I was talking with a friend of mine who is expecting her fourth baby this summer. She wasn’t terribly thrilled over having to get a gestational diabetes screening— after all, her only risk factor was being over 25. She was already getting the bubble wrap treatment because she will be turning 35 a month before her due date.
Having a baby after 35 is considered “advanced maternal age” (formerly known as “geriatric mother”) and is classified as “high risk”. I haven’t hit the big 3-5 time bomb yet, but in a couple of years I will. And I’ve always been annoyed that despite exercising daily and eating a diet high in produce, whole grains, and different protein sources and devoid of refined sugar, I’m considered higher risk for gestational diabetes than some 20 year old bingeing on gummy worms and Coke.
And that brings me to my point: How high risk is pregnancy over 35?
When doctors say that there are special concerns for pregnancy over 35, here is specifically what they are talking about:
- High blood pressure and cholesterol as risk factors for stroke and heart attack
- Down syndrome
- Pregnancy problems related to fertility treatments
- Impaired muscle contraction in the uterus
- Higher risk of stillbirth among first-time mothers over 35
- Gestational and type 2 diabetes
You’ve probably noticed that many of these things are not a universal “over-35 risk”. Most mothers over 35 are not first time mothers, many get pregnant naturally and many lifestyle related problems like high cholesterol, high blood pressure and type 2 diabetes would be problematic in mothers under 35 as well. Down Syndrome is more likely to occur in births to mothers over 35, but Down Syndrome isn’t a definite indication for pregnancy and labor complications. As for the impaired muscle contraction in the uterus, that was a study on mice and it doesn’t take into account the many variables surrounding birth such as having a doula or the place of birth.
According to the CDC, in 2016 the fertility rate for women ages 30-34 surpassed the fertility rate for women ages 25-29 for the first time in three decades. The average age of first birth for American women is now 28. For now, more and more women are having babies after 35. It’s time to get rid of the idea that age alone is a risk factor for pregnancy. Being under 35 (or 25 in the case of gestational diabetes) doesn’t mean a woman is healthy or low-risk and being over 35 doesn’t mean a mother is unhealthy or high risk. Let’s take look at the actual risks for different mothers and provide care based on real-not theoretical- risks.
I have had two miscarriages. Both were very early. It hurt to lose the promise of a new baby, but I was fortunate that each was followed by a successful pregnancy. I like to think that each of those miscarriages was my baby trying to get here against difficulty.
Everyone has a different way to view pregnancy and infant loss, including Buddhists.
According to Buddhist teachings, the souls of those who die before birth or shortly afterwards would be doomed to pile rocks in limbo because they could not accrue enough karma for themselves in this life. And every night the demons are said to knock down the piles of rocks. But Jizo is there to help them.
Jizo is said to be a monk who reached enlightenment through great personal effort. But he postponed his ascension into Buddhahood to save all souls from the torments of hell between the time of the passing of Shakyamuni (the Buddha of our age), and the arrival of the future Buddha, Maitreya. Jizo is most popular in Japan where he is revered as the “good” judge of hell who has the power to save souls from the punishments meted out by the other nine judges of hell. He is also regarded as a protector of travelers, so statues of Jizo line the roads of Japan.
Perhaps it is because of this special power that he has come to be known for protecting the souls of babies who die before they are born (through miscarriage, abortion or stillbirth) and children who die at a young age. In Japan, parents who have lost a child have placed statues of Jizo by the grave of their child as a way of asking Jizo to relieve their child of hard labors. Sometimes there are little piles of rocks built by the statues as a way of helping the child with his or her labors.
These statues of Jizo often depict him as a small monk with smiling features. Since clothing a Jizo statue is a way of gaining merit, parents will often decorate the statues with clothes, toys or red bibs or hats. (Red is a color of protection.) Offerings of candy or fruit are also sometimes left at the base of the statue. Some of the major Buddhist temples in Japan have sections of graveyards with Jizo statues as a remembrance of children who left too soon and a prayer that they will have peace in the world to come.
Outside of Japan, some parents who have experienced pregnancy or infant loss will keep a Jizo figurine as a reminder that no life is too brief to be important. In America, some Buddhist monasteries will do a special ceremony called a mizuko kuyo for parents who have experienced a loss. The mizuko kuyo is a recent development- it’s only been around since after World War II. In Japan, the ceremony focuses on Jizo’s intervention. In America, it’s more about helping parents with the grief. Participants make a token, like a necklace or bib, before the ceremony. During the ceremony, they chant the mantra associated with Jizo and place their token on the statue and a piece of paper with the baby’s name on it.
Many of you have noticed that it’s been a while since I last posted. Here’s why:
We were all buckled up according to the laws of the state we were driving in, though some people definitely take more extreme measures, like 4 year olds in rear-facing carseats and tweens in booster seats. Our kids were in basic carseat/booster seat that were on the approved list. But being hit in a major car crash has made me wonder about our current car seat laws/beliefs. Here is what I have found:
Forward facing vs. rear facing
Wow. The level of zeal over rear facing car seats reaches a level of near religiosity. How did it start?
In 2007 the Henary, Sherwood, Crandall, et.al. study was published in the Journal of Injury Prevention. It analyzed data from the US National Highway Traffic Safety Administration vehicle crash database for the years 1988–2003 for children ages 0-23 months. The results of this study found that children in forward facing car seats were significantly more likely to be seriously injured in a car crash than children in rear facing car seats.
The world of children’s health and safety exploded with rear-facing zeal.
From KidsSittingSafe.com: “The data relating to the type and location of child car seat are also striking. The car seat statistics on rear-facing car seats backup the latest recommendations of the American Academy of Pediatrics (AAP) that kids should remain in rear-facing car seats until at least the age of two.”
From CarSeatsfortheLittles.com: “Rear facing is not a choice to be made based on parenting style or opinion; it’s one based on scientific fact. The more we know about physics and physiology, the better we’re able to protect our kids from severe injury as a result of a crash.” (The title of this article claimed that it was a “science junkie’s guide” to carseats.)
From the Carseat Lady: “It’s not a coincidence that flight attendants sit rear facing. Rear facing is the safest way for everyone to travel, not just babies. Therefore it is our recommendation that children ride rear-facing until at least age 2– and ideally longer, until reaching the maximum height or weight for rear-facing in their convertible car seat, which for most kids is 2-4 years old.”
From SafeRide4Kids.com: “So it baffles me when parents want to turn their children forward facing earlier than necessary. I’ve spoken to a lot of parents who treat a first birthday as some sort of graduation to forward facing. Many other parents begin to get concerned about possible leg injuries because the child’s legs are folded. Other parents simply are under the impression that their child must be uncomfortable.
Why is this? Because the parent would be uncomfortable sitting criss-cross applesauce? Personally, I like sitting criss-cross applesauce and could definitely sleep better in the car leaning back with sides upon which to lean my head. Do they make a rear-facing adult passenger seat? It’s coming, I know it, because it’s soooo much SAFER for everyone!”
Awfully high praise for a practice that has no grounding in sound data.
Yep. I just said that. And here is the data and analysis to back up that assertion…
Henary, Sherwood, Crandall, et.al. Study Retracted
This study formed the basis for the rear-facing car seat policy that has been accepted as fact. In order for an idea to be accepted as scientifically based, it has to be replicable. If the results can’t be replicated, it can’t be classified as science. If the results can’t be replicated it’s a fluke or bad research.
Sweden’s “rear-facing until 4” laws are often cited as another proof that rear-facing is safer than forward-facing, but this is what we in the research world call confounding. Sweden just has the lowest rates of traffic related fatalities in the world— across all age groups. Sweden has built roads and pedestrian crossings to be safer and is aggressive about enforcing drunk driving. They also have lower speed limits in urban areas. So there are a multitude of factors that are behind Sweden’s low rates of traffic fatalities for adults and children.
You could only attribute Sweden’s low rate of child traffic fatalities to rear-facing car seats if all other factors were the same when comparing Sweden to other countries. Since there are other factors that are at play in Sweden, Sweden’s use of rear-facing car-seats until age 4 can not be used as proof that rear-facing car-seats are safer than forward-facing. In fact, according to the National Highway and Traffic Safety Administration, in 2016 6% Of infants under the age of 1 who died in a car crash were forward facing while 21% were rear facing. (In 2015, those numbers for fatalities for children under 1 were 6% forward-facing and 33% rear-facing.) If rear facing car seats alone were really responsible for Sweden’s low rates of infant traffic mortality, then the rear facing car seat mandate should have resulted in similarly low rates in the US. But it hasn’t.
As A Side Note… This Kind of “Science” Would Have Gotten Bad Grades In My MPH Classes
Now, this is where the double standard of research in the classroom vs. policy in the real world. I’ve taken classes for my MPH in public health policy, research methods and program planning. If I had come to any of my professors and said I wanted to do a research proposal or public health program using a study that can’t be replicated and a case study with confounded data, I would have gotten the research smack down. My professors would have told me I need to select a different topic or do more/better research. But in the real world where public health can be a matter of life and death, we’re often quick to jump on unsubstantiated research if it seems to hold the promise of solving a problem or saving lives.
Now there’s no conclusive evidence yet that placing your child rear-facing is harmful. (The stats from the NHTSA for 2015 and 2016 aren’t specific enough to account for all variables and only cover two years.) But the data is pretty clear that it won’t provide better protection than forward-facing.
What About Booster Seats?
The longer you keep a child in a booster seat, the better right? After all, the American Academy of Pediatrics says that kids should be in a booster seat until 8-12 years. Not quite…
So here’s the deal behind the research that informed this policy. Some of it came from telephone surveys— which are informative but may be more limited than data from sources like the NHTSA. Another weakness is that much of the data comes from 1998 to 2003 when booster seats were not as widely used. This means that the sample sizes would have been much smaller, so it can’t tell us as much about what it means to have all children in booster seats. (Fun fact: the CDC is still using this data and has not addressed any of the newer findings about booster seats.) A 2013 study that compares larger data sets found that children in booster seats had an equal level of overall risk for injury when compared with children restrained with only a seat belt, however children in a booster were more likely to receive non-fatal injuries to the neck and chest than children who were restrained with only a seat belt. Seat belts and booster seats were equally effective at preventing death. More research is needed to find out if this can be improved with proper usage of booster seats or if there is still no improvement.
Ok, so what can I do to protect my child?!
Buckle your kid up according to the law and don’t drive intoxicated. 35% of all child traffic fatalities were in unrestrained children. Between 2001 and 2010, 1 in 5 child traffic fatalities (<15 years old, passengers) involved drunk driving. 65% of those were children in the car with a drunk driver.
Even with all the new safety measures mandated, the United States has some of the highest traffic fatality rates of any nation in the developed world. Sweden is particularly aggressive at preventing traffic fatalities and sees them as 100% preventable not as inevitable or “accidental”. America has not adopted that approach. According to the releases from the NHTSA I cited above, traffic fatalities are on the rise here in the US- including among children ages 0-8. According to the lore of paramedics and the Insurance Institute for Highway Safety, in a crash the bigger car will generally come out ahead, so driving a SUV might give you more protection in a crash, though that’s not practical for everyone.
The front of our SUV took the brunt of the crash and the air bags deployed, so it’s a good thing the kids were in the back. Even with all the new gadgets and harnesses being touted on the market and the fervor over rear-facing preschoolers and booster seats for tweens, your best bet is still to make sure your child is adequately restrained in a good car seat. Watch the straps, make sure they are tight enough and the seat is latched in properly.
Here in America, many of the decisions about health care are based on how hospitals can gain a competitive edge in the marketplace, not on benefits to patients. Read my post here for more details on how this works. Prenatal surgery for spina bifida myelomeningocele is a specialized service that hospitals can offer to stand apart from other hospitals that might be competing for patients. And that dynamic means that it’s in the hospital’s interest to perform as many prenatal surgeries as possible– whether the child and mother will benefit or not.
I have seen some centers that do explain that prenatal surgery has risks and that it’s not a guarantee…and then I see others that really push it as the answer to parents’ problems. And then I see news articles that get in on the act talking about the heroism of the whole endeavor.
This may be why I see so many parents, surgical centers (and news articles) who are excited about what amount to very average results for SB, like walking with a walker and not being a vegetable. There some children who are doing better like walking consistently without a device or not having a shunt. But most parents have been told by doctors that their child will be a bed ridden vegetable so their expectations are very low. The equation looks something like this: (Spina bifida-accurate information) + 10 (prenatal surgery)= MIRACLE!!!
I see a need to further explain the issues related to this procedure beyond my previous post on the subject. And so this is one question I tackled in a health ethics class paper…
“Media sensation can also cloud the issues surrounding new treatments. When the results of the randomized trial comparing outcomes for infants receiving prenatal and postnatal surgical repair of lesions associated with spina bifida myelomeningocele were released, news outlets quickly began broadcasting stories of the surgery, primarily focusing on the positive outcomes such as reduced need for ventriculoperitoneal shunts at 12 months of age and an increased ability to walk with crutches at two and a half years of age. For news coverage, the stories of grateful parents who believe their children have a dramatically improved life from a new medical procedure is very appealing.
However, the actual article published by the researchers who conducted the trial was optimistic but contained several cautions. The authors noted that surgery dramatically increased the risk of preterm birth and pregnancy complications and had future reproductive consequences for mothers. They also pointed out that while the in-utero surgery group averaged better outcomes at 12 months and 24 months, that some children who underwent in-utero surgery had no better outcome that children who underwent postnatal surgery. It was also unknown how long the benefits from the in-utero surgery would last or if the surgery would have any benefit for bowel and bladder or sexual function in children with myelomeningocele (Adzick, Thom, Spong, et. al., 2011).
As in-utero surgery has expanded and more hospitals are trying to attract potential patients, the temptation to overemphasize the benefits of the surgery remain. In their announcement of the first in-utero surgery for myelomeningocele in Texas, Children’s Memorial Hermann (2017) stated that the surgery had many risks, but summarized the findings of the 2011 Adzick study by stating “The study found that if a baby undergoes surgery in utero, the serious complications associated with spina bifida could be reversed or lessened with the operation.” While the statement is not entirely inaccurate because the surgery did find a reduced risk for certain outcomes, it is not accurate either since it neglects to point out the limitations of the procedure as well.
Children’s Hospital of Philadelphia (2017) states on their website that the procedure “… is shown to offer significantly better results than traditional repair after birth.” This statement also neglects to mention that some children may receive no benefit from the surgery. Vanderbilt Hospital (2010) has a presentation on their website about Emily Dotegoski, the 19th infant to undergo in-utero repair and the benefits they feel the surgery has had for her. The benefits cited were attending a regular school, getting good grades and going to physical therapy- all of which are normal for a child with spina bifida myelomeningocele whether repair happens before or after birth. Emily can walk unassisted over short distances, but still uses a wheelchair most of the time- also normal for any child with spina bifida myelomenigocele. In the case of Emily Dotegoski, the surgery may have had few benefits over traditional repair, though the outcome is represented as being exceptional and due to the procedure.
While a webpage does not constitute a full disclosure of risks and benefits, the nuances of how the procedure is “sold” to parents is an issue of concern. In utero surgery for repair of myelomeningocele can only be performed between 19 and 25 weeks gestation while diagnosis typically comes at 15-20 weeks gestation. This gives parents a very short window of time to make a decision about in-utero surgery when they are in a very emotionally vulnerable state. For the hospitals that offer in-utero surgery as a distinguishing specialty, it is in their best interest to recruit as many qualifying patients as possible. Complicating the issue further is the fact that no research has yet been able to pinpoint which children will derive benefit from the procedure and which will not, only that the average outcome as measured during 12 months and two and a half years of age is better for children who underwent prenatal versus postnatal surgery.
Prenatal surgery for myelomeningocele falls into a crossroads between beneficence and maleficence because it may benefit some infants but not others and the associated risks of pregnancy complications may harm some mothers and infants but not others. The tolerance for risk and the expectation of benefits may vary from family to family. The important issue is whether parents have an accurate understanding of the risks and benefits when the option is presented to them or if they are consenting to the procedure based on an unrealistically negative perception of postnatal surgery and unrealistically positive perception of the prenatal surgery.
Adzick, N. Scott, Thom, Elizabeth A., Spong, Catherine Y., Brock, John W., Burrows, Pamela K., Johnson, Mark P. , Howell, Lori J., Farrell, Jody A., Dabrowiak, Mary E., Sutton, Leslie N., Gupta, Nalin, Tulipan, Noel B., D’Alton, Mary E., and Farmer, Diana L. (2011). A Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele. New England Journal of Medicine; 364:993-1004. DOI: 10.1056/NEJMoa1014379
Children’s Memorial Hermann (2017). Faith: Surgery in the Womb to Repair Spina Bifida. Retrieved from http://childrens.memorialhermann.org/patients-families/faith–surgery-in-the-womb-to-repair-spina-bifida/
Children’s Hospital of Philadelphia (2017). Fetal Surgery for Spina Bifida (Myelomeningocele). Retrieved from http://www.chop.edu/treatments/fetal-surgery-spina-bifida
Children’s Hospital at Vanderbilt (2010). Emily’s Dotegoski, fetal surgery for repair of spina bifida. Retrieved from https://www.childrenshospital.vanderbilt.org/services.php?mid=6296&slideshow_id=88“
“Yes, it can be sad and messy and powerful and
hard and normal and absurd and
everything in between.”- Zen Hospice Project website
I’ve always felt that birth and death were very similar in many ways. If you believe in the concept of a soul or spirit, the idea that birth is a type of death and death is a type of birth applies, since leaving one world means moving into the next.
Have you seen BJ Miller’s TED talk on hospice care? It sounds counter-intuitive, but the model of care that is slowly taking over end-of-life care has LOTS to teach us about beginning of life care. BJ Miller has a lot of very astute observations borne out of his experience of being on palliative care after losing both legs and an arm and sustaining serious burns in an accident. He has also helped hundreds of people die with dignity and love at the Zen Hospice Project in San Francisco. Here are some ways we could take his thoughts on hospice care and translate them to birth care:
A system designed with diseases in mind and not people
Dr. Miller says that health professionals go into the healthcare field with good intentions but become unwitting agents of a system that doesn’t serve the needs of patients. He says this is because we have a system that is centered around treating diseases and not treating people.
We have this exact problem with birth care in America. Childbirth is seen as a dangerous medical condition that is so fraught with peril that constant vigilance is required to keep both mother and baby alive.
Of course this is the height of hubris.
Evolutionary biology would require that for any species to survive, the process of reproduction must allow both the mother and the offspring to survive without intervention most of the time. Our interventions are there to improve on that and allow more mothers and babies to live who might not live otherwise.
People are afraid of suffering
Folks, I’m going to level with you about something:
You can not get a human being out of your body without some kind of discomfort.
There will be some kind of suffering associated with giving birth- any birth. Cesarean, vaginal, natural, medicated and hell yeah you would be suffering if you were to get something like scopolamine. (You just wouldn’t remember it. It was kind of like the GHB of obstetrics.)
I love how Dr. Miller gets into this concept of suffering. He says that there is suffering we can’t do anything about, that is just a part of life and then there is suffering that can be alleviated.
Suffering we can’t alleviate
Dr. Miller says this is the kind of suffering we need to make space for. It gives us a sense of cosmic proportionality. (Remember, he was a burn victim and triple amputee. He knows about suffering.)
Labor is like this. I’m not going all “curse of Eve” here. Labor pushes your body to the maximum and it is an intense experience. The immediacy you will feel to get this little body out of your body is overwhelming. As I said in my bio, I’m just not one of those birthing goddesses. When I give birth I suffer.
But to me, there is beauty in that suffering.
Even the fear and sadness that accompanied my first son’s birth has beauty. What was most beautiful is how much I did love him. Despite all the depression and anxiety, the moments I bonded with him touched my soul and bound him to me even when he was separated from me. The victory I felt when my second son was born would not have been possible without the hardship of my first son’s birth. The sweetness of my daughter’s birth stands out as one of the most incredible moments of my life. I think I was able to feel that attachment and joy better because I went through each stage of suffering. I felt alive as I was giving life.
A pain free birth shouldn’t be the goal. A birth with dignity and respect, whatever way it happens, should be our goal. As Dr. Miller says, “Necessary suffering creates compassion and unites caregiver and care receiver.”
Suffering we can alleviate
Dr. Miller points out that on the systems side, much suffering is created and invented that serves no purpose.
And this is true of birth care in the US. The vast majority of labor interventions in the United States do not improve the safety of the mother or baby. Some are outright more dangerous than a simple natural labor. Some simply need to be used less frequently and more judiciously. (For a whole run down on all of the unnecessary and overused procedures that are still being commonly used in childbirth in America, see this post complete with scholarly citations embedded.) We need to get rid of the things that cause unnecessary suffering in birth.
Palliative care- living well at every stage
Dr. Miller makes a distinction between palliative and hospice care. The two are often used interchangeably but are different. Hospice care is about end-of-life care. But palliative care is about living well at every stage and eliminating suffering as much as possible.
He gives the example of Frank, a patient with prostate cancer and HIV who went rafting on the Colorado River. Dr. Miller’s response to this was, yeah, it was dangerous. But what an adventure! This man knows that his time on earth is limited and he wants to experience an adventure while he still has the chance. Rafting the Colorado River helped alleviate his suffering and allowed him to live better.
Mind-blowing idea: What if approached birth like palliative care? What if the idea behind birth care was to birth well, no matter what your circumstance?
Rose petals at the end
Dr. Miller says that at the Zen Hospice Project where he works, they have a ritual they perform for everyone who dies there. When the person dies, the coroner’s office comes to collect the body. The staff at Zen Hospice have arranged that before the body is taken away, loved ones and staff come and sprinkle rose petals over the body and say anything they want to. They might sing songs or read poems before the body is taken away.
Rose petals on the body don’t serve any medical or physical need.
But it’s beautiful. And dignified. It shows honor for what has taken place.
What if we treated birth like this, with warmth and joy rather than repugnance and contempt?
Hospitals are anesthetic, not aesthetic
Dr. Miller says that hospitals offer an anesthetic experience, not an aesthetic experience. That numbness takes away the pain and the joy. He very rightly points out that hospitals are for acute trauma and treatable illnesses.
Of course, birth is generally neither of these. This is why moving more births into birthing centers makes sense– and even improving care for home births.
First eliminate unnecessary suffering, then comfort the senses
This is Dr. Miller’s framework for end of life care. And it should guide us for maternity care as well. There is nothing about eliminating unnecessary suffering or providing comfort that inherently makes birth unsafe. Even when cesareans or inductions are medically indicated, the parents and baby can be treated with respect and allowed reasonable comfort measures. Skin-to-skin contact for breastfeeding initiation after a cesarean can almost always take place.
Truly, we need to lift our sights to well-being as Dr. Miller says. Health care should be about living better. In the context of maternity care, we need to move past the “live baby standard”. We need to start asking if the birth was about the well-being of the mother and baby, not just whether the baby survived. (And that “at least your baby is alive” standard takes on a dark irony when you find out that the State of the Mothers World Report ranks the United States as having the highest rate of first day mortality of any developed nation.)
Dr. Miller says we need to give rise to art in dying. We need to make space for “a crescendo”.
Let’s do that for giving birth too.
“Rituals could feed conflict by turning opinions into ‘sacred values’.”– Scott Atran, director of anthropological research at Centre National de la Recherche Scientifique
“Definition of myth: a usually traditional story of ostensibly historical events that serves to unfold part of the world view of a people or explain a practice, belief, or natural phenomenon.”– Merriam-Webster Dictionary
Once Upon A Time…
“Do you know what women were dreaming of when they were giving birth in a cabin with the wolverines prowling around? A hospital! This sterile environment where their baby would be safe!!!”
I was listening to one of my favorite podcasts and had encountered a moment in an otherwise great podcast that irked me. Two men- only one of whom had even witnessed a birth in a hospital- expounding on the history of childbirth. ( I love how anyone, man or woman, who may not have ever even seen a birth but believes hospital birth to be 100% safe is suddenly more of an expert on childbirth than any midwife, doula or mother.)
It’s completely understandable that they would think that hospital birth reduced neonatal and maternal mortality. Most people think that’s how the story goes.
But it’s not.
The Actual Data Behind Hospital Birth
Hospitals and even doctor care were actually much higher risk for most births in the 19th and early 20th centuries. For example in her book Inside The Victorian Home, Judith Flanders describes how women who had midwife care had lower rates of death than women who delivered with doctors because doctors spread infections from vaginal dilation checks. Ignaz Semmelweis formed his ideas of the transmission of puerperal fever after noticing that women who gave the birth in the street had lower rates of death than women who gave birth in the obstetrical clinic with doctors in attendance. (These clinics catered to low-income women who wanted the doctor care after their baby was born, but were terrified of the 10% mortality rate of the clinic. These women frequently chose to give birth on their own claiming precipitous labor rather than risk delivery in the clinic.)
Even into the 20th century women who delivered with midwives had a better chance of surviving delivery. Records from England and Wales in the 1930’s showed that the wives of manual laborers who had midwife care had better survival rates than higher income women who had doctor care for pregnancy and birth. And infant mortality? Many hospitals in the early 20th century had higher rates of infant mortality because of the increased use of forceps and other equipment. The White House Conference on Child Health and Protection of 1933 found that during the period between 1915 and 1929 there was a sharp increase in the number of hospital births, along with a 40-50% increase in infant mortality due to birth injury.
Long story short, if you believe that women with uncomplicated pregnancies can deliver safely outside a hospital, you are right. It is a myth that hospitals and doctors lowered the rates of maternal and neonatal mortality. Birth moved into the hospital because scopolamine was touted as a way to spare women the pain of childbirth. But if you really believe that tying a laboring woman to a hospital bed and giving her a hallucinogenic drug that leaves her paranoid is an improvement over a natural birth, I think you need to reevaluate your morals.
Legends And Tall Tales From Public Health
Let’s take on another popular myth: Jonas Salk single handedly saved the world from polio out of sheer altruism. It makes a great epic, something like Beowulf or King Arthur, but there is no data to back that story. The 1955 Vital Statistics report states that the Salk polio vaccine could not be completely responsible for the decline in polio because polio declined for all age groups, though the vaccine was given only to children. The Salk and Sabin (sugar cubes) vaccines were both widely used so the Salk vaccine can not be credited with ending polio.
Salk and his work also had their own sets of flaws. He tested flu vaccines on mental patients who were unable to consent and unable to adequately describe symptoms for research purposes. And a mysterious batch of the Salk vaccine from Cutter Laboratories also caused the death 10 and paralysis of more than 200 children. Salk’s remark that he could no more patent the sun than his vaccine was more a reflection on how he could not patent his vaccine because of prior art. (Others had done similar vaccine research and trials.) In fact, Salk and the National Infantile Paralysis Foundation had looked into patenting Salk’s IPV. Getting personal about Salk, a book that came out a little while ago about him and Sabin portrays Salk as an ambitious scientist who could be difficult to work with. And for that matter, statistics show that before either Salk or Sabin vaccines were released polio rates were in an overall downward trend.
Louis Pasteur a genius? He stole ruthlessly from others and misrepresented his work. (It’s no wonder he didn’t want his notebooks released to the public.) Edward Jenner was known to be very proud of his son Edward Jr. and loved him dearly. However, he also Used his son as a test subject over and over again, repeatedly inoculating him and then exposing him to diseases. Sometimes Edward Jr. recovered and other times he became seriously ill. (Some have speculated that Edward Jenner Jr.’s mental and physical impairments may have been caused by the repeated cycle of illness or contaminated inoculation materials, though it’s hard to say one way or the other.)
Even breastfeeding comes with its own set of myths from both sides- either that it makes your baby smarter or that it really doesn’t have any substantial health benefits. Both are untrue, but different sides of the breastfeeding debate cling to these myths. Ultimately, those myths end up hurting mothers and babies because they alienate women who encounter difficulties and create a “us” vs. “them” dynamic. That’s why I designed my curriculum to be as “myth free” as possible. I want any woman who is interested in breastfeeding to feel welcome to learn more.
The More Things Change, The More They Stay The Same
In so many ways, we are no different than our ancestors. We tell stories about heroes, monsters, rituals and weapons to try to understand our world. And we live in a world that is still full of fear and uncertainty despite our technology and efforts. 99% of births in the US take place in hospitals, 30% of which are c-sections- and the US still has the highest rate of maternal and first day infant mortality of any developed nation. People don’t worry about polio any more, but acute flaccid paralysis is on the rise and emerging diseases like the nonpolio enterovirus EV-D68 are causing more cases of serious disease. We still have little control over our world.
What If We Approached New Health Data Like A Black Hole?
In my opinion, we in the health field need to take some lessons from the astrophysics folk. They are always finding out new information about our universe that makes them re-think current models. When that happens, they say, “COOL! This helps us better understand the universe we live in!” I think it’s hard for public health and medical professionals to take that attitude because everything feels so high stakes. After all, discovering a super massive black hole from the early days after the Big Bang doesn’t impact anyone’s health or life.
Kevlar Vest Or Security Blanket?
The problem with myths is that they are security blankets: they feel comforting but don’t provide any actual protection. Myths becomes an even bigger problem when people start thinking their security blanket is actually a Kevlar vest. This is what happened with puerperal fever. Though Dr. Semmelweis had shown strong evidence that doctors’ lack of hygiene was spreading the disease, the widely accepted myth that puerperal fever spread through the air and was exacerbated by womens’ emotional nature prevented the acceptance of handwashing for almost a century, costing the lives of millions of mothers.
Just because “everyone” says things are a certain way doesn’t mean it’s true. If you find something doesn’t match up, it’s OK to ask questions and look for data to find out if you are dealing with a sound hypothesis or a myth.
If you’re breastfeeding you need fenugreek, right? Who couldn’t use a little more milk supply?
When you’re breastfeeding, fenugreek might seem like the go-to remedy when things aren’t going well. But before you rush out to your local health foods store or look for Amazon’s top pick, STOP.
Fenugreek may not be the answer for you.
Some studies and several moms have reported that fenugreek can increase milk supply.
…sometimes a galactagogue is not the answer.
Will Fenugreek Help?
There are certain times that fenugreek may not help:
- Tongue-tie/ lip-tie
- Stress induced drop in milk supply
- Inverted nipples
So it doesn’t matter how much fenugreek (or lactation cookies or teas) that you take, your baby won’t nurse well if you’re having one of the above problems. The good news is that most of these problems have solutions, but the solutions just won’t involve fenugreek. (Having a problem and you don’t what the cause is or what the heck to do about it? Take one of my breastfeeding classes and you’ll get some answers and solutions. I designed my curriculum with you in mind.)
It’s also important to understand that any kind of galactagogue is only a small part of addressing real milk supply issues. Milk supply depends primarily on the stimulation provided by the baby suckling at the breast or from using a breast pump. So if you’re separated from your baby because of an emergency c-section or your baby is in the NICU, taking supplements WILL NOT be enough to build an adequate milk supply– you will have to pump. (Believe me, I spent two weeks pumping around the clock for my oldest and if I could have breastfed him by eating teas and cookies instead of pulling out that pump one more time at some forsaken hour of the late night or early morning, I would have done it. I feel it your pain.)
So even if you really do have low milk supply, you’ll have to do frequent nursing and pumping sessions to build your milk supply. Supplements, teas and cookies can bump it up a little, but they can’t do anything without the stimulation of nursing a baby or pumping.
Fenugreek- What It Can Do
So when do you use fenugreek? And what can you expect?
If you are regularly nursing and/or pumping and you or your baby don’t have any of the other conditions listed above, you can take fenugreek to help bring your milk supply up a little bit more.
Fenugreek isn’t the only galactagogue out there either. My personal favorite was hops tea. (Though hops tastes pretty bitter and you’ll want to add some lavender flowers and/or spearmint leaves to make it test palatable.) Oats and leafy greens are also supposed to be good for milk production. Personally, I think they do help. When I was exclusively pumping I had lots of green smoothies and oats and I always had enough milk. Again, it doesn’t take the place of pumping and nursing, but in my opinion, I think it helps. I also think that leafy greens and whole grains improves the nutritional quality of breastmilk.
Do You Really Need Fenugreek?
Most women can make an adequate supply of milk for their babies without any special supplements. However, perceived insufficient milk supply is actually quite prevalent. (Which is why include it in my curriculum.) A lot of women are turning to fenugreek and other supplements because they think they have a low milk supply- not because they actually do.
If you have breast hypoplasia, some supplements might be helpful in boosting milk supply. No guarantees, because breast hypoplasia can be really difficult. But this is a great story of a mom who had breast hypoplasia (also known as insufficient glandular tissue) and used a combination of several strategies- including some galactagogues- to bring up her milk supply.
Galactagogues like fenugreek do have a place in breastfeeding, but there is no magic pill for milk production. The bulk of your milk production is still determined by nursing your baby and pumping.
Two new videos have been added to the “Let Me Level With You” series!
So many parents have questions about hepatitis B and what the real risks are. Here’s the info on who is really at risk for hep B and why.
Prenatal testing seems simple on the surface. You get a test, it tells you if your baby has a birth defect or not.
Except that it doesn’t actually work that way.
In so many ways, prenatal testing has more in common with a roulette wheel or game of craps than a diagnostic procedure. This video has the most important things you need to know about prenatal testing like false positives, false negatives, perinatal hospice care, and quality life:
Unless you’re really into World War II history or you have been keeping up on the latest individuals to be beatified by the Catholic Church, you may not have heard of Stanislawa Lecysynska.
She didn’t attempt to assassinate anyone. She didn’t win any battles. She didn’t blow up any munitions factories or bridges. She didn’t find out any crucial bits of military intelligence. She never even wrote a book about her experiences. In fact, she rarely talked of her time as a midwife in Auschwitz.
But that’s OK. Because a lot of the mothers who knew her have told us about her- and even a couple of the babies she saved.
The Midwife of Auschwitz
Stanislawa Lecysynska was a midwife in Poland before the war. She was imprisoned in Auschwitz when she was suspected of collaborating with the Resistance. When the camp officers found out she was a midwife, they put her in charge of delivering babies for pregnant prisoners and killing the newborns. She delivered over 3,000 babies during her time in Auschwitz, but she refused to kill any of them- even when the infamous Dr. Mengele threatened to kill her for refusing to comply.
By all accounts, Stanislawa was a woman of great hope and compassion. All the pregnant women in the camp called her “Mother” because she gave the best care she could to every mother and baby- Jewish or Christian. Women described her as going hours without sleep to attend to laboring mothers and doing everything she could to keep babies alive for as long as possible. She had a deep conviction that if a baby was born alive, it was meant to live.
She delivered babies in the most hellish environment imaginable- and yet she never stopped caring for her mothers and babies. Some accounts describe the German doctors of being incredulous that she never lost a mother or baby to labor complications- despite the abysmal resources she had to deal with. It’s little wonder that she has been beatified by the Catholic Church (the first step towards sainthood).
Saving Babies Through Breastfeeding
Infant formula was not available in concentration camps. Mothers who weren’t able to make enough milk turned to other prisoners who were lactating to feed their babies. One of these babies, Barbara Puc, lived out the first two years of her life in Auschwitz. When her mother was unable to breastfeed her, another woman who had just lost her baby offered to wet-nurse baby Barbara, saving her life. One Auschwitz inmate, Maria Saloman described how Stanislawa found two women to wet nurse her baby who ended up living to adulthood.
Kazimera Bogdanska was unable to breastfeed her little girl at first, but Stanislawa encouraged her to keep putting the baby to the empty breast in hopes that it would eventually stimulate lactation. When the camp was liberated, Kazimera was able to see a doctor who encouraged her to follow the midwife’s advice.
“Mother [Stanislawa Lecysynska] was right,” says Kazimera, “How lucky I was that I believed her. When liberty came in January 1945 and I was taken to a real hospital (since I had typhoid fever) the doctor allowed me to continue to give my child my breast devoid of milk. After some time milk returned. My daughter began to gain weight. . . . She started to become round and rosy cheeked. . . . Mother’s wisdom and faith saved my only child.”
I just think it’s beautiful advice for any mother who is struggling with breastfeeding. Even when you feel like nothing is happening, even if you have to supplement or get donor milk for a time, keep putting the baby to the breast. It might stimulate the glands.
The answer is yes… and no… and maybe under certain conditions…
In no particular order, here are some of the most commonly questioned substances and the verdict on each one:
Obviously, no one should smoke. Ever. But there are certain risks associated with breastfeeding and smoking. Heavy smokers (20+ cigarettes a day) increase the likelihood of passing nicotine to the baby. The half-life of nicotine (the amount of time it takes for it to be eliminated from the body) is 95 minutes, so even smoking before a feeding can pass nicotine to the baby. Smoking increases the risk of SIDS and respiratory problems for the baby. Studies have found that breastfed babies of smokers were more likely to have episodes of colicky crying and fussiness than breastfed babies of non-smokers.
Also, smoking and breastfeeding is associated with early weaning, lowered milk production, and inhibition of the milk ejection (“let-down”) reflex. And it lowers prolactin levels- crucial to milk production. According to Thomas Hale, Ph D, author of Mother’s Milk and Medications (the go-to book when you have questions about how stuff in your milk affects your baby), smoking cessation aids are generally less hazardous to the baby than continued smoking.
Alcohol (in Moderation)
Drinking occasionally is fine if you’re breastfeeding. The Mayo Clinic is pretty stiff on the subject and their article generally discourages drinking and breastfeeding. And truthfully, not drinking while you are breastfeeding eliminates any chance of alcohol being passed to the baby.
However, research shows that 1-2 drinks generally doesn’t pose any risk to the baby. Thomas Hale says that mothers can return to breastfeeding after ingesting alcohol as soon as they feel neurologically normal. Many health professionals recommend keeping alcohol intake to 1-2 drinks a week while breastfeeding.
What about “pump and dump”? You can pump after drinking, but it won’t take the
alcohol content out of the milk any faster. However, if you’re away from your baby for a few hours and need to keep your milk supply up or relieve engorgement, by all means pump it and dump it. (FYI, Jane the Virgin didn’t need to drag her whole electric breast pump with for a night on the town with her best friend. She could have taken a small hand pump or even hand expressed milk to maintain supply and relieve engorgement.)
Here is my big post on marijuana and pregnancy for those of you who didn’t catch the controversy the first time around. Don’t use marijuana while pregnant and don’t use it while you’re breastfeeding either. Here’s why…
Marijuana 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. THC also passes to the baby during breastfeeding and it stays in the body longer than many substances. THC is stored in body fat, which means it actually stays in your body (and your baby’s body) for much longer than alcohol. Because THC stays in the body for long periods of time, you can’t consume marijuana and then breastfeed after a couple of hours and not pass THC to your baby. So “pump and dump” won’t work.
What about edibles and vaping? No and no. Edibles and vape pens still contain THC and that THC will pass to your baby. And while some research shows that vape pens result in lower tar, some of the newest research suggests that there might be a chemical trade-off in the form of toxic ammonia levels in the lungs from vaping. The effects of THC from marijuana edibles will actually last longer than the effects of THC from smoking marijuana.
Caffeine (In Moderation)
Don’t over-do it on the Starbucks or energy drinks, but other than that a couple of cups of coffee or cola are usually OK. (Chocolate is A-OK.) The amount of caffeine that ends up in a mother’s breastmilk is 1% of what she actually consumes. Babies younger than six months may take up to 80 hours to process caffeine, but in small amounts that’s usually OK. By about six months, babies can usually process caffeine in about 2-3 hours. It’s important to factor all caffeine sources into your caffeine consumption equation, so remember that even some OTC medications can contain caffeine. And if your baby seems especially fussy, alert or wakeful, consider that he might be a little more caffeine sensitive.
The majority of medications are actually safe for breastfeeding. Most doctors do not get information about medications and breastfeeding from actual research on a particular drug and lactation, but from package inserts of a book called The Physician’s Desk Reference. Both of theses resources come from pharmaceutical companies and may include out of date and/or incomplete information or disclaimers meant to cover the manufacturer’s collective @$$. One of the big medical treatments that is incompatible is chemotherapy because it uses radiopharmaceuticals. Sudafed can cause a drop in supply for some women, though it’s not generally harmful to the baby.
But other than that, pain relievers, anti-depressants, anti-anxiety drugs, cough medicines and many other types of medications are actually safe to take while breastfeeding. I do advise all expectant mothers to understand their options for pain medications that might be used during or after labor so they can make a choice that will cause fewer breastfeeding difficulties. (That’s why I included a section on it all my breastfeeding classes.)
Make sure to check out any supplements you are thinking about taking. Certain herbs can decrease milk supply or pass to the baby in harmful amounts, though culinary herbs and some herbal teas like chamomile are usually fine. Large amounts of certain candies, teas, cough drops, etc. might cause a drop in supply for some moms, but everyone is different.
Dairy/wheat/soy/peanuts/other potential allergens
If your baby isn’t displaying any signs of gastrointestinal upset or colic symptoms related to certain foods, you don’t need to avoid any foods. It might be a good idea to be cautious and avoid certain foods if there is a family history of food allergies on either parent’s side though. If your baby seems to be especially fussy, at different intervals, it might be time to keep a food diary and see if there is any pattern related to certain potentially allergenic foods. What about peanuts? Well, the latest information seems to indicate that exposure to peanuts through breastmilk may actually decrease the risk of peanut allergies. So go ahead and have that peanut butter cup. =)