example, Lamaze has worked in collaboration with other organizations and lawmakers to improve breastfeeding services under the Affordable Care Act. As a result, there are several benefits now available to women who receive coverage through the Health Insurance Marketplaces (exchanges) and private non-grandfathered plans. Benefits such as lactation support and counseling by trained professionals are now covered without co-pay or co-insurance. Breast pumps are also covered at no charge and most employers must provide access to clean and private locations to pump for women who are hourly employees.

These victories are impressive and it is important to note that they did not occur in a vacuum. Advocates flooded the halls of Congress for years to ensure that policymakers appreciated the importance of breastfeeding. A key component of the success of these advocacy efforts was that they were based on research, focused on higher quality health outcomes, and provided fiscal benefits to the health care system and the federal government.

The Lamaze Board of Directors’ “Hill Day”

cbe graphicBearing all this in mind and in conjunction with their in-person meeting in Washington, DC, members of the Lamaze Board of Directors took to Capitol Hill on March 19, 2015 to meet with their Representatives and Senators about the excellent childbirth education that Lamaze provides and its potential to reduce costs and improve outcomes. The members of the Board met with a total of 23 Congressional offices, the majority of whom sit on committees with jurisdiction over health policy.

Our advocacy efforts on Capitol Hill centered on the following core messages:

  1. Promoting greater utilization of evidence-based childbirth education is a critical element in closing quality outcomes gaps and reducing unnecessary costs. In the face of high rates of cesarean sections, early inductions, and maternal/infant mortality, there is an increasing imperative for women to be informed and in charge of their maternity care to improve birth outcomes.

Maternal or neonatal hospital stays make up the greatest proportion of hospitalizations among infants, younger adults and patients covered by private insurance and Medicaid, which is why improvements in care are a major opportunity to reduce overall healthcare spending. Increasing quality outcomes by reducing the rates of unnecessary interventions, such as early induction of labor and cesarean section, are critical to reduce healthcare spending, particularly with Medicaid.

  1. The ACA has provided an opportunity for millions of uninsured Americans to access health care coverage through the creation of the exchanges. For those that do not enroll in a plan during the “open” enrollment period, there are qualifying “life events” that trigger special enrollment periods. One of those life events is when a woman gives birth. After the birth, the mother can sign herself and her infant up for coverage.

Lamaze believes, along with many others, that pregnancy, rather than birth, should be the life event that triggers the special enrollment period. Recently, 37 Senators and 55 Representatives sent a letter to U.S. Health & Human Services Secretary Sylvia Mathews Burwell  requesting this change. It appears Secretary Burwell can make this change administratively, as it does not require an act of Congress. Lamaze will join a chorus of other organizations that are making this request directly to the Secretary. Lamaze will also emphasize the importance of ensuring that ACA and state Medicaid plans include childbirth education as a covered service under maternity care benefits.

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Hill Day meetings

While meeting and communicating with legislators and staff on Capitol Hill may seem intimidating, it is actually very easy. Legislators are elected (and re-elected) by their constituents (you) so they have an obligation to listen to their constituents (you). That is a very important dynamic to remember. They are naturally inclined to help address the issues raised by their constituents.

However, advocates should always be well-prepared, a task that proved to be almost second nature for the Lamaze Board members as they met with Congressional offices. As experts in the field and natural educators, Lamaze leadership did a fantastic job representing the views of childbirth educators and establishing a rapport with the officials and staffers they met – the most important accomplishment of any first meeting on Capitol Hill.

Check out all the pictures of our Board of Directors on the “Hill” last month here.

Getting Involved

If you want to get involved and contact or meet with Congressional offices in your state, the most important action is to convey who you are, what you do, how you do it, and why it is important. Then, continue a dialogue of how specific policies might be improved for safer, higher quality, lower cost birth outcomes. In preparation for the first Lamaze “Hill Day,” several key documents were developed, including a policy paper and supporting documents to convey Lamaze’s core message in meetings with Congressional offices. By following this link, you can access and use these documents for advocacy efforts with your state’s representatives and in your local communities with insurers, health care providers, and hospitals.

Providing Lamaze’s unique perspective on the state and national level is extremely important and we can only be successful with the help of our members and supporters. In the coming months, we will provide a webinar on how to become an effective advocate and what Lamaze is doing to have an impact on access to high-quality childbirth education. Stay tuned!  If you are already an advocate in your community, on the county or state level or even nationally, share what you are doing to help families receive good care and improve outcomes in our comments section.

About John Richardson

John_Richardson headshot 2015

© John Richardson

John Richardson joined SmithBucklin, Lamaze International’s management company, in 2001 as Director of Government Relations, Healthcare Practice Group. He guides the policy efforts of healthcare organizations whose members include healthcare administrators; allied health professionals; physicians and hospitals. His experience provides his clients with a deep understanding of policy and politics and their effects on the healthcare system.

John lobbies Congress and government agencies at the federal level and also develops strategy for state lobbying efforts. He also has experience pursuing client objectives such as the development of practice guidelines, CPT codes, evidence based research, and technologies that promote efficiencies within healthcare administration.

Prior to joining SmithBucklin, John served as an Associate to the House Committee on Appropriations for a former member of the committee. Preceding his work of 5 years on the Hill, John acquired extensive political and grassroots experience working as a campaign aide to congressional and presidential campaigns.

A New Hampshire native, he graduated with a B.A. in Political Science from Roger Williams University in Bristol, R.I, and currently resides in Bowie, MD with his wife Kristin and sons Garrett and Holden.

 

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Lamaze International, Lamaze News, Maternal Quality Improvement, Push for Your Baby, Research for Advocacy , , , , , ,