Category Archives: Natural childbirth

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

Is it the cesarean, or the absence of labor?

Stem cells, pondering the future

Stem cells, pondering the future

I’ve written a fair amount about the association between cesarean birth and the increased risk of immune-related diseases like asthma, diabetes, celiac disease, and even obesity. Most of the research out there has focused on the newborn gut microbiota—the collection of bacteria that colonize a baby’s intestines at birth and play a key role in the development of the immune system. These bacteria are primarily acquired from the mother’s birth canal and rectum during a vaginal birth, but for cesarean-born babies those “pioneer” bacteria are often derived from the hospital environment. Such “wrong” bacteria in the bowel early on can lead to inflammation and, the theories go, to immune-related diseases later in life.

But is the cesarean per se at the root of all this? Or might the absence of labor (or an incomplete labor) have something to do with it? Childbirth is, after all, a fabulously complicated dance of maternal and fetal hormones, anti-oxidants, and other chemicals that are known to influence the immune system. What happens to the newborn’s immune system development when that dance is cut short, or never starts in the first place?

A study from Sweden’s Karolinska Institutet published in the current issue of the American Journal of Obstetrics and Gynecology has me wondering about the “absent-labor” scenario again. The study’s authors compared cord blood samples from babies born by elective cesarean section (ECS) with those who were vaginally born (VB). They looked specifically at hematopoietic stem cells—the precursor cells that go on to become, among other things, the white blood cells that play a critical role in the human immune system.

Here’s what they found: the DNA in stem cells from ECS babies was significantly different from that of the VB babies, particularly in an area devoted to production of antibodies. The study’s genetic analysis is way above my pay grade, but boiled down to the essentials, the differences are all about epigenetics, which is defined as:

 “…the study of changes in gene function that are mitotically and/or meiotically heritable and that do not entail a change in DNA sequence.”

Ouch!

Plain English version (mine): Epigenetics is the study of how genes are turned on and off, typically by the addition of methyl groups (ouch, again!) to genes. The timing of all this light-switch-like activity, and the potential for permanent change, has big-time implications for health throughout life.

The Swedish researchers found that stem cell DNA methylation (the addition of methyl groups to genes) increased steadily with the duration of labor. So one could conclude, couldn’t one, that normal labor plays an important role in preparing future white blood cells for their task, and, ergo, the absence of labor is why everyone’s so chubby these days? Sure, one could conclude that…but one would be jumping the gun, big time.

Hold that smokin' gun, pardner!

Hold that smokin’ gun, pardner!

Why? Because this was a small, observational study—the kind of study designed to make readers sit up and take notice (Hmm…that’s interesting!”) but that requires much more research before any guns start smoking. The small numbers of subjects in this study makes it easier for error to creep in, for example, and there were significant differences between the mothers as well—the ECS group was significantly older than the VB group, and their babies were born an average of a week and a half earlier, factors which might cause their own epigenetic effects.

It’s going to take much larger studies to see if these findings are in fact true, and if so to tease out how significant such cesarean-related epigenetic changes may be in the grand scheme of childhood immune system diseases. A lot of vaginally born kids end up asthma, after all. Including me.

But still, how fascinating! I’m looking forward to reading more about this.

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Photos courtesy Joseph Elsbernd, Jim Sher

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Filed under Asthma, Cesareans, Gut microbiota, Natural childbirth, Obesity

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

More good cord-clamping news!

The time, they are a-changing...

The times, they are a-changing…

Well, things are moving mighty fast in the world of cord clamping…

A study just released in the The Lancet, Britain’s leading medical journal, found that where a baby is placed during the 2-3 minutes between birth and delayed cord clamping (DCC) doesn’t seem to matter. The researchers found that all the babies in the study (500+) received the same amount of blood from the placenta, whether they were placed at the level of the birth canal (e.g., being held by the obstetrician or midwife) or placed on the mother’s abdomen or chest. The authors’ conclusion:

Position of the newborn baby before cord clamping does not seem to affect volume of placental transfusion. Mothers could safely be allowed to hold their baby on their abdomen or chest. This change in practice might increase obstetric compliance with the procedure, enhance maternal-infant bonding, and decrease iron deficiency in infancy.

So, as long suspected by DCC advocates, there’s no problem with immediate skin-to-skin placement.

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Cord-clamping news: Somebody call ACOG!

Finally… the current issue of Obstetrics & Gynecology includes an article that supports delayed cord clamping (DCC) for healthy term newborns. (Obstetrics & Gynecology is the official journal of  the American Congress of Obstetricians & Gynecologists, better known as ACOG.)

Tying_Umbilical_Cord

Just a matter of when…

Written by pediatrician Ryan McAdams of the University of Washington, the article reviews the evidence that delayed cord clamping (DCC) is beneficial for healthy term newborns compared with early cord clamping (ECC), mainly because DCC provides increased iron to the newborn.* (For a brief tutorial on the timing of cord clamping and why iron is so important to infant brain development, click here for a couple of posts I wrote for Science & Sensibility, Lamaze International’s blog.)

Despite the proven benefits of DCC, and the ease of switching from ECC to DCC (there’s no training or equipment needed–the obstetrician simply has to wait two or three minutes after delivery to clamp the cord), the American Congress of Obstetricians and Gynecologists (ACOG) has been lukewarm in recommending the practice. In a 2012 policy statement, ACOG stated that:

“…insufficient evidence exists to support or to refute the benefits from delayed umbilical cord clamping for term infants that are born in settings with rich resources.”

That phrasing was a bit of a puzzler. Given that a) it’s been known for several years that DCC increases iron stores in infancy, and b) that as many as 1 in 6 American toddlers are iron deficient, it’s not exactly clear what “insufficient evidence” and “settings with rich resources” ACOG was referring to.

McAdams dismantles that logic:

“Delayed cord clamping in term neonates promotes improved iron stores, prevents anemia beyond the neonatal period, and is more physiological than early cord clamping. Although the effect of delayed cord clamping may be more apparent in settings with a high prevalence of anemia in neonates and children, it is likely to have an important effect on all newborns, independent of birth setting.”

It’s hard to know if this will be enough to get ACOG to amend its 2012 statement on the timing of cord clamping for term babies. Regardless, now comes the hard part–convincing reluctant maternity care providers to change old practice habits and adopt DCC, with or without ACOG’s official blessing. This article should help.

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*There are even greater benefits for premature babies, but that’s the topic of a different post.

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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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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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