What is the right time for twins?

37 weeks is becoming the due date for twins- which is actually considered too early for an elective induction or c-section for singletons. There’s a reason for this. In 2016 a large, international study came out saying that allowing twin pregnancies to continue to 38 weeks dramatically increased the chances of still birth.Breast-feeding Twin Babies At Home.

But if you have been in the home birth community for a while, you may have heard stories of a few rare moms who had home births twins at 39 or 40 weeks. There are some stories here.

It’s an interesting divide.

Who is “right”?

Well, first of all, I don’t think this subject is about getting the right answers. I think it’s actually about asking the right questions.

It’s A BIG Study. Is That a Good Thing?

The authors said they included all studies in the “Medline, Embase, and Cochrane Library using the NHS Evidence website and Cochrane online library platforms from inception until December 2015 for studies on twin pregnancies that reported rates of stillbirth.” The studies reviewed in this study covered different countries. They looked only at dichorionic pregnancies- twin pregnancies where the babies each had their own placenta. (Monochorionic-monoamniotic pregnancies are rarer and known to carry additional risks. These occur only in identical twins.)

This study did very little to limit confounding variables. Confounding variables are these darling little factors that suggest correlation when there isn’t any. In this case, the confounding variables include:

  • Monozygotic (identical) vs. dizygotic (fraternal) twin pregnancy- monozygotic twins are considered to have more risks than dizygotic twins.
  • Spontaneous (no fertility treatments) vs. conceived with fertility treatments.
  • Age of mother (moms over 40 have a higher likelihood of twins, but also a higher risk of complications. Moms under 18 have higher rates of complications as well).
  • Nutritional deficiencies such as anemia or iodine deficiency- especially important if any of the included studies came from developing countries.
  • What type of prenatal care women were receiving, in fact the authors were aware of this variable and its potential for confounding and state that “The variation observed in the clinical management of twin pregnancies and neonatal care after delivery between centres could also have influenced the outcomes.”
  • Any pre-existing conditions the mothers may have had.

So because there was so little control for confounding variables, the authors of this study are like, “Oh gee! ALL twin pregnancies are at risk for stillbirth at 38 weeks!!!”

Twins at Home vs. Twins in the Hospital

In the few places where midwives are able to deliver twins (a number which is dwindling), the twin pregnancy would have to go past 37 weeks or the midwife would not be allowed to attend. So accounts of mothers who have had home births of twins are already in a different situation with gestation than many mothers who have delivered in a hospital. These are anecdotal accounts and there are very few- but I still think they are an interesting phenomenon to consider.

Mary Cronk, a British midwife with over 45 years of experience and who has delivered several sets of twins advises mothers that identical twins generally carry more risks. (You can read her guidelines for midwife care of twins at the above link.)

However, there are a few very rare cases of identical twins born at home in the 20th century, midwife Jeanine Parvati Baker’s being one of them. (I don’t know of any online publications of her twin birth but you can read about it in Elizabeth Noble’s Having Twins and More and Jeanine’s book Prenatal Yoga and Natural Birth.)

An interesting side note is that her twins were considered at risk for being “locked twins” because Baby A was in breech and Baby B was vertex. However, Jeanine didn’t have many of the other risk factors for locked twins such as small babies, first birth, oligohydramnios, uterine hypertonicity, early rupture of the second sac (and I think her twins were dichorionic). Her babies were born at term and healthy and lived to adulthood.

On the other hand, the study in the BMJ acknowledged that one of its limitations was that recommendations of delivery for twins have varied between 34 and 38 weeks- which means that some pregnancies that may have gone longer didn’t because a delivery was scheduled earlier. And as, the authors point out, because of the high rates of pre-term delivery (both spontaneous and planned) they had a smaller sample size of births going to 37 and 38 weeks. And a smaller sample size means that any anomaly can throw the numbers off. (One death in ten looks riskier than one in a thousand- even if that one in ten was a fluke.) So the bottom line is that we have very little good data on what it would mean to carry a twin pregnancy to 39 or 40 weeks because it doesn’t usually happen in a hospital setting and midwives attend very few twin births.

 

Are We Asking The Right Questions?

So the 2016 BMJ study merely found an average across a VERY broad spectrum of twin pregnancies and has urged that delivery for all twin pregnancies be based on this average.

But I don’t think the question should be “How can we schedule the delivery to avoid preterm complications and stillbirth?”

The question should be, “How do we get more precise about predicting which pregnancies are at risk of stillbirth?” Since delivery at 37 weeks can cause an increased incidence of issues like respiratory problems, are there some twin pregnancies that could go full-term without risk to the mother and babies? And along with that, how can we prevent preterm labor and delivery of twins? Shouldn’t we be looking for how we can do better than 37 weeks?

Feeding a Baby When An Emergency Strikes

I realize that for my readers living in the American Tornado Alley this post might be a little late. But if you’re living near the Atlantic Ocean, hurricane season is just getting started. (And NOAAA says this season is going to be a doozy.) And if you’re living on a fault-line the threat of an earthquake is ever present. After you’ve stockpiled your buckets of food, generator and jugs of water, what about the baby?

There’s a couple of things to know…

Breastfeeding During An Emergency

Breastfeeding is ideal during an emergency. Breastmilk straight from the breast is sterile and requires no water or power to prepare or store- both of which may be in short supply in a disaster scenario. Remember, after a serious hurricane, earthquake, etc. power and water will probably not be available. Even if you have powdered formula and stored water available, the bottles and nipples will still need to be sterilized for safe feeding and if there is no power available to heat water for cleaning and sterilizing and no refrigeration for stored formula then the baby is at risk for illness from contamination.

There is an idea circulating that women can’t breastfeed during a disaster because they won’t make milk or have a let down. This is only sort-of true. Adrenaline release during a stressful situation can inhibit the letdown reflex. And some women do experience a temporary supply drop during stressful times. But this doesn’t mean that you can’t or shouldn’t breastfeed during a disaster situation.

You can help both your milk supply and letdown reflex during stressful times by nursing your baby frequently and using relaxation techniques. Deep breathing skin-to-skin contact with your baby (if safe) can help reduce the levels of adrenaline and allow for letdown to occur. There are also some scripts and exercises for visualization and relaxation that have been shown to help mothers with inhibited letdown. Ask emergency workers if there is a quiet place for you to breastfeed, they should be willing to help because breastfeeding a baby will reduce the risk of the baby getting sick. You can still breastfeed even if your calorie intake drops for a short time or eating gets a little crazy during evacuation.

I did experience inhibited letdown and a supply drop during stressful time. My baby was nine months old, so we gave her a little more solids to be on the safe side and I just kept nursing her frequently- really frequently. The more a baby feeds at the breast, the more milk the mother will make, so if you keep nursing it will drive up your supply. My letdown returned and my milk supply came back up after about a day and returned to normal within about two days. I do wish I had tried a few more relaxation techniques though. I think it would have helped.

Formula feeding during an emergency

If you are partially or fully formula feeding, ready-to feed-formula is the safest choice!!! Make sure you have plenty in your emergency storage. Only use powdered formula if there is bottled or boiled water available and it can be put in sterilized bottles.

Supplies for Emergency Infant Feeding

From the International Breastfeeding Journal:

An emergency preparedness kit for exclusively breastfed infants should include:

  • 100 diapers
  • 200 wipes

The contents of an emergency preparedness for formula fed infants will vary depending on whether ready-to-use liquid infant formula or powdered infant formula is used.

For ready-to-use liquid infant formula, an emergency kit should include:

  • 56 servings of ready-to-use liquid infant formula
  • 84 L water
  • storage container
  • metal knife
  • small bowl
  • 56 feeding bottles and nipples/cups
  • 56 zip-lock plastic bags
  • 220 paper towels
  • dishwashing soap
  • 120 antiseptic wipes
  • 100 diapers and
  • 200 wipes.

If powdered infant formula is used, an emergency preparedness kit should include:

  • two 900 g cans powdered infant formula
  • 170 L drinking water
  • storage container
  • large cooking pot with lid
  • kettle
  • gas stove
  • box of matches/lighter
  • 14 kg liquid petroleum gas
  • measuring container
  • metal knife
  • metal tongs
  • feeding cup
  • 300 large sheets paper towel
  • dishwashing soap
  • 100 diapers
  • 200 wipes
  • The instructions on how to use all this are pretty lengthy, so see the article here.

If you’re concerned about the possibility of baby and mother being separated in a disaster situation, you can store materials for formula feeding as well.

To help with relaxation for milk supply and letdown, you can try storing some things like a vial of lavender essential oil to sniff. Kelly Bonyata says some mothers have used a homeopathic remedy called Rescue Remedy and it has helped them with inhibited letdown and stress.

You can also have printed and laminated scripts for visualization and relaxation in your kit  as well. Links for these are here, here (biofeedback techniques for pumping, but can be applied to relaxation for breastfeeding), and here (scroll down to the bottom the page, it’s the one called “relaxation and desensitization scripts by David Ross, College of Lake County”; it’s downloadable).

From the WHO- An article on supporting breastfeeding mothers during disaster and in refugee camps.

From Diana D. Bienvenu, Breastfeeding Coordinator and Pediatrician at LSU Health Sciences Center- Powerpoint on infant feeding during natural disasters.

 

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Feeding Your Body, Baby and Spirit During Fasting Days

My daughter was screaming at me because I had put her in the play yard after she tried to eat a piece of paper that was destined to become an orange origami rose. (I was having “Special Time” with my 7 year old. He said he wanted me to help him make an origami box and and an origami rose so that he could put the origami rose in the origami box and send me a flower. The kid has style.) She desperately needed a nap and all the nursing, cuddling and sweet talk would not convince her that it was time to make like a Samuel L. Jackson bedtime story and go the @#$% to sleep.

Meanwhile, I tried to return back to the origami box which was relatively simple normally, but difficult today as my cortisol levels were rising. Then I realized that it was time to turn off the oven because the batch of blueberry muffins I had baked were done. I still had a forum post to write and an assignment to proofread and turn in for my MPH class. And an assignment I wanted to finish for my childbirth educator certification. And a handout for the new breastfeeding class I’ve been preparing.

I needed an escape. I needed chocolate. I needed Facebook. I needed to have a meltdown.

Unfortunately, I had made a promise to God that today I was going to fast by giving up chocolate, Facebook, and meltdowns today. So I could either break my promise to the Almighty or start dealing with my emotions.

I did the latter. I took a deep breath and had a drink of water. I finished the box and rose and calmed my daughter- who did not nap.

But God has a sense of humor.

That evening we left on what was supposed to be a walk around the neighborhood and ski resort where we live. After a few wrong turns, it turned into a three hour trek around the mountain with three kids and a stroller in tow as darkness fell. And I was wearing sandals.

I needed an escape. I needed chocolate. I needed Facebook. I needed to have a meltdown.

And again, I chose to look at my emotions instead.

After realizing that I was actually more scared than angry, I took stock of the situation. My husband was staying calm and getting the boys and the stroller down the steep hill. We were getting close to home. It wasn’t too cold. The boys were being real troopers. My daughter was sleeping. We had a flashlight.

It wasn’t pleasant. But we would be OK. My fear left me and so did my anger.

I knew the kids needed calm leadership, so I decided keep my suffering to myself. When we got back I was in a calmer state of mind and able to get dinner ready instead of lashing out at everyone. And I did realize that I could not only navigate a mountain in the twilight, but also my emotions as well. It was because I was fasting.

Why Fasting?

Most religions have a history of some form of fasting:

  • Catholics fast during Lent,
  • Jews fast during Yom Kippur and other holy days throughout the year
  • Muslims fast from sunrise to sunset during Ramadan
  • Orthodox Christians fast weekly and during certain holy days
  • Latter Day Saints (Mormons) hold a fast Sunday every first Sunday of the month

In addition to public fasts, members of some religions will observe private fasts. For example, Jews often fast on the anniversary of the death of a parent or teacher and Latter Day Saints will hold private or local congregational fasts for guidance or for sick friends or family.

In the tradition of Kundalini Yoga, there are many types of fasts that one can do, all with the goal of gaining greater spiritual strength. Even people with no religious affiliation have gotten into fasting. Silicon Valley start-up investor Tim Ferriss has talked extensively about the benefits of fasting for health and athletic performance. He has also challenged his social media followers to follow him in giving up substances and behaviors like alcohol, caffeine, complaining and masturbation for 40 day periods, citing increased productivity and discipline.

There are many reasons for fasting: sacrifice, discipline, repentance and a desire to help others who are less fortunate. Because reducing caloric intake and nutrients can have an effect on our developing babies or our milk supply, so most religions exempt pregnant and breastfeeding mothers from fasting. However, this makes it difficult to fully participate in religious activities that require fasting. But we can still gain the spiritual benefits of fasting by abstaining from other things.

What Are You Grabbing For?

“What happens with you when you begin to feel uneasy, unsettled, queasy? Notice the panic, notice when you instantly grab for something.”
― Pema ChödrönWhen Things Fall Apart: Heartfelt Advice for Hard Times

When you hit that edge, when you feel angry, scared, sad, what do you grab for? We all agree that it’s bad to go get high on crack-cocaine, beat your kids or cut yourself if you’re feeling upset about something.

But what about shopping, yelling, chocolate, going out to eat, soft drinks, energy drinks, social media, online gaming, criticizing, gossip, eating disorders (anorexia, bulimia, binge-eating disorder) and codependent behaviors?

We typically don’t experience a stigma (or as much of a stigma) for grabbing an ice cream cone or energy drink or checking our Facebook or Instagram accounts. Codependency is one of the most beguiling addictions because it makes you look so good- you’re always serving others and saving the day.

When faced with the fact that we can use these as emotional pain-killers, sometimes we give blanket statements: “No more social media/TV/junk food, etc.” But it’s not just a matter of the substance or behavior. The underlying motivation behind the compulsive use is still there. And if you delete your Facebook account or throw out your TV or computer, something else will be there to take its place. This why the health field is using something called emotional regulation to help reduce rates of drug use.

So fasting a particular behavior or substance gives us the chance to take our spirituality up a few levels by getting real with ourselves. Even if you’re healthy enough to fast food and water, I still recommend this because I’ve seen how much it has helped me.

But there are some things that are just flat-out bad for us and others like smoking, junk food, gossiping, criticizing, whining, etc. Fasting gives a chance to work on cleaning these things out of our lives.

Fasting Strategies for Pregnant and Breastfeeding Moms

I highly recommend choosing a behavior related fast- for everyone. Possibilities include:

  • Whining/complaining
  • Criticizing
  • Gossiping
  • Co-dependency
  • Negative self- talk (The first time I did a fast for this, I was surprised at just how many times I criticized myself every day.)
  • “Why me?” thought patterns
  • Making excuses
  • Swearing
  • Shopping
  • Faultfinding
  • Video games
  • Nail-biting

Food and drink possibilities:

  • Junk food (candy, chips, etc.)
  • Chocolate
  • Soft drinks/ sodas/ juice (Why juice? Check it out on this previous post.)
  • High caffeine content drinks
  • Meat and/or dairy (If you are going to give these up for a few weeks, please check with your care provider about ensuring you will have adequate iron, vitamin B 12 and protein.)
  • Refined grain products (white flour, white rice, white bread, etc.)
  • Microwaved, canned and fast foods

Another option is a kitchari fast from the yogic tradition. Kitchari is a pretty simple mung bean and vegetable soup with spices like turmeric, ginger, cardamom, chiles and black pepper. On a kitchari diet fast, you eat only kitchari, rice, yogurt, fruit and drink water or simple herbal tea- but you can have as much as you want. This kind of a diet would supply mom and baby with lots of nutrients and protein for a day or two, though it would probably be insufficient over a period of weeks. For mothers who are fasting between sunrise and sunset, other foods could be added in during early morning and evening. Make sure to check with your care provider to ensure that you and your baby will have your nutritional needs met. This site has some good menu ideas for kitchari fast and a good recipe for kitchari. (Note: many people specifically say that white basmati rice is best for a fast because it is supposed to be easier to digest. Personally, I choose whole grain rice.)

Supporting Yourself During A Fast

Fasting is a great time to connect with others who are also working on self-improvement. It can be helpful to join a support or recovery group for past grief or trauma- sometimes these feelings come up when we take away a substance or behavior that we have been using to cope. You can also get other pregnant and breastfeeding mothers from your congregation involved. Create a group that meets during holy days to focus on fasting intentions and provide encouragement to each other.

The natural thing to do is to binge when you’re done fasting- resist the urge. Once your fast day is over, don’t grab for the Hagen-Dazs immediately or head on a shopping spree. Fasting is an opportunity to develop new, healthier habits. Try to be mindful. (Family and friends who are fasting food and water might also feel better if they eat simple meals after fasting rather than big meals.)

We often think of fasting as taking away nourishment, but for pregnant and breastfeeding mothers fasting by eliminating unhealthy behaviors or substances can be a great way to actually nourish themselves and their babies better. It’s a great way to participate more fully in holy days and nurture ourselves spiritually.

 

 

 

 

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21st Century Digital Moms

Yes, that’s a reference to Bad Religion’s “21st Century Digital Boy”, one of my husband’s favorite songs.

I’ve definitely been seeing a shift in my own profession of breastfeeding support as online social networking is taking off. I think at this point social media is kind of like The Force (or duct tape): it has a light side and a dark side and it holds the entire universe together. Social media is becoming a more and more crucial part of breastfeeding support. Facebook and other online communities serve many important purposes for us Millennial moms…

Easier Connection

I’m not talking about high speed internet here.

Many women have few friends or relatives who have breastfed, so Facebook groups and other online communities are a great way to feel more “normal” about breastfeeding and get advice from other mothers. Social media also has the advantage of offering support on a much more instant basis than many other types of support. For example, breastfeeding clinics are typically held at one particular hospital during business hours and La Leche League meetings happen once a month- if there’s a group in your area. Facebook and online communities offer much faster support since a mom with a question can log on from her home any time of the day or night and reach other people who may be able to offer advice or encouragement.

Geography

I’ve had some requests to start a local breastfeeding support group. Since the local community center doesn’t want to get involved, I may have to get a bit more guerilla marketing style and come up with some scrappy alternatives- one of which may be online support. We live in a rural area and people tend to be more spread out here. Living in a resort town also means that many residents work non-traditional schedules. Connecting digitally can allow mothers in rural areas to connect with help that may not be easily accessible otherwise.

The Downside…

On the other hand, we’ve seen more moms getting all kinds of inaccurate advice online. And there are some anatomical issues that absolutely need an in-person assessment of a qualified practitioner. Tongue-tie is one particularly troublesome issue and a frequent refrain among lactation consultants, breastfeeding educators and doctors and dentists who specialize in this issue is “You can’t get an accurate diagnosis on a Facebook group.”

We Like Texting As A Form of Communication

In the most recent meeting of my local Breastfeeding Coalition, the observation came up that many women prefer text message help rather than phone calls. In one area, they said that they had seen their Loving Support Hotline cut back- it’s just not being used as much. But everyone agreed that moms will text. I know I feel more comfortable writing out a text than having to talk to a stranger in a phone call. Because they can’t interrupt me, I feel like I can explain myself better.

Before the rise of smartphones hotlines may have been used more, but I think that is changing- a lot. One big review of breastfeeding support studies that covered 56,000 women from 21 countries showed that face-to-face support was the most effective at helping mothers to exclusively breastfeed longer and that methods that required the mother to actively find help- specifically telephone hotlines- were much less effective. I think in the next ten years breastfeeding support hotlines might go the way of dinosaurs and dodos- replaced by peer counselors with smartphones and unlimited text plans.

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I Love WIC- But We Need Some Changes To Food Packages

First of all: Happy World Breastfeeding Week!!! Along with that, this week is also the first ever National WIC Breastfeeding Week.

I love the concept of the WIC program. The Supplementary Food For Women, Infants and Children (WIC) program is supposed to increase access to healthy food for low-income pregnant and breastfeeding mothers, babies and children under 5. The problem is that some of the food options may actually be doing more harm than good…

Juice is actually a risk factor for diabetes

WIC gives $8.00 in cash vouchers for canned/frozen/fresh fruits and/or veggies for children and $11.00 for women. You can also get roughly 1 gallon of juice every month. But here’s the problem with juice:

“Conversely, those who consumed one or more servings of fruit juice each day increased their risk of developing type 2 diabetes by as much as 21 percent. The researchers found that swapping three servings of juice per week for whole fruits would result in a 7 percent reduction in diabetes risk.

The fruits’ glycemic index (a measure of how rapidly carbohydrates in a food boost blood sugar) did not prove to be a significant factor in determining a fruit’s association with type 2 diabetes risk. However, the high glycemic index of fruit juice — which passes through the digestive system more rapidly than fiber-rich fruit — may explain the positive link between juice consumption and increased diabetes risk.” – Harvard School of Public Health, about a 2013 study in the British Medical Journal

So the WIC program is probably contributing to the problem of type 2 diabetes among low-income women and children.

In my opinion, a better strategy would be to replace the juice with an extra $3-$5 of vouchers for fruits and vegetables. Preferably a separate one so that families can use the second another time during the month instead of all at once.

I’m Not Asking Much- I Just Want A 42 oz Cardboard Canister of Rolled Oats

You can only buy 16-32 oz. bags/boxes/cardboard canisters of oats on WIC. But one of the most common sizes for rolled oats are 42 oz. cardboard canisters. And that 42 oz. canister of rolled oats costs about as much as a box of Cheerios or Honey Bunches of Oats- which are WIC approved cereals. Seriously, just approve the 42 oz. cardboard canister of rolled oats already.

…And, Here It Comes: Allow Full-Fat Dairy Products

Yes, I actually said that.

Folks, the science behind the “low-fat diet for everyone” idea is actually pretty sketchy.

In 2006, the results came in from the large scale Women’s Health Initiative Dietary Modification trial came in. The WHI Dietary Modification trial tracked 49,000 women over 8 years. It showed that a low-fat diet hadno effect on heart disease, breast cancer, colorectal cancer, or weight.” 

That’s the right. The cornerstone of dietary advice from the 1990’s, was not exactly evidence-based.

But it’s actually not too surprising since no large scale dietary trials on the low-fat diet for everyone were ever conducted before it became accepted as “fact”. Trials had been conducted on individuals with heart disease. Researchers noticed that cutting down the fat intake of high-risk individuals reduced heart attacks, and the idea took hold that if everyone followed a low-fat diet then everyone would be healthy. (If you are into diet and health, I highly recommend taking a read through the above cited article because it is an eye-opening account of how cold pressed olive oil and raw nuts became “bad food” and Snackwell’s low-fat cakes became “healthy”.)

 

Unfortunately, the US government has not caught up with some of the more recent dietary research. But hopefully in the future women and children on WIC will have better access to healthy food.

 

Bioethics Is Not A Sequel To A Pauly Shore Movie

“Is your wife one of those people who will go along with it? Just sign him up for the surgery and you can go home and discuss it with her later.”

My husband had come to a prominent teaching hospital in Southern California affiliated with the Seventh Day Adventist faith seeking orthotic braces for our son. Instead, he was getting a hard sell for an experimental surgery. The surgeon was conducting a study on a procedure for certain hip problems and was looking for another subject in his study. My husband kept asking what the potential risks were with the procedure, but all the surgeon would say is that the procedure was “controversial”. (He was in full-blown authority mode too since he had medical students shadowing him.)

The surgeon kept pushing, but my husband didn’t feel good about the way the surgeon was refusing to disclose possible risks. We had worked so hard to get our son walking unassisted after being told that he never would and we knew that surgery is like getting a tattoo- you can never go back. (Sometimes that’s a good thing, like closing the lesion on the back of a spina bifida baby.) Ultimately, my husband left saying that he needed to do more research and talk to me before committing to anything.

That night we started researching medical journals and studies online and found out that while this surgery has shown some benefits for kids with cerebral palsy, it has no demonstrated benefits for kids with spina bifida and could potentially cause long-term damage to CJ’s ability to walk. We breathed a sigh of relief that we waited, did our research and got informed- even though the doctor neglected his responsibility to disclose the risks of the procedure.

Unfortunately, the orthopedic surgeon at said hospital refused to provide our son with the orthotics our son needed to maintain mobility. That started us on a nightmare of trying to get adequate orthotics for our son that we are still dealing with a year and a half later. But that’s another story.

I don’t think this surgeon (who would have made one helluva used car salesman) was thinking, ” Wow, I really want to screw this dad and his special needs kid over.” I think he was probably thinking something like “This kid isn’t going to have much mobility over the long-haul anyway. The surgery can’t be that damaging and I’ll get another subject to help further my research which will help other children.”

As parents, we chose our son’s mobility. Our son also wasn’t a good candidate and so we felt that including him in the trial wasn’t that beneficial to kids with CP anyway.  But we were disturbed by the actions of the surgeon. It was like he had never heard of the term “bioethics”. (Is that some kind of sequel to the 1996 comedy Bio-Dome?)bio-dome

Bio-what???

Bioethics is the practice of ethics within the field of medicine and healthcare. The Center for Practical Bioethics says that bioethics is about asking the following questions: What is the right thing to do and the good way to be? What is worthwhile? What are our obligations to one another? Who is responsible, to whom and for what? What is the fitting response to this moral dilemma given the context in which it arises? On what moral grounds are such claims made?



Medical and public health issues tend to bring up a lot of sticky ethical situations about things like responsibilities, informed consent  and conflicts of interest. And when you’re dealing with people’s lives- either in the immediate as a patient or loved one or on a broader scale in public health or an experimental procedure- it’s tempting to feel like the end justifies the means. For example:

A teenage boy died of organ failure from MRSA, but was also infected by influenza at the time. Is it ethical to present his case as an example of why people should get a flu shot when a flu shot would not have prevented the infection and spread of MRSA?

Parents who have received a diagnosis of spina bifida for their unborn child have a few weeks to enroll in a trial for prenatal surgery. The surgery may or may not improve their child’s function and carries a high risk of premature birth, but could add to the body of research on the procedure, potentially helping other children. The parents are in a state of shock, reeling from the diagnosis. Should the parents be encouraged to undergo the surgery?

How do we feel about Jonas Salk experimenting with flu vaccines on mental patients who could not consent to the experiments and could not give accurate feedback about the experiments? How about Joseph Goldberger causing pellagra in prison inmates to study the disease?

Do parents have a right to sue a care provider because their baby’s birth defect wasn’t detected until birth? Sonograms and prenatal testing are not guarantees of health.

Should we in the breastfeeding community tout gains in IQ as a primary benefit for breastfeeding when intelligence is actually a combination of many factors working together?

How reliable are studies that have been funded by a corporation or have been conducted by researchers who also receive consulting income from corporations?

A doctor is recommending a procedure or medication to a patient. The doctor thinks the procedure or medication will be highly beneficial. There are risks- but the doctor thinks the risks are very, very unlikely. Is it OK for a doctor to simply tell patient that the procedure is “safe” when there are risks? Driving a car and air travel are generally “safe”, but have risks.

Is it OK to allow pharmaceutical companies to advertise directly consumers? Pharmaceutical manufacturers stand to benefit from people asking their doctors for a particular medication- regardless of whether drug is useful or safe to consumers. This means that it’s in the pharmaceutical company’s interest not to focus on how a drug might not be effective or could have serious side effects. (Note, most developed countries do not allow this.)

The Charlie Gard case has (in my opinion) highlighted many different sides of bioethics. It shows the responsibilities and rights of parents, doctors and researchers. Who gets the last say about when to go off life support? When do experimental treatments create false hope? Should parents or doctors have more say in a child’s care? Who is a more reliable judge of what the child needs? Maybe that should be determined on a case-by-case basis?

Another recent case in ethics is USC’s former medical school dean Carmen Puliafito. Puliafito was only recently barred from seeing patients after the Los Angeles Times published an expose of his substance abuse and abusive behavior towards faculty and staff. However, USC had been receiving complaints for years about his heavy drinking- and still allowed him to see patients during that time. However, they have stated that they never had any complaints from patients.

Still, is it ethical to allow an intoxicated physician to care for patients? (Writing as a parent who has had to leave her hours old infant in the hands of surgeons and doctors and not knowing if they have had adequate sleep or are sober, I can tell you this kind of situation haunted my nightmares while my son was in the NICU.)

Inequities Exist

Sometimes there are inequities in knowledge between the care provider and the patient and/or parents. This is why we have informed consent:

Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment. (Appelbaum, 2007)1   It originates from the legal and ethical right the patient has to direct what happens to her body and from the ethical duty of the physician to involve the patient in her health care.

The surgeon who was pushing the experimental surgery had violated informed consent by refusing to disclose the risks to us. Though it was his responsibility to do that, we knew that as parents we had the responsibility to our son to make a decision that was informed. When we couldn’t get the information we needed from the surgeon, we went looking for it ourselves.

A conflict of interest, such as career advancement or funding should go into our decision about how reliable we gauge information to be. Doctors, scientists and everyone who works at a drug company are people. They have their own biases and they have their own agendas. This is why conflicts of interests have to be noted in a medical or science journal.

How Ethical Are We?

And bioethics should always be challenging. We humans have a tendency to think we are doing the right thing- especially if we think there will be a benefit for the greater good. But that altruistic bent can also lead us to do terrible things as well. The Nazi’s believed they were making the world a better place through ethnic cleansing. In the 1970’s doctors often refused care for infants with spina bifida because they felt that these children had so little possibility of any quality of life that letting them die quickly was the most merciful thing to do- despite the fact that treatment existed for the associated health problems with spina bifida.

Jonas Salk, Joseph Goldberg and their colleagues felt like testing vaccines and diets on inmates and mental patients was moral because they hoped to provide better disease prevention for the rest of society. And USC probably felt that the money Puliafito brought in for the medical school from fundraising outweighed the damage of his behavior. I personally believe it’s important to understand the belief system others are operating under- even if we don’t agree with it.

I think bioethics is everyone’s responsibility. Do your research, look for possible conflicts of interest. And always question yourself and others.

Pregnancy, Breastfeeding And That Little Legalized Leaf

Note: This post is only looking at marijuana use in women who are not taking other drugs. Mothers who are taking marijuana in addition to drugs like cocaine, meth, heroin, etc. have more complicated issues and probably somewhat different perceptions of marijuana use than women who are only using marijuana, especially under legalized circumstances. OK, onwards…

I had to write a paper for my MPH class on using an ecological framework to deal with a

Marijuana Yes - No , Marijuana leaf , cannabis , cannabis leaf

public health issue. I decided to write on marijuana use in pregnancy because legalization has created an interesting new landscape with marijuana use. But I was in for a couple of surprises. First of all, more women are using marijuana during pregnancy!

Marijuana use among pregnant women is still relatively rare, but it is increasing. In 2002 2.37% of pregnant women reported using marijuana within the last month. In 2014, that number had climbed to 3.85%. Also startling is that some data from Hawaii showed that women who are suffering with severe nausea in pregnancy are more likely to use marijuana during the first trimester than those who are not suffering from severe nausea and vomiting of pregnancy. The THC levels of both recreational and medicinal marijuana have increased from 4% in 1995 to 12% as of 2014 (Volkow, Compton, Wilson, et. al., 2016).

Perception is important

If people think something is harmful, it’s unlikely they’ll do it. On the other hand, if they believe something to be safe, they probably will continue. The catch is that our perceptions don’t always match with the actual risk level. Research indicates that many young adults who use marijuana perceive it to be “natural” and “safe”. Individuals who believe marijuana is natural and safe often believe that tobacco products are addictive and can cause long-term adverse health effects, so they are aware that smoking and tobacco products like cigarettes and e-cigarettes are harmful, they just don’t believe that marijuana carries the same kind of negative effects (Popova McDonald, Sidhu, et. al., 2017.)

But marijuana use can be harmful to a baby! 

bigstock--132650111Marijuana smoke contains the same chemicals as tobacco smoke with the same risks to lung health for both the mother and baby. (American Lung Association, 2015).  Any chemicals that the mother takes in through smoking marijuana are passed to the baby, just like smoking tobacco products. Marijuana has been shown to decrease milk supply in animals and smoking tobacco products is known to decrease milk supply for human mothers. If you’re trying to make a good supply of milk for your baby, marijuana might not be a good choice.

Marijuana use in pregnancy has also been linked to cognitive impairments such as impulse control, attention and visual memory in children whose mothers smoked marijuana during pregnancy (Volkow, Compton, Wilson, et. al., 2016). Some studies have associated marijuana use in pregnancy with pre-term birth, low birthweight and intrauterine growth restriction, but these studies haven’t always controlled for other drug use. Because the mothers in these studies were using other drugs, it’s difficult to say whether marijuana alone would cause these pregnancy complications. (That’s why I’m leaving them out of the discussion.) Based on my research, the most reliable findings for marijuana use are the dangers of smoking in pregnancy and the possibility of long-term cognitive impairments. THC also passes to the baby during breastfeeding. But all of these reasons should be enough to avoid using marijuana during pregnancy and breastfeeding!!!

Marijuana is a medicine- treat it like one  

“Weed out of all these, to me, is not as harmful … because they suggest it to cancer patients. It’s medicinal.” – 19 year old respondent to survey about perceived harms and benefits of alcohol, tobacco and marijuana.

Medicinal and legal and even “safe” are not the same thing as risk-free. There are plenty of substances that are safe under other circumstances but not during pregnancy and/or breastfeeding. Moderate consumption of alcohol outside of pregnancy is relatively safe and thalidomide is a pharmaceutical that can treat leprosy and myeloma. But during pregnancy, alcohol can cause fetal alcohol syndrome and thalidomide causes birth defects. (In an eerie parallel, thalidomide was prescribed to mothers in the 1950’s and 1960’s to treat morning sickness and caused tens of thousands of babies to born with severe birth defects. It remains one of the great cautionary tales of medications and pregnancy.)

Competent herbalists will tell you that certain herbs and essential oils should not be used during pregnancy or breastfeeding because they can have harmful effects on the baby. Even a relaxing trance state can be harmful when used improperly. My Kundalini yoga teacher is also a certified hypnotherapist and all of her imagery journeys begin with the warning that you should not drive while listening to an imagery journey track because it can put you in a profoundly relaxed state and affect your ability to drive safely. Marijuana is like any other medicinal substance and needs to be used with caution.

But the morning sickness is killing me!!!

Believe me, I feel your pain. When I was pregnant with my oldest, I lost 15 pounds in 6 weeks because I was either too nauseated to eat or throwing up almost everything I did eat. But please, please, please, don’t use marijuana to relieve the misery. Here are some other things you can try:

  • Unisom and vitamin B6– Unisom is a safe-for-pregnancy OTC sleep aid. When taken with vitamin B6 it can help with nausea. I have heard a lot of women with severe morning sickness swear by this. The American Congress of Obstetricians and Gynecologists recommends Unisom with vitamin B6 for relieving morning sickness. Check with your doctor or midwife before you start taking it.
  • Essential oil candies– sour and ginger flavored candies are another recommendation, but I feel like the ones flavored with essential oils really work best. I’ve used Preggie Pops and Preggie Pop Drops during my pregnancies and they have really helped. They helped take the edge off the nausea in my first pregnancy so I was able to eat. (I really liked the sour flavors. But the herbal ones were good too.)
  • Essential oils– Peppermint, orange, lemon, lavender, ginger can all be helpful. Use with caution, consult your care provider. You don’t even have to apply these to the skin, you can sniff them.
  • Sea Bands– Some moms swear by these. Sea bands are a little band that you can wear that applies continuous pressure to an acupressure point called Pericardium 6 (the Chinese name for this point is Nei Guan).
  • Cut out dairy products for a little while– I tried this during my first pregnancy and it helped a lot! Add in other sources of protein to help keep your blood sugar level.
  • Add in a green smoothie- This also helped during my first pregnancy. Drink slowly and take little sips. Dark leafy greens are extremely nutrient dense and can help replenish your stores of calcium and iron.

6 Reasons Why Breastfeeding Problems Are Not Your Fault

Yes, I don’t believe it’s entirely your fault that you are struggling with breastfeeding. (That’s not to say that you can’t breastfeed or don’t have any control over it.) I think most of our public health and private programs that aim to help with breastfeeding forget that we live in a very different situation than ever before in human history when it comes to breastfeeding and childbearing.  So here are the six reasons why it’s not your fault that you are struggling with breastfeeding…

Reason #1: Anatomical issues

Tongue-tie, lip-tie, hypoplastic breasts… these can all cause difficulties with breastfeeding. In these cases, you or your baby were the unfortunate winners of a genetic lottery. However, you can still breastfeed even with these issues. In the case of hypoplastic breasts, you may not be able to give a full milk supply (or maybe you can), but you can partially breastfeed and use a supplementary nursing system to get your baby at the breast when you give supplementary feedings with formula.

With tongue-tie and lip-tie, it’s super important that you have a competent professional who knows how to effectively care for these conditions. Unfortunately, you can’t just walk into the average pediatrician or dentist’s office and get informed advice on tongue-tie and lip-tie, which is why I included an entire detailed section of it in my curriculum.

Please, please, please do your research and learn before you get your baby evaluated or treated for tongue-tie! That way you can do it right instead of getting an ineffective frenotomy that has to be revised later on!!!

Reason #2: Most women around you don’t breastfeed

The first infant formulas were introduced around 150 years ago and breastfeeding rates started dropping. Think about it. For most of human history, the vast majority of women breastfed their babies. Never before in human history have we lived in a time where so many women did not participate in this biological function. If most of the women around you didn’t breastfeed or breastfed only a short time before moving to formula, it’s difficult to establish a baseline of what’s even normal.

Reason #3: Hospitals aren’t always breastfeeding friendly

UNICEF has spear-headed the Baby Friendly Hospital initiative, though some hospitals are still not on board. And even those that are certified as Baby Friendly may not always follow guidelines for encouraging breastfeeding.

Also, gentle/natural/family-centered cesareans that allow the mother skin-to-skin contact with her baby are still pretty rare here in the US. (Though they totally rock for moms and babies who need them!!!) And of course there is the elephant in the room that most births do not require cesarean delivery thought 1/3 of all births in the US are c-sections. C-sections can make it more difficult to breastfeed- though not impossible. (I have known plenty of c-section moms who have breastfed successfully.)

Reason #4: The medical and health professions haven’t caught up

It wasn’t about the late 1970’s that scientific research started coming out with all theformula ad 1950 benefits of breastfeeding over formula feeding. So it wasn’t that long ago that doctors were recommending formula. By that time, breastfeeding had become more or less a dying art.

On top of that, the climate of maternity and neonatal care has changed dramatically since that time. We have more mothers delivering by c-section. We also have more premies and babies with birth defects in the NICU who would not have survived before because technology or medical practice was not in place to preserve their lives. A micro-premie may not have survived 40 years ago and a baby with spina bifida may have been denied care, but we now have better care for premature babies and medical ethics now dictates that babies with spina bifida receive care. So we have a whole lot of special cases with a more limited base of knowledge among medical and lactation professionals.

Reason #5: No one told you that some kind of complication would come up.

Did you go through pregnancy thinking that breastfeeding is normal and therefore easy and then get blindsided by some complication you could not have anticipated in your wildest dreams? Welcome to the club. When I was pregnant with my oldest, I was going to be the perfect breastfeeding mom. I read up on all those breastfeeding positions, determined that I was going to get it right. Then I ended up having a baby who needed back surgery at 36 hours old and all those breastfeeding positions went out the window. during my observation, I heard one mother remark, “It’s like they don’t want to tell us something could go wrong because they’re afraid we might not breastfeed.”

Reason #6: Breastfeeding has been presented to you as an all-or-nothing endeavor.

If you have hypoplastic breasts or had certain types of breast surgery, exclusive breastfeeding may not be in the cards for you. Biologically speaking, there are some cases where it won’t work out. But any degree of breastfeeding is still beneficial for both moms and babies. This isn’t a zero-sum game. Breastfeeding may be different for you than your neighbor, friend, sister or cousin, but you and your baby can still get many of the benefits!

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Kombucha: The Good, the Bad, the Ugly and the Neutral

Most labels describe kombucha as a tea, but that’s actually only true in the loosest sense. Kombucha is a fermented drink, very similar to raw apple cider vinegar.

How is kombucha made? Well, you make some black, green or oolong tea and add some sugar. When the tea is sufficiently cooled off, you dump in some starter kombucha and a SCOBY. (SCOBY stands for Symbiotic Colony of Bacteria and Yeast. Basically, a big blob of good bacteria and yeast. Sometimes called the “mother”.) Over a period of approximately 2-4 weeks, the SCOBY eats the tea and sugar from the liquid and excretes out probiotics which soon permeate the liquid. The result is what we call kombucha.

Calling kombucha a tea is popular way of positioning it for businesses that sell it. Calling it a tea vinegar or bacteria and yeast juice does not sound appealing to most Americans.

How Healthy Is It?

This depends a lot on the particular brand of kombucha and how it’s made. A traditionally brewed kombucha will have trace amounts of caffeine and alcohol. However, the alcohol and caffeine content can be controlled with the right fermentation conditions.

Kombucha that has been fermented between two and four weeks will have a relatively low alcohol and caffeine content because at this point the SCOBY will have eaten up most of the tea and sugar, but won’t start fermenting to the point of high alcohol content yet. This usually considered the ideal for kombucha. If you want to flavor kombucha, you put it in bottles with flavoring like juice or herbs and let it sit for a few days, a week at the most. After about a week, it will start developing higher alcohol content because the sugars from the additional flavoring (especially fruit juice) will quickly be converted to alcohol.

Federal law requires that all beverages that are marketed as non-alcoholic have 0.5% or less alcohol content, so the kombuchas that you find in the store have to meet this standard. In 2010, a public health official in Portland, Maine noticed some bottles of kombucha leaking and thought that the beverages might have high alcohol content. Four brands were taken from the store and tested at the University of Maine and found to have alcohol content ranging from slightly over 0.5% to 2.5%. In the United States, a drink with over 0.5% alchol content has to be regulated by the Alcohol and Tobacco Tax Trade Bureau. So many kombucha brands did a voluntary recall while they reformulated to strictly comply with the 0.5% standard.

Reformulation has meant different things for different brands, and herein lies the central issue with the kombucha vs. soda question. Most brands of commercial kombucha now use a short fermenation process, so the SCOBY doesn’t eat up much of the sugar and tea. This makes the kombucha sweeter. It also makes it much easier for manufacturers to get under .5% because the kombucha isn’t as active. Long brew kombucha can meet the 0.5% standard, but it requires more care. You have to make sure that your fermentation time and conditions are balanced to get to that happy medium.

Because short brewing doesn’t give as much time for the fermentation process, this kind of kombucha ends up being on the flat side. Most short brew brands use forced carbon dioxide to make their kombucha effervescent, just like a soda. The downside to forced CO2 is that it can make the kombucha more acidic.

So long story short, most commercial kombuchas are short brewed with forced CO2 making them more like a sweet tea soda with a little bit of probiotics. There are a few traditionally brewed brands that do a long brew and have very probiotic rich kombucha. Of course whether you do a long brew or short brew, the probiotic benefits will be negligible if the kombucha has been pasteurized.

Most brands of kombucha that use forced CO2 don’t list it on their label, so it is hard to tell from the label alone. Reed’s Culture Club uses forced CO2 as does Kosmic Kombucha. Nationally distributed Kombucha Wonder Drink is pasteurized as well.

From an article in the journal Comprehensive Review of Food Science and Food Safety, the following benefits have been found from kombucha:

  •  High levels of probiotics
  • Antimicrobial effects against both Gram positive and Gram negative pathogens
  • Inhibits the growth of some types of cancer cells
  • hepatoprotective against various environmental pollutants (i.e. protects the liver from nasty pollutants)
  • High antioxidant content
  • B vitamins- including vitamin 12

What about alcohol and caffeine content (especially for pregnant and breastfeeding women)?

 An average kombucha is usually listed as having approximately 24 mg of caffeine per 8 oz. GT’s brand kombucha says that theirs has about 8-14 mg of caffeine per 8 oz. serving. For a point of reference:

  • Starbucks 16 oz. coffee has 330 mg of caffeine
  • 2 Tbsp of Maxwell House ground coffee has about 100-160 mg of caffeine
  • 8 oz. of black tea brewed for 3 minutes has 30-80 mg of caffeine
  • 8 oz. of Lipton black or green decaf tea has 5 mg of caffeine
  • 16 oz. Starbucks decaf coffee has around 15-25 mg of caffeine
  • 2 Tbsp. of Maxwell House ground decaf coffee has 2-10 mg
  • 12 oz. diet Coke has 47 mg of caffeine
  • 12 oz. Sunkist soft drink has 41 mg of caffeine
  • 12 oz. of Barq’s regular root beer has 23 mg of caffeine
  • A Rockstar Citrus Punched energy drink has 240 mg of caffeine
  • A 1 oz. package of Jelly Belly Extreme Sport Beans has 50 mg.
  • 16 oz. Starbuck’s hot chocolate has 25 mg. of caffeine
  • 1 Tbsp. of Hershey’s cocoa has 8 mg of caffeine
  • A 1.5 oz serving of Hershey’s Special Dark chocolate has 20 mg of caffeine.

So a store-bought kombucha will have about as much caffeine in it as a soft drink like Barq’s root beer or Sunkist or 3 oz. of dark chocolate.

Alcohol has been a much publicized issue with kombucha. However, seeing as how any kombucha being sold as a non-alcoholic beverage has .5% or less alcohol the alcohol content is very low. A regular beer is 5% alcohol, so you would have to drink 10 kombuchas to even start approaching the alcohol content of one can of beer. Wines usually have 12% alcohol content in a 5 oz. serving and hard drinks like whiskey and gin are at around 40% alcohol content for a 1.5 oz serving. How does it compare to other non-alcoholic foods/beverages?

The Washington State Toxicology Lab conducted a study on the alcohol content of foods and drinks that are considered non-alcoholic and found that many breads actually have alcohol content greater than 0.5%. The apples in a Great Harvest Apple Walnut Roll actually have an alcohol content of 1.066% and the roll itself has a total alcohol content 0.956%. Rosemary onion bread has an alcohol content of 0.98%. Home Pride brand wheat bread has 0.48% alcohol content.

Fruit juices also have naturally occurring alcohol in them. In fact, the United Arab Emirates has pulled juices from stores for exceeding 0.03% alcohol content  (their legal limit for non-alcoholic beverages). In August 2013, Snapple’s fruit punch drink and peach flavored tea were pulled from the UAE because they were found to have alcohol contents of .48% and .05% respectively. So a carefully long-brewed non-alcoholic kombucha has about the same alcohol content as a fruit juice drink. 

The article fromComprehensive Review of Food Science and Food Safety also noted that some cases of toxicity had been reported, such as dizziness and nausea after consuming certain kombucha products. Lead poisoning has been known to occur in home brewed kombucha that is brewed in containers with lead content. According to this article, kombucha is contraindicated in pregnant and lactating women. I do know several women who have drunk kombucha through pregnancy and breastfeeding and seen no ill effects. Of course, you should always consult your doctor before consuming a substance when you are pregnant or breastfeeding.

 

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Measles, Dying in Childbirth, VBAC’s, Hospitals and Why Bambi Is Deadlier Than An Alligator

The odds of measles complications are high at 1/1000…

The CDC says that 1 in 1,000 people with measles will develop encephalitis and that 1 in 1,000 people with measles will die. 1 in 1,000 is pretty high.

…But the odds of maternal death from blood clots are low at 1/1,000

On the other hand, the risk of maternal death is concerning but relatively low. Here’s what Dr. Shilpi Mehta-Lee, MD Assistant Professor of Maternal Fetal Medicine at NYU Medical Center says about maternal death from blood clots: “We actually know the risks are between 1:500 and 1:2000, which makes 1:1000 about average. When you put the statistic that way, it sounds pretty bad, but what that really breaks down to is about a 0.25 to 0.1 percent risk. That means more than 99.5 percent of women won’t have this problem.”

Amniocentesis is safe, VBAC’s aren’t?

Amniocentesis has a 0.6% risk of miscarriage- a slight risk according to the Mayo Clinic. But a VBAC is pretty risky. Which is why many doctors and hospitals don’t do them. No one wants to mess around with a 0.07% uterine rupture rate.*

Which is more likely to kill you, an alligator or a deer?

There were 9 alligator and crocodile related deaths during 1999-2007Nine. Isn’t that crazy? Better cancel your trip to Florida. You’ll be much safer driving on the interstate in October where vehicle collisions with deer cause only 200 deaths a year. (And an estimated $4 billion in damage annually.)

But you can’t any get safer than going to the doctor…

Except that 1.7 million Americans develop nosocomial (healthcare-acquired) infections each year, and 99,000 die from them every year. And 3/4ths of these infections start in places like nursing homes and doctor’s offices- the other 25% mostly come from hospitals. The total economic burden of nosocomial infections may be as high $45 billion per year. That’s billion, with a “b“. (For a point of comparison, consider that a measles outbreak can cost state and local health departments about $2 million to $3 million.)

What kills more people than emphysema, HIV/AIDS, Parkinson’s disease, and homicide combined?

Antibiotic resistant methicillin staphyoloccocus aureus infections (MRSA).

How we perceive risk

What if I tell you that vitamin A reduces the risk of measles death and complications? What if I tell you that c-sections increase the risk of deadly blood clots? Do you feel differently about measles? About c-sections? Should you be less concerned about measles or more concerned about maternal death? Both? Neither? Equally concerned?

We like to think of ourselves as rational human beings, but the truth is that we make decisions based on emotion. Sometimes we listen to the loudest screams rather than what is most likely. But on the other hand, being that one in a thousand isn’t fun.

The bottom line is that every decision we make has some kind of risk associated with it. When you make a choice about your health or your child’s health, there is no such thing as risk free. You will always be choosing a set of risks and benefits. The question will always be which benefits and which risks are worth committing to for you?

*Yeah, I had to do a double take on this too because I had heard the 0.4-0.7% statistic most often quoted. Apparently the risk of rupture is even lower than previously described. This is from newer research: “From 1976-2012, 25 peer-reviewed publications described the incidence of uterine rupture, and these reported 2,084 cases among 2,951,297 pregnant women, yielding an overall uterine rupture rate of 1 in 1,146 pregnancies (0.07%).”