Category Archives: Maternal-child health

Mode of delivery and childhood illness: A randomized trial in 2004.

03c62f38ce31d41b01e1b5a4031bf11aOne of the biggest difficulties in proving a causal link between cesarean birth and chronic health problems in childhood is the type of research studies that can practically and ethically be done during pregnancy.

The gold standard in medical research is the randomized controlled trial (RCT). In an RCT researchers randomly place subjects into either “treatment” or “control” groups, then expose the treatment group to something—a new vaccine for Infection X, for example—and then compare outcomes in the two groups later on. (In this example, how many kids in the treatment [vaccinated] group came down with Infection X versus how many in the unvaccinated control group?) If there’s a significant difference in outcomes between the two groups, you’ve got a strong argument that the treatment made the difference.

How a randomized controlled trial works. (Credit: SUNY Downstate Medical Center)

How a randomized controlled trial works.**

As you can imagine, randomly assigning pregnant women to cesarean (treatment) or vaginal birth (control) groups is nigh onto impossible—ergo, you can’t do an RCT. This means that virtually all research studies on the issue of cesareans and chronic childhood have been observational in nature—looking backward in time at databases, for example, or trying to fish significant trends out of hospital registries, birth cohorts and the like. The best an observational study can tell you is that A and B are associated with one another, but that’s it—you can’t prove that A actually causes B. An observational study can’t prove that cesareans are a cause of asthma; it can only say that cesareans are associated with an increased risk of childhood asthma.*

So mode-of-delivery RCTs are out of the question…or are they? Actually, in 2004, a Canadian research team did one.

Well done, Northern Neighbors!

Well done, Northern Neighbors!

The multi-center, multi-nation Term Breech Trial wasn’t about whether cesareans might increase the risk of childhood asthma, diabetes and such. It was about trying to figure out whether elective cesarean section or vaginal birth was the safest way to deliver a breech baby at term. Since the existing research was somewhat murky at the time, it was considered ethical (with informed consent) to randomize women to have either a planned cesarean or attempt a vaginal birth.

The particulars of the breech birth debate are best left for another post, but tucked away in the study’s results section was this little nugget:

“…more parents in the planned cesarean birth group than the planned vaginal birth group reported that their children had had medical problems in the past several months…relative risk, 1.41; 95% CI, 1.05-1.89; P=0.2.”

Plain English version (mine): The toddlers who had been in the planned cesarean group were about 40% more likely to have been sick in the previous few months than those in the planned vaginal birth group. The types of medical problems—typical 2 year-old stuff like colds, ear infections and stomach flu—were no different between the groups. The only difference was in the numbers of children who’d gotten sick.

As is the case with all medical research, you can find things in the study to complain about: relatively small numbers, for example, the use of parental questionnaires and the fact that some mothers in planned vaginal birth group ended up having cesareans (and vice-versa), etc.

But here’s my bottom line:

In a randomized trial of pretty well-matched subjects, those babies whose mothers were in the planned cesarean group tended to get sick more often than those in the planned vaginal birth group.

This doesn’t address the issue of chronic illnesses like asthma, type 1 diabetes and the like, but it does support the theory that cesarean birth can mess with a baby’s developing immune system.

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*Here’s an exaggerated example of the trouble with mistaking association for causation: Virtually all adults who die suddenly of heart attacks drank water in the 24 hours before they died. So, drinking water is associated (time-wise) with heart attacks. But you would be wayyyy wrong to say that, based on that association, a glass of water can cause a heart attack.

**Credit: SUNY Downstate Medical Center

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Filed under Asthma, Canada, Cesareans, Immune system, Maternal-child health, Newborns, Vaginal birth

Epidurals: Do they prevent postpartum depression?

Leonardo da Vinci

Leonardo da Vinci

Do epidurals prevent postpartum depression? That’s the intriguing conclusion some people are drawing from a study published in this month’s issue of Anesthesia and Analgesia. But is that conclusion correct?

In a study of 214 women at Peking First University Hospital in Beijing, researchers found that 14% of women who received epidural analgesia during labor reported symptoms of postpartum depression (PPD) six weeks later, compared with 34.6% of women who refused epidurals. The authors point out that their findings don’t necessarily prove that epidurals can prevent PPD, but the language in the discussion sure sounds like that’s what they believe.

But…the premise of this study is flawed from the start, because the investigators compared epidural analgesia to, well, nothing:

“Each parturient made a decision by herself to have epidural labor analgesia or no pain relief at all. Other forms of analgesia are not available at our hospital.”

What does “no pain relief at all” mean at Peking First University Hospital?  Were spouses/doulas/other support people allowed in the room? Did the mothers labor alone? Does “no pain relief at all” mean no freedom to move about, no bath/massage/music/visualization exercises/birth balls, none of the myriad other comfort measures that can reduce pain during labor? It obviously means no nitrous oxide, and I presume no tylenol or ibuprofen, either. In this particular hospital it seems, the choice is pretty stark: you get an epidural or you tough it out.

Which means we’re left with a study of unaddressed labor pain and postpartum depression, not the benefits of epidurals.

Karl Gauss, inventor of Twilight Sleep

Not exactly “new news”: Dr. Karl Gauss, inventor of Twilight Sleep

It’s hardly news that uncontrolled pain can lead to postpartum depression. One of the main drivers in the “painless childbirth” movement of the mid-19th century and the development of Twilight Sleep in the early 20th century was the prevention of neurasthenia—a debilitating combination of anxiety and depression that haunted many postpartum women.* 

This study would be more compelling if the authors had compared epidurals with other pain relief modalities in the setting of a well-supported labor. Otherwise we’re left with the conclusion that uncontrolled labor pain can make women miserable, and medically obliterated pain makes them less so. 

I can’t think of any other form of human pain that would be studied in such an all-or-none way.

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* Department of Shameless Self-Promotion: You can read more about the history of painless childbirth, as well as what a lousy labor coach I was, in my book, Birth Day: A Pediatrician Explores the Science, the History, and the Wonders of Childbirth.  

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Filed under Birth Day, Labor pain, Maternal-child health, Natural childbirth

Shout-out #1: Enlightened Mama in the Twin Cities

Such a place!

Such a place!

I’ve given a couple of talks in the Midwest this month, and I want to give a shout-out to two very worthy organizations: Enlightened Mama in St. Paul, Minnesota (this post) and Southwest Tech in Fennimore, Wisconsin (coming soon).

I first met Liz Abbene, Enlightened Mama’s founder and “Alpha Mama,” a couple of years ago when I was speaking at the 2012 REACHE conference in Seattle. As we chatted about the conference I was impressed by Liz’s ability to carry on a coherent conversation while buried in children (she has four beautiful kids). Anyone who could keep that many balls in the air at one time, I figured, must run a pretty interesting business.

When the conference wound down, Liz extended me an invitation to speak at Enlightened Mama if I was ever in the Twin Cities. Sure, I said, figuring what are the chances of that ever happening? I’d never been to the Twin Cities and didn’t really have any plans to travel there.

Liz Abbene

Liz Abbene

Ah, but life has a way of changing one’s plans. Last year I enrolled in the University of Minnesota’s Masters in Public Health program, which requires online students to spend a couple of weeks on campus during the year. So I came to the Twin Cities for UMN’s Public Health Institute in early June and, as Liz had willed back in Seattle, I wound up at Enlightened Mama talking on the wonders of the newborn microbiome.

Space does not allow me to describe all that Liz does at Enlightened Mama. Suffice it to say that along with doula services she and her staff and partners provide lactation support and breastfeeding classes; massage, acupuncture and chiropractic care; family therapy and career counseling; and a number of other classes and services that promote wellness before, during, and after childbirth. Alas, there is no brewpub or nail salon at Enlightened Mama, but for all I know these are in the works.

Enlightened Mama is a great resource for families in the Minneapolis-St.Paul area. So if you live there and you’re pregnant, give Liz a call!

P.S: When I asked one St. Paul mother how her town differed from Minneapolis, she told me this:

“People from Minneapolis love to tell you how cool it is to live there. People from St. Paul already know we live in a cool town. No need to brag about it.”

I remain neutral in the matter…

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Filed under Breastfeeding, Doulas, Maternal-child health, Natural childbirth

Flu shots help prevent preterm birth

5278448067_f76b92377cA research team in Georgia recently published a study that shows the protective effect of flu vaccine for pregnant women.

Led by Dr. Saad Omer of Emory University, the team examined the records of more than 3,300 pregnant women between April 2009 and 2010. They found that those women who received influenza vaccine overall had a 40% lower likelihood of giving birth before 37 weeks of pregnancy than women who were not vaccinated. That protection increased to 72% during the peak of the flu season.

The protection extended to birthweight as well. Vaccinated women were 69% less likely to have a small for gestational age baby than were the unvaccinated women.

Dr. Omer’s study underscores the importance of flu shots for pregnant women. Keep that in mind come next October, when the 2013-2014 vaccine  comes out!

(Photo credit: International Ladies Garment Workers Union Photographs, 1885-1985)

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Filed under Infectious diseases, Maternal-child health, Vaccines

Pollution and birth weight

Beijing in January

Beijing in January

What with continuing air pollution woes in such diverse locales as Beijing and Salt Lake City,  a study released last week in Environmental Health Perspectives–which found a direct relationship between particulate air pollution and low birth weight in term babies–couldn’t be more timely.

The study’s authors compiled data on more than 3 million births in nine countries and found a 10-15% increased risk of low birth weight in the most polluted locations.

This isn’t just about turning out slightly less pudgy newborns. The consequences of low birth weight are far-reaching, even multi-generational. Low birth weight babies are more likely to develop chronic health conditions as they grow up, like heart disease, hypertension, and diabetes–just the sort of health problems that make for high-risk pregnancies a generation down the road.

In other words, today’s low birth weight baby girl is more likely to one day produce an unhealthy baby of her own. It’s a cycle that’s tough to break once it starts, and this study is more food for thought as world leaders (hopefully) get serious about addressing climate issues.

(Photo credit: jaaron)

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Filed under Environment/Toxins, Maternal-child health, Newborns

Birth centers: Safe, economical, and great places for low-risk births

2852282606_22551640c8An American woman with a low-risk pregnancy who chooses a midwifery-led birth center for her maternity care is four times less likely to have a cesarean than if she chooses a hospital birth, according to a review published today in the Journal of Midwifery & Women’s Health.

The review highlights the findings of the National Birth Center Study II (NBCSII), which followed 15,574 women who planned and were eligible for birth center births at onset of labor.

Among the NBCSII’s findings:

  • 84% of women who planned and were eligible for a birth center birth at onset of labor were successful in having one.
  • Only 6% of women intending a birth center birth ultimately required a cesarean section, compared with nearly 24% of comparably low-risk women receiving care in hospitals.
  • Emergency transfers from birth center to hospital were uncommon.
  • Fetal and newborn deaths were rare, and comparable to those in low-risk births in hospital settings.
  • There were no maternal deaths.
  • Birth center care is economical and in keeping with the fiscal goals of the Patient Protection and Affordable Care Act (aka “Obamacare”).

Some nuts and bolts of the NBCSII, FAQ-style:

What, exactly, is a “birth center”?

  • The American Association of Birth Centers defines a birth center as “a homelike facility existing within the health care system with a program of care designed in the wellness model of pregnancy and birth.” The key here is “within the health care system”—the integration between birth center and hospital is critical to the success of any birth center. When emergencies arise, a smooth transfer is vital to keeping mother and baby safe.

Who runs these birth centers?

  • The birth centers in the study were all midwifery-led. 80% were staffed by certified nurse midwives (CNMs), 14% by certified professional midwives (CPMs) or licensed midwives (LMs), and the remaining 6% by teams of CNMs,  CPMs, and LMs. (The different types of midwives in the U.S. can be a bit confusing for the layperson—the American College of Nurse-Midwives provides a handy comparison chart.)

What is a “low-risk” pregnancy? Who qualifies for a birth center birth?

  • Here are the AABC’s eligibility requirements for birth center birth: a single fetus in head-down position, with no medical or obstetrical risk factors that might interfere with normal vaginal birth or require interventions like continuous fetal monitoring or labor induction.
  • By those standards, approximately 85% of pregnancies are “low-risk.”

Why did 16% of the women who planned a birth center birth end up giving birth in hospitals anyway?

  • Of that 16%, about one-fourth were transferred to hospitals before being admitted to the birth center, due to medical issues. Of the rest, the majority were for non-emergency problems, such as prolonged labor. Only 0.9% of the birth center women required an emergency transfer during labor.

Is birth center birth really as safe as hospital birth?

  • Yes, according to the NBCSII’s findings. The rates of fetal death (4.7/10,000 women admitted to a birth center in labor) and neonatal death (4/10,000) in the study were comparable to those in other studies in the U.S. and elsewhere, including those of low-risk birth in hospitals. There were no maternal deaths.

Does birth center care really save money?

  • Yes. In this study alone, cost savings–mainly from fewer medical interventions (including cesareans)–were estimated at more than $30 million, and these 15,574 pregnancies represent less than 1% of all U.S. births. Given that expenses for hospital birth in 2008 exceeded $97 billion nationwide, the opportunity for savings in these health-care-dollar-scarce times is enormous.

A few quibbles:

  • The women in the study were mainly white (77.4%), well-educated (71.8% had at least some college education, and 51.8% were college graduates), and married (80.1%). They were also relatively slender (only 5.7% were overweight or obese, compared with more than 50% of all pregnant American women), mentally healthy (3.3% were being treated for depression or other psychiatric disease), and largely free of substance use (1.5% smokers, 0.5% users of other substances). Though the study’s findings on safety and cost-savings compare favorably with other studies of low-risk pregnancy outcomes, it isn’t clear that these findings can be extrapolated to the U.S. population as a whole.
  • Death rates are crude tools for measuring safety, particularly in low-risk pregnancies. I’d like to know more about morbidity–were the birth center babies more, less, or just as likely as hospital-born babies to suffer birth trauma, for example? I suspect they were less likely to have such complications, given the tendency of birth center staff to perform fewer interventions, but I can’t be certain from this study. Hopefully that will be addressed in a future review.
  • What about breastfeeding? Were the birth center mothers more likely to breast feed than those who gave birth in hospitals? Again, I suspect so, and hope that information on breastfeeding will appear in future reviews of NBCSII data.
  • The 79 birth centers that participated in the study represent only 32% of American birth centers. All 79 are AABC members and as such support the AABC’s Standards for Birth Centers. Other, non-member birth centers may or may not adhere to such standards, and their safety records may or may not be as good as those in this study. With new birth centers appearing at a remarkable pace (up 27% since 2010), ensuring high quality care in all birth center settings may be challenging.

Conclusion:

Withe the publication of this review, the well-entrenched belief that hospitals are the safest place to have a baby takes yet another beating. It’s increasingly clear that most women with low-risk pregnancies can safely give birth at midwifery-led birth centers. A personal/professional note: I’ve taken care of a number of families who’ve had their babies at the Women’s Health and Birth Center here in Santa Rosa, California, run by Rosanne Gephart, CNM. (Rosannne and I go way back). They speak glowingly of their experience at the Birth Center.

One caveat, though. Not all birth centers are alike, and it behooves expectant parents to check out things like staff credentials and birth center accreditation, and to ask pointed questions about how the center handles emergencies and hospital transfers, and how often these occur. Membership in the American Association of Birth Centers is a plus, too. Whether choosing an auto repair shop, a law firm, a pediatrician, or a birth center, it definitely pays to do your homework.

Photo credit: JER_0079

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Filed under Cesareans, Maternal-child health, Natural childbirth

Back in the saddle…at Science & Sensibility

Some days are like that…

Been away from the blog too long! But I haven’t been snoozing…

Science & Sensibility just put up a post of mine about delayed cord clamping (DCC)–i.e., the practice of waiting 2 or 3 minutes after birth before clamping the umbilical cord.

It’s hard to believe that it’s so difficult to get maternity care providers to sign on to DCC (versus immediate cord clamping, or ICC) in uncomplicated vaginal births. The benefits of DCC–better iron stores for babies, improved cardiovascular transition from fetal life to babyhood, and a big dose of stem cells–are well known, and there’s no evidence that ICC is beneficial to anyone. Still, tradition is a hard habit to break, especially when it comes to medical practice.

So skip on over to S&S and have a read!

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Filed under Cord clamping, Maternal-child health, Natural childbirth, Newborns