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Milkscreen Breastfeeding Assessment Calculator; Reducing Mothers’ Breastfeeding Confidence?

April 23rd, 2013 by avatar

Press time update: Over the course of my research on Monday 4/22/13, I noticed that by the end of the day, Milkscreen’s main website no longer shows links to the Breastfeeding Assesment Calculator. The Facebook page for this product has also been removed.  An email received from the company confirms that the product has been removed from the website and retailers have been instructed to pull the product from the shelves. I can only speculate that this is due to pressure from social media. ~ Deena

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© Deena Blumenfeld

I recently became aware of a new product, the Milkscreen Breastfeeding Assessment Calculator by Upspring Baby, designed to help new breastfeeding mothers be more confident in their breastfeeding abilities. This product tells them whether their milk supply is “low, normal or high” and how they can correct problems.  

This product assumes that many mothers are worried about having a low milk supply and therefore this product will reassure mothers that they are normal. To use this product, a mother must pump her milk. Additionally, this product assumes that pumping breastmilk will yield the same quantity as when a baby nurses.  We know: what a mother pumps is not indicative of what she may be producing to feed her baby. 

From the product description: 

“The Milkscreen Assessment home test determines daily breast milk supply. It was created to address the common concern many moms have: how much breast milk do I make and is that enough for my baby? Milkscreen Assessment gives mom confidence to keep breastfeeding by telling her how much breast milk she makes and how that relates to baby’s growth, identifying possible breastfeeding issues and providing recommendations on how to overcome these issues.”

This description may play directly into a mother’s fear that she isn’t making enough breastmilk for her baby. 

From the product box:

“Problem: About 50% of moms stop breastfeeding because they are concerned they don’t make enough milk for their baby. Solution: Milkscreen Calculator”

How do we know that this percentage is accurate? 

The company does not cite a source for this statement. Moms cease to breastfeed for many reasons, including, but not limited to; going back to work, pain while breastfeeding and personal preference. 

The real data on low milk supply

 An estimated 5% to 15% of all mothers experience either primary or secondary lactogenesis failure, with the actual numbers being unknown. 

Hypoplasia or Insufficient Glandular Tissue is a rare condition that some women may have. and it needs a clinical diagnosis to confirm. Many women with this condition supplement with donated breastmilk or formula while continuing to breastfeed.

I believe that the Milkscreen Calculator doesn’t help to eliminate low production worries, as advertised. I believe that it promotes this fear! 

How does Milkscreen test the breastmilk?

After scouring their website, I am not able to find any information on what nutrients they are testing for or what testing procedures they use because they don’t actually test the breastmilk! A mother doesn’t send the breastmilk to their lab for testing. A mother fills out a questionnaire and enters the amount of milk pumped in three pumping sessions, one hour apart. Milkscreen looks at a mother’s production level as “low, normal, or high” and gives her results and recommendations as to what to do if she’s having a problem, and then makes suggestions as to their other products she might like to purchase. 

From Milkscreen’s FAQ

How accurate is this test?

Milkscreen Assessment is modeled after a scientific paper, published in a peer-reviewed journal, and interpretation and recommendations provided in report are based on published scientific literature found in our list of references. However, each woman will respond differently to pumping breast milk. If a woman gets a result that shows low production, it’s possible that pumping was not as efficient for her as feeding at the breast.  In this case, the report will suggest to explore this possibility with a Lactation Consultant.

When I took a look through their references list, I was unable to find the paper they referred to.. They do offer useful citations and background information, but nothing supports the need or usefulness of this product.

From the video with breastfeeding expert Dr. Landers:

This test is based on data that are normative. Hundreds of mothers have had very special calculations of daily milk supply. Our test takes an estimated amount of breastmilk supply over a shorter period of time and lets a mother know if she’s low, normal or high. Milkscreen calculator is an estimate of the day’s milk production, but in a scientifically studied, peer reviewed paper it’s actually a good approximation….. This test is an accurate estimate of daily milk supply…. It is the growth of the baby that is the most important thing. Gives mom an idea of whether baby’s weight gain is low, normal or high. (Uses the WHO growth chart)”

If the growth of the baby is “the most important thing” why don’t we weigh and measure the baby. That would tell us if the breastmilk supply is adequate.

This product oversimplifies the issue of low milk supply. “Low, normal or high,” doesn’t give a mother any real data to go on.

How do others test* for nutritional quality of breastmilk?

The Mayo Clinic provides us with some insight as to how breastmilk is tested and what it is tested for. They use thin-layer chromatography (TLC)/colorimetry/spectrophotometry (SP)/other methodologies as appropriate. With their testing, they use samples that are 4-5ml of breastmilk.

From the Mayo Clinic:

“The nutritional content of breast milk changes considerably from day 1 to day 36 postpartum. Subsequent to that time the nutritional content is considered to be stable.

Measured nutritional components are glucose, lactose, triglyceride, and protein. Deficiency of any of the measured or calculated parameters is suggestive of decreased nutritional quality of human breast milk.”

Mayo Clinic, Breast Milk Nutritional Analysis

“Several different methods are used in the analysis of human breast milk. The sample is analyzed for triglycerides using an enzymatic method. One aliquot of breast milk is tested for total protein using biuret reagent and titration methodology and for measurement of glucose using a glucose oxidase method. A second aliquot of breast milk is pre-incubated with beta-galactosidase and glucose is measured. Lactose is calculated using results obtained by the methods listed above.”

*These tests are not FDA approved.

What is the rate of false positive / false negative results from the Milkscreen test?

An incorrect assessment can have a huge impact on the mother’s breastfeeding relationship. If a mother is led to believe falsely reassured that she is making enough milk, she may not seek appropriate help from a lactation consultant or other breastfeeding professional and her baby may suffer, Alternately, a mother may choose to supplement with formula when in fact, there was no issue or her supply could have been corrected with professional help.

Breastfeeding confidence 

In the video explaining the science behind Milkscreen, Dr. Landers states;  

“Anything we can do to help a new mom, especially a first time breastfeeding mom, to have confidence in her body’s ability to make milk and nourish her baby would be a huge, huge addition to our tools to help breastfeeding moms and babies. We know from clinical studies that moms stop breastfeeding because they think they don’t have enough breastmilk supply. It’s the mother’s perception of an inadequate supply and that she doesn’t know what she’s doing… Modern women don’t have confidence in that process (supply and demand). So one of the reasons this product is so important is that it is a huge confidence builder for the average mom.’

Phrases like  “they think they don’t have enough milk” and “mother’s perception of inadequate supply” or “doesn’t know what she is doing” reinforce the idea that women are not capable of being knowledgeable or confident about breastfeeding. 

© Deena Blumenfeld

Milkscreen Assessment also claims that if a mother has too much milk, she will likely have growth issues with her baby as well. They attribute this to the foremilk/hindmilk imbalance, including the problem of ‘loose stools’ with the infant.  Current research no longer supports the foremilk/hindmilk theory, and exclusively breastfed babies normally have loose, mustardy stool.  According to Kellymom.com, “Your breasts don’t “flip a switch” at some arbitrary point and start producing hindmilk instead of foremilk. Instead, think of the beginning of a nursing session as being like turning on a hot water faucet.” In other words, there is always fat in breastmilk but the quantity varies dependent upon how long baby nurses. Feeding from a relatively empty breast will yield a higher fat content in the milk. However, it’s the fat over the course of the day, not just in a single feeding which is important.

As educators and professionals, we know to refer a mother who is questioning her milk supply to seek help from a qualified lactation consultant or other breastfeeding professional.  Additionally, we can be sure that our breastfeeding and newborn care classes are evidence based, offer useful information and instill confidence in new mothers so they can start their breastfeeding relationship off on the right foot.  We also make sure that new mothers are aware of support groups and local resources that can help them if they run into problems and concerns. 

Lamaze’s Healthy Birth Practice #6: Keep Mother and Baby Together- It’s Best for Mother, Baby and Breastfeeding is a great resource for parents and includes a wonderful video for use in class. 

Resources and References:

 AAP Breastfeeding and the Use of Human Milk (2012) 

American Academy of Pediatrics, Adequacy of Milk Intake During Exclusive Breastfeeding: A Longitudinal Study, (2011)

Butte NF, Garza C, Smith EO, Nichols BL. Human milk intake and growth in exclusively breast-fed infants. J Pediatr. 1984 Feb;104(2):187-95.

Daly SEJ, DiRosso A, Owens RA, Hartmann PE. Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk. Exp Physiol 1993;78:741-55.

Highlights of, and thoughts regarding the AAP’s Policy Statement “Breastfeeding and the Use of Human Milk”

Hurst, N (2007) Recognizing and Treating Delayed or Failed Lactogenesis II, Journal of Midwifery & Women’s Health

“Hypoplasia/Insufficient Glandular Tissue.” KellyMom RSS. N.p., n.d. Web. 22 Apr. 2013.

“I’m Confused about Foremilk and Hindmilk – How Does This Work?” KellyMom RSS. N.p., n.d. Web. 23 Apr. 2013.
 “I’m Not Pumping Enough Milk. What Can I Do?” KellyMom RSS. N.p., n.d. Web. 22 Apr. 2013.
“Is Baby Getting Enough Milk?” KellyMom RSS. N.p., n.d. Web. 22 Apr. 2013.
Mayo Clinic, Mayo Medical Laboratories Test ID: BMNA Breast Milk Nutritional Analysis
“What Affects the Amount of Fat or Calories in Mom’s Milk?” KellyMom RSS. N.p., n.d. Web. 22 Apr. 2013.

 World Health Organization on Breastfeeding

Babies, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Newborns, Social Media , , , , , , ,

Defeating the Formula Death Star, One Tweet at a Time: Using Social Media to Advocate for the WHO Code

March 26th, 2013 by avatar

by Jeanette McCulloch, IBCLC and Amber McCann, IBCLC

Jeanette McCulloch and Amber McCann recently presented a session at the 8th Breastfeeding and Feminism Symposium on March 21, 2013, speaking about the ways that social media can be used to support breastfeeding by protecting and promoting the WHO code.  They share their presentation today on Science & Sensibility to encourage all of us to be active participants in promoting action steps that help mothers and babies.  Sharon Muza, Community Manager, Science & Sensibility.

© http://flic.kr/p/e2E4Cu

Reaching breastfeeding women today means being savvy about the use of social media. While breastfeeding organizations – long without sufficient marketing resources – are stepping up to increase online efforts, formula companies are better funded and are developing sophisticated tools for reaching mothers using the Internet. Nestle, in particular, has launched a well funded social media center that has the effect of undermining women’s breastfeeding efforts. This “Formula Death Star,” though, is not going unchallenged. Using the unprecedented capacity of social media for advocates to educate and mobilize concerned consumers, a rag-tag group of rebel forces – online WHO code activists – are working to protect the WHO code and breastfeeding mothers everywhere. 

Meeting Women Where They Are At Means Using Social Media

Social media represents a revolution in communications that rivals the introduction of the printing press. Ninety-three percent[1] of the “Millennial Generation” (those born after 1982, who have come of age in a time of dependence upon technology) are communicating online, and in the United States, for example, nearly 3 of 4 are using a social networking Website, such as Facebook, Twitter, or Pinterest.[2]  Social media is widely accessed by women 18 – 29, regardless of race, ethnicity, or socio-economic status.

These changes are having a significant impact on how we talk about, learn about, and share information around birth and breastfeeding. More than half of all women responding to one survey expressed their intention to share their birth experience, as it happens, on social media.[3] Moreover, time online increases after the birth—44% of US women spend more time online after a new baby is born—and the likelihood that a new mother will seek breastfeeding information and support online is high.[4]

Women Are Seeking Information about Health Care – Including Breastfeeding – Online

Research tell us that health care providers continue to be the “first choice for most people with health concerns, but online resources, including advice from peers, are a significant source of health information in the United States.”[5] Eighty percent of US Internet users have sought health care information online, and birth and related topics are an area of focus. Consumers using social media are not only seeking information online, but are sharing their knowledge with others. As connectivity soars through increased Internet access and the rise of the smartphone,[6] so does altruistic sharing of what mothers learn online.[7]

Formula marketers are fully aware of these changes. As advocates for breastfeeding mothers, we argue that it is our responsibility as advocates to understand these changes. We also can take advantage of unparalleled opportunities social media provides for advocacy organizations to engage in dialogues with mothers and affect change.

What is the WHO Code?

The International Code of Marketing of Breastmilk Substitutes (commonly called the WHO code) was written with the goal of reducing the impact of predatory marketing worldwide of formula and related products to new and expectant mothers.

The code was written and adopted in 1981 by the World Health Organization by a vote of 118 to 1 (United States was the lone dissenting vote). Thirty two countries have adopted the code as national law, with 76 others adopting portions of the code. Ethically and morally, the code should be considered worldwide, even where it has not yet been adopted as law.[8]

Despite common misconceptions, the code does not limit access to or use of formula or related products. The code addresses marketing. And for good reason. When marketing spending on formula goes up, breastfeeding rates go down.[9]

Formula Companies Are Making Significant Investments In Social Media

Savvy institutions understand what we’d teach you in any social media 101 presentation: social media is an unprecedented tool for listening to and engaging with an audience. Nestle has become a leading example of the use of social media both to reach consumers and to manage conflict and dissent.

Nestle is the world’s largest food company and also one of the world’s most controversial.[10] Nestle was founded on the formulation of artificial infant milk, made of cow’s milk, wheat flour and sugar.[11]

But they are not alone in their use of social media to reach parents. Research conducted in 2011 – before Nestle doubled their social media budget – found that 10 out 11 brands commonly available in the US have a social media presence. Examples of their use included Facebook pages, Twitter accounts, YouTube channels, mobile apps, sponsored reviews on blogs, and interactive web sites.[12]

How Do the TOP Breastfeeding Profiles Stack Up?

Nestle and other formula companies have built these audiences using significant budgets. While overall marketing budgets are not generally available, at least $50 million was spent on formula advertising in 2004[13]  and Nestle has been quoted saying they have doubled their social media spending in recent years.[14] Compare this to the resources of top breastfeeding organizations, groups like La Leche League International, which is by far the best resourced breastfeeding organization in the US. In 2011, LLL International had total revenues of $1.5 million and spent a little over $115,000 on “public relations, external relations, and advocacy.”[15]

Other organizations, like KellyMom, BestforBabes, and the relatively new Breastfeeding USA have small budgets and rely largely on volunteer efforts. The result? Although all of these organizations make a significant impact on the women they reach, compare the total number of all of their followers on Facebook – about 145,000 as of this writing – to that of Nestle Good Start at five million followers.[16] 

Rebel Forces vs the Death Star

Nestle has combined its significant financial resources with social media experts and tools that have made it a shining example of how corporations should handle social media. Nestle’s “Digital Acceleration Team” has a trained staff monitoring each and every mention of Nestle’s brands. Team members identify negative “emerging issues” based on the volume of mentions and respond to those with a high level of engagement using a scripted playbook for team members.[17]

The Formula Death Star, as it has become known to WHO code activists, can feel overwhelming, both because it limits our capacity to reach families and because it can feel impossible to influence change at the world’s largest food company.

However, Nestle developed these tools in response to their inability to manage an onslaught of angry advocates and consumers on social media. In 2010, Greenpeace activists were able to secure significant changes in how Nestle sources palm oil, all thanks to a YouTube video spoof that garnered over 1.5 million views, along with a resulting social media campaign that netted more than 200,000 e-mail complaints.[18] Policy change at Nestle based on calls from consumers is possible.

Examples of Efforts to Support the WHO code Online

Although Nestle may have the Death Star, rebel forces are pulling together to provide much needed social media support for the WHO code.

A recent campaign demonstrates the power of using social media tools to organize individuals, even without an official organizing body like Greenpeace. A blog post[19] exposing that Pan American Health Office – the regional representative in the Americas for the World Health Organization – accepted more than $150,000 in donations from Nestle sparked outrage among activists concerned that the fox was helping to buy the hen house. Within days, a private Facebook group experienced rapid growth to 400 members, now at 900 members as of this writing. Each day, members were given specific action steps, including suggested scripts for tweets directed at PAHO and WHO.[20] Members provided impromptu trainings on Twitter use and etiquette, researched the money trail, and quickly developed strategy, including a decision to target WHO and call for a rejection of the Nestle funding.

The result: A relatively small group of consumers and advocates – through the use of Facebook and Twitter alone – were able to force the World Health Organization to respond. But more importantly, advocates began to organize and mobilize a group of motivated individuals, who will come to the next battle more organized and prepared to engage. 

How The Rebel Forces Can Defeat The Death Star

As the Greenpeace example shows, social media provides advocates with a unique opportunity to influence how companies do business. With ongoing support to the rebel forces, much-needed pressure can be put on Nestle to change their policies. But this will not come without significant work. Some areas that need support:

  • Ongoing consumer support and education around the WHO code. In our anecdotal experience, mothers generally are unaware of the WHO code, or if they are aware, think that it limits access to formula (rather than limiting marketing of breastmilk substitutes). The importance of the WHO code needs to be distilled into social media friendly images and infographics to build awareness and support for future efforts.
  • Ongoing education of maternal health advocates. The WHO code impacts more than just breastfeeding. Anyone concerned with infant and maternal health should be aware of and providing support for the adoptions and enforcement of the WHO code worldwide.
  • Bring even more social media savvy to the table. After Nestle’s run in with Greenpeace, they brought in a top notch social media strategist to revamp their approach and provide training for the digital engagement team. Nestle uses sophisticated tools to monitor and respond to issues. The Friends of the WHO Code – and any group hoping to use social media for impact – needs people on hand who are savvy in the use of social media and the funding for at least some basic tools to help make the job collaborative.
  •  Keep doing what we know best. One the greatest impacts of the PAHO/WHO crisis was to bring together the community that will need to continue to take action. This and other groups need to use traditional community organizing strategies, with social media as the tools they use to create a more level playing field.
To learn more about what you can do to help promote the WHO Code through social media, join the group “Friends of the WHO Code” on Facebook.
References

[1] Howe N, Strauss W, Matson RJ. Millennials Rising: The Next Great Generation. New York, NY: Vintage Books; 2000.

[2] Lenhart A, Purcell K, Smith A, Zickuhr K. Social media and mobile Internet use among teens and young adults. Pew Internet and the American Life Project. http://web.pewinternet.org/~/ media/Files/Reports/2010/PIP_Social_Media_and_Young_ Adults_Report_Final_with_toplines.pdf. February 3, 2010.

[3] Social media giving birth to new generation of parents-to- be. Chicago Tribune Website. http://connect.mayoclinic.org/ news-articles/863-social-media-giving-birth-to-new- generation-of-parents-to-be/portal.

[4] Bartholomew M, Schoppe-Sullivan S, Glassman M, Kamp Dush C, Sullivan J. New parents’ Facebook use at the transition to parenthood. Fam Relat. 2012;61:455-469.

[5] Fox S. The social life of health information. Pew Internet and American Life Project. http://www.pewinternet.org/~/media// Files/Reports/2009/PIP_Health_2009.pdf. May 12, 2011.

[6] Smith A. Cell Internet use 2012. Pew Internet and Ameri- can Life Project. http://www.pewinternet.org/~/media//Files/ Reports/2012/PIP_Cell_Phone_Internet_Access.pdf. June 26, 2012.

[7] Kibbe D, Kvedar J. Building a research agenda for participatory medicine. J Particip Med. 2009;1:16.

[9] http://www.bestforbabes.org/what-is-the-who-code

[12] J Hum Lact. 2012 Aug;28(3):400-6. doi: 10.1177/0890334412447080. Epub 2012 Jun 6. Milk and social media: online communities and the International Code of Marketing of Breast-milk Substitutes. Abrahams SW.

[14] http://uk.reuters.com/article/2012/10/26/uk-nestle-online-water-idUKBRE89P07Q20121026

[16] www.facebook.com/Gerber

[17] https://www.youtube.com/watch?v=ktsMa8hfgY0

[18] http://mashable.com/2010/05/17/nestle-social-media-fallout/

[19] http://lactationmatters.org/2012/11/08/if-you-dont-advocate-for-mothers-babies-who-will/

[20] http://lactationmatters.org/2012/11/14/world-wide-impact-in-10-minutes-or-less-using-social-media-for-powerful-change-2/

About Jeanette McCulloch and Amber McCann

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, has been combining communications work and women’s health advocacy for more than 20 years. She is a co-founder of BirthSwell, which is working to improve infant and maternal health – and the way we talk about birth and breastfeeding – by making social media accessible for birth and breastfeeding professionals. She is a board member of Citizens for Midwifery, and is active in local, statewide, and national birth and breastfeeding advocacy projects.

© Amber McCann

Amber McCann, IBCLC is a  board certified lactation consultant with the Breastfeeding Center of Pittsburgh. She is particularly interested in connecting with mothers through social media channels and teaching others in her profession to do the same. In addition to her work as the co-editor of Lactation Matters, the International Lactation Consultant Association’s official blog, she has written for a number of other breastfeeding support blogs including for Hygeia, The Leaky Boob, and Best for Babes and is a regular contributor to The Boob Group, a weekly online radio program for breastfeeding moms. Amber is particularly interested in the impact of the WHO Code and has worked on grass-roots campaigns to support its efforts online.

Babies, Breastfeeding, Continuing Education, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, Newborns, Social Media, Uncategorized , , , , , ,

A Game of Telephone and Misinterpreting Information

March 19th, 2013 by avatar

© http://flic.kr/p/bS581K

Regular contributor Deena Blumenfeld shares her recent experience with a “research” article that washed over social media outlets and was shared and discussed by many birth professionals.  Deena explains how she fell in step with others and ended up being lead down the wrong path.  Have you every made this mistake too?  Please share your thoughts in our comment section.- Sharon Muza, Science & Sensibility Community Manager.

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Gathering information from social media can be like playing a giant game of “telephone” with a million of your closest friends.

This is often how it goes:

  • Someone reads an article. They post to Facebook (or other venue) a link and a comment.
  • We read this person’s comment and add our own comment.
  • Then we go back and skim the article, and comment again.
  • Next we post a link to the article, with our own comments and opinions regarding the article.
  • The next reader takes our opinion as gospel, only reads the headline of the article and then shares our opinion on their page, neglecting to link the article with their comment.
  • So now we have a rumor about an opinion and after 345 more postings, no one knows where the original source was of what anyone is talking about anymore.  But, whatever it is, it sounds AWFUL and we are indignant about it.

Does this sound familiar to you? Have you ever taken a rumor, opinion or comment about an article or study to be gospel truth, without fully reading and researching the information on your own… and then go on to repeat that rumor or opinion? 

I’ll sheepishly raise my hand here…

Not too long ago, there was an article on medpagetoday.com entitled New Form of Misoprostol Speeds Up Labor.” Now, without reading the article, doesn’t it seem that we now have a form of misoprostol being used for augmentation? 

This is the misinterpretation that was flying around Facebook, Twitter and other social media sites for days after the article was published on February 18, 2013. The outrage, fear and condemnation of anyone who thought it might possibly be a good idea to use misoprostol for augmentation was overwhelming. I read, and participated in, many discussions regarding the dangers of this drug; uterine rupture, mothers who have died, babies who have died, the Safe Motherhood Quilt Project, and so on. 

But yet we all missed it, me included.  That misleading headline leads us to believe that this was misoprostol for augmentation of labor; when in reality, it is an article about a new form of misoprostol, designed in the appropriate dosage, to induce labor.  This ‘little oops’ caused a big stir for not much. 

So, let’s look at what the article really talks about and what we should know.

  • This is an article about an abstract which was presented at a conference. It is not a peer-reviewed, published study.
  • We do not have access to the full study, since it isn’t published. So, we cannot evaluate it effectively.
  • The study compared the efficacy of this new form of misoprostol suppository to the existing dinoprostone (cervadil) suppository for induction of labor.
  • This study of 1,358 women found that the misoprostol suppository worked more quickly than the dinoprostone to get women to active labor as well as to birth.

“Along with the primary efficacy benefit of shorter time to vaginal delivery, the novel agent was also associated with faster delivery of any type, vaginal or cesarean (median 18.3 hours versus 27.3 hours with dinoprostone, P<0.001).”

“Other secondary outcome benefits were shorter time to active labor at 12.1 hours versus 18.6 hours, respectively (P<0.001), with substantially fewer women needing oxytocin prior to delivery (48% versus 74%, P<0.001).” 

Hang on a minute: “faster delivery of any type, vaginal or cesarean.” If the results of the induction end up as a cesarean, can we call it a successful induction? I’m not sure we can. I think this is a failed induction. Sure the medication worked to get labor started, but for whatever reason she ended up with a cesarean section. Faster to a cesarean section – wouldn’t it have been even faster to just schedule the cesarean section? 

“T’he primary safety outcome of cesarean delivery came out similar between groups at 26% with misoprostol and 27% with dinoprostone (P=0.65). Nor was there a difference in indication for cesarean section.”

When asked at the session why a faster vaginal delivery didn’t translate into fewer cesarean deliveries, Wing pointed to the myriad other factors that play into delivery mode. “We can flip the switch on but that doesn’t always get us the desired result,” she told the audience.” 

The article is leaning towards “faster is better” in terms of labor. We are left with more questions than answers. The answers may be found within the study itself, however, we don’t have access to the study. My questions:

But why? Why is a faster induction (or faster labor) better than a slower one?

Aren’t faster labors more painful? Aren’t contractions more challenging to cope with when they are more intense?

Do we have high rates of fetal distress with a faster labor vs. a slower one?

Who benefits from a faster birth?

The articles states that fewer women needed to be augmented with pitocin with a misoprostol induction vs. a dinoprostone induction. Is that a good thing? Bad? Neutral?

We also don’t know the researcher’s intentions. Without being able to read the study, we can only make assumptions. Do we assume the intention is a faster labor? Do we assume the intention is to make misoprostol safer for induction? Something else? Or maybe, just maybe, we don’t assume anything at all. Assumptions can be very dangerous and in most cases, they are wrong. 

How to avoid misinterpreting the data and spreading rumors:

  • Always go to the study! An article about the study is someone else’s opinion. The abstract is the Cliff’s Notes version of the study.
  • Admit when you don’t understand something and talk to someone who does.
  • Look to the citations and in the study to check for further information.
  • Use the Cochrane Library and other sources for more information.
  • Don’t make assumptions based on other people’s opinions.
  • If you don’t know for sure, don’t spread the information!
  • If you made a mistake and misinterpreted a study or article, say so. It’s better to admit you are wrong than to continue to spread inaccurate information.

My Take Away

The take away from all of this is that an article about an abstract presented at a conference leaves us with more questions than answers. We cannot accurately evaluate that which we cannot read in its entirety. Social media is a good tool, but we should be cautious about that which sounds too good (or bad!) to be true. We should take others opinions as just that – opinions, until we’ve done our own solid research. We should also be cautious about the ‘click and share’ phenomenon. Double check, do your homework and make sure the information we share is accurate. I’ll do better next time too.

For more on misoprostol for labor induction please read:

  1. Science & Sensibility: Update on Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose
  2. Science & Sensibility: ACOG’s 2009 Induction Guidelines: Spin Doctoring Misoprostol (Cytotec)
  3. Journal of Perinatal Education: The Freedom to Birth—The Use of Cytotec to Induce Labor: A Non-Evidence-Based Intervention by Madeline Oden
  4. WHO: Misoprostol for cervical ripening and induction of labour
  5. WHO: WHO Recommendations for Induction of Labor, 2011
  6. Induced and Seduced: The Dangers of Cytotec by Ina May Gaskin
  7. Adverse Events Following Misoprostol Induction of Labor by Marsden Wagner, MD, MS

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternity Care, Medical Interventions, New Research, Research, Uncategorized , , , , , , , , ,

Lamaze International Webinar: Social Media for Childbirth Educators! Are You Signed Up?

December 12th, 2012 by avatar

There is an exciting and free webinar offered by Lamaze International tomorrow, December 13, 2012 and I wanted to make sure that you were signed up!

http://flic.kr/p/5uhL7d

Social Media for Childbirth Educators presented by: Kathryn Konrad, MS, RNC-OB, LCCE, FACCE will be an opportunity to learn about, discuss and explore the different methods of communicating with today’s parents.  What forums and venues do young families use to gather information and how can you harness the power of social media to build your business, market your skills and interact with the families you are working with?  Even if you are already familiar with this topic, you will be sure to learn a few new tips and discoveries that can only enhance your skills.

The specifics:

Social Media for Childbirth Educators Webinar

Date:  Thursday, December 13, 2012

Time: 1:00 PM – 2:00 PM EST

Reserve your Webinar seat now!

You may also receive 1 Lamaze Contact Hour, and one Nursing Contact Hour upon purchase and completion of a quiz. This is optional, the webinar is free.

Come back and let us know your thoughts, what you are excited to try and how you use (or will use) social media to help you in your business practices!

Please contact the Lamaze International office with questions about registering, contact hours or other webinar focused needs.  See you online!

 

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One in Three Suffers Posttraumatic Stress Disorder: A Look Behind the Headlines

August 21st, 2012 by avatar

by David White, MD CCFP, Associate Professor, Dept of Family & Community Medicine, University of Toronto

Dr. David White reviews the study “Postpartum Post-Traumatic Stress Disorder Symptoms: The Uninvited Birth Companion” that made news headlines earlier this month.  This post,  is part two of a two part series. (Read part one here, where Penny Simkin discussed how the media created sensationalistic headlines from the study.) Dr. White demonstrates how important it is to go to the source,  and evaluate the study design for oneself.  I appreciate Dr. White sharing his  summary and review of the research behind the study. – SM

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Creative Commons Image by Horia Varlan

The dramatic headline caught my eye: “One in Three Post-Partum Women Suffers PTSD Symptoms After Giving Birth: Natural Births a Major Cause of Post-Traumatic Stress, Study Suggests.”[i] As a family doctor who provides maternity care, I was both puzzled and alarmed. Where were all these women? Each year, I care for about 50 women through pregnancy, birth and post-partum. Am I failing to recognize the 16 or 17 who develop PTSD? Are they suffering without proper care?

The article claimed “Of the women who experienced partial or full post-trauma symptoms, 80 percent had gone through a natural childbirth, without any form of pain relief.”

On reflection, I became skeptical. So I read the original research paper.[ii] To their credit, the authors acknowledge, “Controversy remains whether childbirth should be included under the definition of a traumatic event that meets the criteria for post-traumatic stress disorder.” Unfortunately, their own study is so riddled with problems that it can only add confusion.

First, there is the matter of selection: 102 women agreed to participate, 89 completed the two assessments. There is no mention of how many women were approached, or how many women had births at the hospital during the study period. So there is no way to assess possible selection bias. Suspicion is warranted when a crucial methodological detail is omitted.

Then there is the issue of diagnostic criteria. The diagnosis of PTSD requires that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning (both DSM-IV-TR and ICD-10). The researchers administered their survey instrument within a few days of birth and again at one month post-partum. The latter just barely meets the criterion for duration. And could there be a cuing effect from administering an initial questionnaire within a few days of birth?

The findings report “full PTSD”, “partial PTSD” and “PTSD symptomatology”. However the tool used by the researchers, a self-administered questionnaire called Posttraumatic Stress Diagnostic Scale (PDS®), indicates only whether someone meets the DSM diagnostic criteria or not.[iii]

Now to the analysis, which piles questionable analysis onto this shaky diagnostic platform.  “For processing the data we needed to select a group large enough to be statistically significant but homogenous enough to offer meaningful results.” So they lump together those missing one or two symptoms with those who actually have PTSD. The justification for this methodological legerdemain is that others have done it. They reference a study by Stein, Walker et al[iv] that is considerably more careful. It differs substantially in that it used telephone interviews, a different assessment tool and analyzed full and partial PTSD separately.

The results are reported in a way that even makes it difficult to determine what group they are analyzing. Is it the “full PTSD” (3) + “Partial PTSD” (7) = 10? No, it is 3 (“full) + 4 (“missing 1 or 2 symptoms”) =7. But look at Table 2, showing 5 in the row labeled “PTSD”. Table 3 has it back up to 7.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

The terminology for the groups seems variable. At times it is “PTSD group”, at others it is “women with PTSD symptoms” and the Tables simply apply the label “PTSD.”

Terminology problems continue: “control group” is used regularly to denote those who did not manifest PTSD symptoms, an odd usage for a study in which there is no intervention or randomization.

While studying Table 2, check out the mode of delivery: Natural 45, Cesarean 42 (20 elective), Instrumental 2. That indicates a Cesarean section rate of 47%. Could this be a biased sample?

More fun with numbers: the text reports that 80% of women with PTSD symptoms reported feeling very uncomfortable in the undressed state: Table 3 shows 3 out of 7 reporting this.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

And the figure that 80% of those with PTSD had gone through natural labour? It appears to come from Table 2, showing that 4 out of 5 women in the “PTSD” group had “Natural” childbirth. I scoured the tables and text in vain to find why the PTSD group is 5 in Table 2 and 7 in Table 3.

The definitions of mode of delivery should be more precise. The authors describe natural births as “non-interventional” but we really don’t know about analgesia use in this group. This matters, because they found “A significantly smaller number of women who developed PTSD symptoms received analgesia during delivery compared to the control group.” For this to make sense, it is essential distinguish vaginal births with and without effective pain relief.

This definitional and analytic fog leads to the conclusion that a lot of women have PTSD symptoms following birth. The authors don’t trouble themselves to explain why their numbers don’t square with the excellent community-prevalence study in the references, in which “The estimated prevalence of full PTSD was 2.7% for women and 1.2% for men. The prevalence of partial PTSD was 3.4% for women and 0.3% for men.”4

This study brings discredit to an admittedly difficult field, one in which researchers must address the criticism of medicalizing normal life experiences.

I’m a GP, not an expert in PTSD. But I think I can recognize “significant impairment in social, occupational, or other important areas of functioning.” The important issue for practitioners is whether we identify and help those at risk and who need assistance. Screening for post-partum depression is important. Adding a simple open-ended question such as “tell me about your birth” is likely to yield much more benefit in practice than this study.

I appreciate Dr. White’s analysis and wonder how many other professionals bothered to examine the research behind the headlines, in order to come to their own conclusions about the study design, assumptions and findings.  What do you think of this research?  Did you understand the terms being used or how the results were determined?  Do you think any journalists who wrote the sensational headlines took the time to look at the study themselves?  It is always important to be a critical thinker for yourself, examine the information and ask questions.  Sometimes, the research does not match up with the front page news, or the study may not have been well-designed.  Please share your thoughts, questions and comments here, with Dr. White, Penny Simkin, myself and Science & Sensibility readers. – SM

References

[i] American Friends of Tel Aviv University (2012, August 8). One in three post-partum women suffers PTSD symptoms after giving birth: Natural births a major cause of post-traumatic stress, study suggests. ScienceDaily. Retrieved August 14, 2012, from http://www.sciencedaily.com­ /releases/2012/08/120808121949.htm

[ii] Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion, Inbal Shlomi Polachek, Liat Huller Harari, Micha Baum, Rael D. Strous: IMAJ 2012; 14: 347–353, accessed at http://www.ima.org.il/imaj/ar12jun-02.pdf

[iii] The actual PDS® tool can be downloaded at (for a price): http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg510&Mode=summary

A useful review of the PDS® is at: http://occmed.oxfordjournals.org/content/58/5/379.full.pdf+html

[iv] Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic stress disorder: Findings from a community survey. The American Journal of Psychiatry, 154(8), 1114-9. Retrieved from http://search.proquest.com/docview/220491145?accountid=14771

A useful overview of PTSD at

http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp

A review of research issues in PTSD following childbirth:

Pauline Slade: Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics & Gynecology (January 2006), 27 (2), pg. 99-105, accessed at http://resolver.scholarsportal.info.myaccess.library.utoronto.ca/resolve/0167482x/v27i0002/99_tacffucaiffr

About David White

David White is a community-based family doctor in Toronto and Associate Professor of Family & Community Medicine at the University of Toronto. (DFCM, U of T). He currently serves as the Interim Director of UTOPIAN, the practice-based research network comprising all teaching sites affiliated with the Department of Family & Community Medicine at the University of Toronto.

He obtained his medical degree and completed residency in Family Medicine at the University of Toronto. He began clinical practice in 1977 at Sioux Lookout, working at the Zone Hospital and flying into remote First Nations villages in northwestern Ontario. In this setting he began a long-term affiliation with U of T. On returning to Toronto in 1980, he joined the Family Medicine Teaching Unit at Toronto Western Hospital, and later moved to Mount Sinai Hospital. In 1999 he was appointed Chief of Family & Community Medicine at North York General Hospital (NYGH).

His current academic activities include clinical teaching in his community office and in obstetrics, research in health care delivery, and mentoring of junior faculty. Contact Dr. White

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, Maternity Care, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , , , , , , , , , ,