Thursday, January 31, 2008

Evidence-based medicine

A family practice physician I am acquainted with wrote the following about evidence based medicine. Reposted with her permission.

I am young enough to have trained in the era of "evidence based medicine" (EBM) where we attempt to only do those things that have evidence to back them up. In EBM, the gold standard is the randomized controlled double blinded study (RCT) Study subjects are assigned to one group or another randomly, the groups are monitored "controlled" so that you get a relatively similar type of people in both groups, and the results are interpreted by a researcher who doesn't know what group your were in, and the study subjects themselves don't know what group they are in.

This works great for a new medicine, for example, where you can make up 2 identical white pills to give someone, but not so well for behaviors. How on earth would you randomize someone to UC, and expect them not to know it? With the lack of RCTs to use, we are left with case studies, population studies, and case control studies, all of which have inherent flaws. This doesn't mean they don't provide useful information, but since they aren't randomized, you never know if there isn't something special about the group that made them choose the behavior you are studying. (For example, if only well-educated women breastfeed, and then their babies have higher IQs, it's hard to know if it's from the breastmilk, or from having better educated parents.)

The other thing that I feel is absolutely vital to remember about evidence, is that just being scientific doesn't mean there aren't belief systems attached to that evidence. Why do things get studied in the first place? Who pays for it? Who benefits or is harmed by results? There is no "evidence" that is completely objective. It isn't "science" vs. "belief"; science is just another type of belief.

I do not suggest that we need to ignore what evidence we have, but an individual will always need to make his/her own decision also taking into account their beliefs, values, background, relationships, fears, etc. Just because someone does something that seems to go against "evidence" doesn't automatically mean they are making a bad decision. I encounter this every day in my family practice. Sometimes, I have great evidence based reasons for wanting to offer a certain treatment, but my patient has even better life based reasons for declining it, or doing something else.

Even if the evidence were ever to come to light that intentional UC isn't as "safe" as another type of birth, there may well be highly intelligent people who continue to choose that type of birth for their own reasons. Having no such evidence at this point (or in all likelihood, such evidence may never be available) women will continue to make their decisions based on evaluating what evidence there is and taking into account the many other areas of their lives that are impacted by birthing choice...

And a clarification of some of the earlier points she made:

[It is important] to consider how evidence is collected, whether it has relevance to the situation you yourself are considering, and whether it is accurate. Also, it is vitally important to remember that although in the age of evidence based medicine, we purport that "evidence" is somehow completely objective, in reality it is not, nor can it ever fully be disconnected from the social constructs from which it arises. Science and even "evidence based medicine" are themselves belief systems. I happen to live in the world where evidence is very important, and I try very hard to stay on top of the latest and greatest, and I very freely share every bit of evidence I'm using in making a recommendation with my own clients. But I also recognize that evidence will never be the sole factor in any decision made by a real person, nor should it be, nor should I feel any personal discomfort if someone receives my knowledge of the evidence, and chooses to do something other than what I recommend.

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Wednesday, January 30, 2008

How to make a dog jealous

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Monday, January 28, 2008

Ahhh, the joys of co-sleeping

Yeah, we often look like this at night. Notice her feet are right where my head usually is. So much fun.
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Sunday, January 27, 2008

Cesarean sections

I have seen so many articles, videos, artwork, and blog posts about cesareans and VBACs recently that I thought I'd put together a list:

Cesarean bodies and scars:
News articles about cesareans and VBAC:
Birth stories and videos

Cesarean art
Research and writing
Improving the cesarean experience
Blogs and more
Anything I missed? Let me know and I will add it.
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Crazy with signs!

About two weeks ago I checked out a sign language video from the library (My First Signs from Signing Time). We watch it together in the mornings while we eat breakfast and I check my email. Last night I brought Zari up to bed, and we played with my birth ball for a few minutes. I did the sign for ball and she did it back, over and over. She was so obsessed with signing "ball" that she'd repeatedly pop off while nursing and sign it.

And today she's done several signs back at me: water, dog, eat/food...where did this come from? It's hilarious!
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ICAN's VBAC ban project

Gretchen of Birth Matters blog (and a member of ICAN's board of directors) has issued the following request for asstiance with ICAN's newest project: documenting the status of VBACs in every U.S. hospital. Please lend your assistance! More information below from Gretchen's blog:

The VBAC ban project is finally up and running! What is this you ask? Well, simply put, we are going to call every hospital in the U.S. and find out what their policy is on VBAC. The International Cesarean Awareness Network did this a few years back and found out that over 300 hospitals officially "ban" VBAC (even though this is patently illegal). Needless to say, we are sure the situation is much worse now. But, the cool thing is that ICAN is about to launch a fantastic new website and included on that website is a map of the U.S. upon which every one of the hospitals we call will appear....with information about that hospital and its policies on VBAC. AND, there will be a way for anyone to leave feedback about that hospital, so you can see what other women experienced there. But, in order for this to happen, we need people to call! So if you are interested in helping out, please email me at and I'll get you set up and going.

Help ICAN shine the light into the oppression that so many hospitals are inflicting on women.
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Saturday, January 26, 2008

Birth, the American Way

A recent article from Newsweek discussing Ricki Lake's documentary and rising cesarean rates: Birth, the American Way.
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Ricki Lake on Larry King Live

Ricki Lake was on Larry King Live last night, and while I couldn't find a video, I did find a transcript of the interview. I've included the excerpt where she discusses her documentary.

KING: Tell me about the documentary.

LAKE: The documentary is called "The Business of Being Born." It's basically -- it's more me than anything else. You know, I did I my talk show for 11 years and I think this was something I wanted to do. I wanted to do something that was pro-woman.

KING: What do you mean by the business of being born?

LAKE: Well, it's very much a business. If you look at the money that we spend for birth in this country, you know, there are decisions being made about women and C-section rates and, you know -- for fear of malpractice, for reasons that are other than being in the best interests of the mother and baby.

KING: So we're seeing birth?

But what do we see in the documentary?

LAKE: Well, that's me -- that's me in labor. That's me probably an hour before I gave birth. It's not the prettiest picture of me. But I think there's images of birth in this film -- not only mine, but other women.

KING: You show births?

LAKE: Yes. We show my birth -- the birth of my second son in my bathtub. It's a very small part of the film. But I think these images of women giving birth on their own terms is so important for women to see. You know, we look at birth and we fear it. And we think that it's something that we need to be saved from or it's an emergency -- a potential emergency.

And, really, it's very natural. And I think in the technology that's been created with women being able to carry children at 50 years of age or premature babies that are able to live earlier gestation, I think it's amazing. Great strides have been made. But I think we've lost natural birth in the process.

And so this message is about women's getting -- women getting empowered and educated when it comes to birth.

KING: Why a bathtub?

LAKE: I had done a lot of research about water. And Michel Odent is in the film. He's a doctor from France. I had studied. I had done all the research. And I felt like that was the safest place for me and for my baby. And I have to say, for me, physically, it was so gentle on my body. And for my baby, which you've seen the film, he was alert. He was clean. There was nothing gross.

KING: Was a doctor there?

LAKE: I had a midwife. I had a midwife. And so this -- I'm very pro-midwifery. I think midwives are underrated. They are undervalued and...

KING: Was this your second baby?

LAKE: This is my second baby. I had a midwife with my first, as well.

KING: All right.

But what was the big difference in water and not in water?

LAKE: Well, I was in the hospital. The first one was in a hospital setting.

KING: A standard birth?

LAKE: Pretty typical. I mean, especially if you look at like what happens today. A lot of births are given -- you're given intervention to move you long because they need that bed filled with other women.

KING: Yes.

LAKE: You know, they don't want you to labor on your own for as long as it takes.

KING: But what was the big difference between the tub and...

LAKE: I think the respect that was given to me at home. I mean I remember giving birth. You know, in the movie you see that I pull my baby out. She says reach down and pull out your baby. And I do.

And he's skin to skin. He's completely alert. There was no drugs, no intervention.

I got into my bed. He was in my arms for a couple of hours. And then at a certain point, my midwife asked permission to take the baby and weigh him and check him over.

And I felt like the respect that was given to me to ask permission, as opposed to in a hospital, where you, as a mom, have to ask permission to see your baby, you know?

KING: The documentary is "The Business of Being Born." It's being shown right now.

LAKE: It is. And it's coming out on Netflix next month.

KING: And we'll be right back with more of Ricki Lake and then Ringo Starr. Don't go away.
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Friday, January 25, 2008

Jan 24 is "Pushday"

The Big Push for Midwives
Launches on Jan. 24 "Pushday"

The Big Push for Midwives is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states and the District of Columbia, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care.

State-by-State Status of Legislation to License
Certified Professional Midwives (CPMs)

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Thursday, January 24, 2008

Ron Paul on Licensure

Presidential Candidate Ron Pal discusses health care licensing.

The first part of the video is hard to make out because of the background noise, but the last half is a discussion of midwifery licensing. Some of his main points:
  • licensing is a monopoly; it keeps other people from competing.
  • licensing is better than prohibition, but the ideal is that people make up their own minds.
  • I'm not in favor of government prohibiting people from making private choices. I might have a medical opinion, but politically people should make their own choices.
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Saturday, January 19, 2008

BRAINED (aka Fun With Acronyms)

Pregnancy, birth, and parenting are filled with decisions: some vitally important, some trivial, some heartwrenching, and some enjoyable. When I was working as a doula, I would often show my clients the following acronyms for making decisions about their pregnancy and birth care. I believe that women are smart enough to make their own decisions. There is no need for coercion, manipulation, guilt trips, threats (subtle or otherwise), or appeals to authority (including mine!). They should research their options from a variety of sources and then carefully weigh their options.

Trying to make a decision? Get BRAINED!
Ask yourself, and your caregivers, these questions:
Benefits - How could the recommended course of action help me or my baby?
Risks - How could the recommended course of action harm me or my baby?
Alternatives - Are there any other courses of action I could consider?
Intuition - What are my gut feelings about this?
Nothing - What happens if I do nothing?
Evaluate - Can you give me some time to consider my choices? Then...
Decide - Now that I have the information I need, I'm ready to make a decision.

Benefits- How will this procedure benefit me and my baby?
Risks - What are the risks to me and my baby?
Alternatives - What are some other things we might try instead?
Instinct/Intuition - What is your gut telling you?
Now/Never/Nothing - What if we don't do the procedure right now? What if we never do it? What if we do nothing?
Safety/Satisfaction - Will this procedure increase the safety and satisfaction of the birth for me and my baby?

To give credit where it's due: the BRAINED acronym comes from a handout that someone gave me from "Lucina Birth Services." The BRAINS acronym was passed around on a doula list serve.
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Thursday, January 17, 2008

"I could NEVER do that"

Thanks to The Human Pacifier for an intriguing post about how achieving a "natural" birth in a hospital is an incredible feat. She raises a very important point that having an unmedicated birth at home or in a freestanding birth center is worlds apart (and arguably much, much easier) from a "natural"* hospital birth. Women who achieve this in a hospital really DO deserve a medal! It's so much more challenging than doing it out of hospital. I think women sometimes assume that it would have been/felt the same no matter the location. Perhaps when we're holding conversations about this, we need to emphasize that a lot of the things that cause pain, discomfort, and stress aren't present when you birth outside a hospital, so things are usually much less painful in the first place.

Now, I don't want to turn this into a simplistic home vs hospital kind of post. But that is one of the fantastic advantages of laboring outside of a medical institution! No IVs or heplocks.** No Pitocin augmentation. No fetal monitor straps. No internal monitors. No restrictions to bed. No one asking you to "rate your pain 1 to 10" or "would you like something to take the edge off/help you relax/help you sleep." Generally vaginal exams are limited-to-none or only on the mother's request. No mandatory birthing in the stranded beetle position. No Valsalva pushing ("hold your breath and count to ten and push Push PUSH!!").***

In some ways, I feel like I got off easy. All I had to do was labor and give birth! No fuss, no fighting, no declining this or that. Just birth.

* I really dislike the term "natural birth." It's too vague to be useful and carries a "holier-than-thou" connotation. You know, "natural" is better than "artificial" kind of thing. So I generally use a more specific word depending on what I am trying to convey: unmedicated, physiological, undisturbed, etc.
** Occasionally you will see IVs/heplocks used outside a hospital setting, usually to administer abx if the woman is GBS positive and requests that treatment, or to correct severe dehydration due to vomiting. But these are really exceptional circumstances.

***Okay, okay, I betcha some out-of-hospital birth attendants have done this...and I know that not every hospital does either. But it's true generally.
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More on GD

Gestational diabetes is a big topic, and with a little person crawling all over me and my laptop, I won't have time to address every aspect of it. Okay, standard mother disclaimer over...

This article from the BMJ, Should we screen for gestational diabetes?, addresses some of the main issues about GD: when and how is screening or treatment effective (health-wise and financially)? Michel Odent's overview of GD in my previous post also raises some interesting questions and issues.

One objection many women have about GD testing is that the test itself is an intervention that changes the body's normal physiology (it involves drinking a large amount of sugar, then testing blood sugar levels X amount of hours afterwards). It also has the potential to create additional stress and worry during pregnancy and, as Michel Odent notes, its possible nocebo effect is something to take into consideration.

Zari needs more attention right now, so I'll have to cut this post short. I'd be interest/ ed to hear other input about GD screening/treatment: benefits, risks, alternatives, etc. If you are a midwife or physician, what information to you give to your clients about GD testing? What do you recommend? If you have given birth, what did you decide to do about GD screening and/or treatment?
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Michel Odent on GD

"Gestational Diabetes: A Diagnosis Still Looking For a Disease?"

Primal Health Research: A New Era in Health Research
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road
London NW3 2JR
Summer 2004 Vol. 12 No.1

An article of the same title appeared in The Journal of Prenatal & Perinatal Psychology and Health (JOPPPAH) Volume 19, Number 2, Winter 2004

Nowhere in obstetrics is there such a discrepancy between evidence and practice as in the matter of gestational diabetes. This diagnosis has been mentioned briefly in several issues of our newsletter, in order to illustrate the frequent “nocebo effect” of prenatal care. (1,2,3,4) I have recently received so many phone calls of sorely distressed women that I find it necessary to provide updated answers to frequently asked questions.

How to explain? How to explain with simple words the real meaning of this scary diagnosis? How to explain that it is not a disease like with symptoms leading to complementary inquiries, but the mere interpretation of a laboratory test?

It is essential to emphasize that such a diagnosis is made after the “glucose tolerance test” is included in the battery of tests routinely offered to pregnant women. It is easy to illustrate this fact by referring to the results of a huge Canadian study.(5) In some parts of Ontario routine screening was interrupted in 1989, while it remained usual elsewhere in that state. It became clear that the only effect of routine glucose tolerance test screening was to tell 2.7% of pregnant women that they have gestational diabetes. It did not change the statistics of prenatal mortality and morbidity.

Simple physiological explanations can also help reassure a certain number of women. One role of the placenta is to manipulate maternal physiology for fetal benefit. The placenta may be presented as the advocate of the baby, so that the transfer of nutrients to the fetus is optimized. It is via hormonal messages that the placenta can influence maternal physiology. The fetal demand for glucose increase gradually throughout pregnancy. The mother is supposed to react to this demand by reducing her sensitivity to insulin.(6) This leads to a tendency towards hyperglycaemia that is easily detectable after a meal or after ingesting glucose. Some women can compensate their peaks of hyperglycaemia more effectively than others by increasing insulin secretion. When hyperglycaemia peaks above a pre-determined conventional threshold, the term “gestational diabetes” is used. In general glucose tolerance will recover its usual levels after the birth of the baby.

Practical recommendations
The practical advice one can give to women carrying the label of “gestational diabetes” should be given to all pregnant women & another reason to question the practical benefits of such a diagnosis. This advice concerns lifestyle, particularly nutrition and physical activity.

Nutritional counseling should focus on the quality of carbohydrates. The most useful way to rank foods is according to their “glycaemic index” (GI). Pregnant women must be encouraged to prefer, as far as possible, low GI foods. A food has a high index when its absorption is followed by a fast and significant increase of glycaemia. In practice this means, for example, that pregnant women must avoid the countless soft drinks that are widely available today, and that they must also avoid adding too much sugar or honey in their tea or coffee. Incidentally, one can wonder if the tolerance test, which implies glucose consumption (the highest substance on the GI), is perfectly neutral and harmless. GI tables of hundreds of foods have been published in authoritative medical journals.(7) These tables must be looked at carefully, because the data they provide are often surprising for those who are still influenced by old classifications contrasting simple sugars and complex carbohydrates. Such classifications were based on the mere chemical formula.

From such tables we can learn in particular that breakfast cereals based on oats and barley have a low index. Wholemeal bread and pasta also are low-index foods. Potatoes and pizzas,(8) on the other hand, have a high index and should therefore be consumed with moderation. Comparing glucose and fructose (the sugar of fruit) is a way to realize the lack of correlation between chemical formula and GI. Both are hexoses (small molecules with six atoms of carbon) and have pretty similar chemical formulas. Yet the index of glucose is 100&versus 23 for fructose. This means that pregnant women must be encourage to eat fruit and vegetables, an important point since pre-eclampsia is associated with an oxidative stress.

The quantity of carbohydrates should also be taken into consideration. French nutritionists showed that, among pregnant women with reduced glucose tolerance, there is no risk of having high birth weight babies if the daily consumption of carbohydrates is above 210g a day.(9) This implies a moderate lipid intake. About lipids, the focus should also be on their quality, the ratio between different fatty acids. For example we must take into account the fact that monounsaturated fatty acids (such as the oleic acid of olive oil) tend to increase the sensitivity to insulin. We must also stress that the developing brain has enormous need of very long chain polyunsaturates, particularly those abundant and preformed in the sea food chain.(10)

Advice regarding physical activity is based on theoretical considerations and on the results of observational studies. Skeletal muscle cells initially use glycogen stores for energy but are soon forced to use blood glucose, thus lowering glycaemia in the short term.(11) In addition, exercise has been shown to increase the insulin sensitivity of muscles and glucose uptake into muscular cells, regardless of insulin levels,(12) resulting in lower glycaemia. The effect of exercise on glucose tolerance has been demonstrated among extremely overweight women (body mass index above 33). 10.3% of obese women who took no exercise had a significant reduction of glucose tolerance, compared with 5.7% of those who did any exercise one or more times a week.(13) “A walk in the shopping mall for half an hour to an hour a couple of times a week is all that is needed”, says author Raul Artal. According to what we currently know, the benefits of a regular physical activity in pregnancy should be a routine discussion during prenatal visits, whatever the results of sophisticated tests.

Looking for a disease
Almost everywhere in the world, “gestational diabetes” is a frequent diagnosis. We should therefore not be surprised by the tendency to assign it the status of a disease. This might appear as a feat, since this diagnosis is not based on any specific symptom, but just on the effects of an intervention (giving glucose) on blood biochemistry.

One of the ways to transform a diagnosis into a disease is to list its complications. The well-documented fact that women carrying this label are more at risk than others to develop later on in life a non-insulin dependent diabetes has often been presented as a complication.(14) But this “type 2 diabetes” is not a consequence of reduced glucose tolerance in pregnancy. It is simply the expression, in another context, of a particular metabolic type. One might even claim that the only interest of glucose tolerance test in pregnancy is to identify a population at risk of developing a type 2 diabetes. But when a woman is looking forward to having a baby, is it the right time to bother her with glucose intake and blood samples, and to tell her that she is more at risk than others to have a future chronic disease? It is probably more important to talk routinely about nutrition and exercise.

Gestational hypertension has also been presented as a complication of gestational diabetes. In fact an isolated increased blood pressure in pregnancy is a transitory physiological reaction associated with good perinatal outcomes.(15, 16, 17, 18) Once more the concomitant expression of a particular metabolic type should not be confused with the evolution of a disease towards complications.

Professor Jarrett, a London epidemiologist, made a synthesis of the questions inspired by such associations. He stressed that women who carry this label are, on average, older and heavier than the overall population of pregnant women, and their average blood pressure is higher. This is enough to explain differences in perinatal outcomes. The results of glucose tolerance tests are superfluous. According to Professor Jarrett, gestational diabetes is a “non-entity”.(19)

The concept of fetal complications is also widespread. Fetal death has long been thought to be associated with gestational diabetes. However all well-designed studies looking at comparable groups of women dismissed this belief, in populations as divers as Western European (20) or Chinese (21), and also in Singapore (22) and Mauritius.(23) High birth weight has also been presented as a complication. In fact it should be considered an association whose expression is influenced by maternal age, parity and the degree of nutritional unbalance. If there is a cause and effect relation, it might be the other way round: a big baby requires more glucose than a small one. It is significant that in the case of twins “when the demand is double” the glucose tolerance test is more often positive than for singleton pregnancies. Only hypoglycemia of the newborn baby might be considered a complication, although there are multiple risk factors.

Another way to transform a diagnosis into a disease is to establish therapeutic guidelines. Until now, no study has ever demonstrated any positive effect of a pharmacological treatment on the maternal and neonatal morbidity rates, in a population with impaired glucose tolerance. On the contrary no pharmacological particular treatment is able to reduce the risks of neonatal hypoglycaemia.(24,25) However gestational diabetes is often treated with drugs. The frequency of pharmacological treatment has even been evaluated among the fellows of the American College of Obstetricians and Gynecologists (ACOG).(26) It appears that 96% of these practitioners routinely screen for gestational diabetes. When glycaemic control is not considered acceptable, 82% prescribe insulin right away, while 13% try first glyburide, an hypoglycaemic oral drug of the sulfonylureas family.

While practitioners are keen on drugs, there are more and more studies comparing the advantages of human insulin and synthetic insulins lispro and aspart,(27, 28) or comparing the effects of twice-daily regimen with four-times-daily regimen of short-acting and intermediate-actinginsulins.(29) Meanwhile the comparative advantages of several oral hypoglycaemic drugs are also evaluated. The criteria are always short- term and “glycaemic control” is the main objective.(30) The fact, for example, that sulfonylureas cross the placenta should lead to caution and to raise questions about the long-term future of children exposed to such drugs during crucial phases of their development.

The nocebo effect of prenatal care
After reaching the conclusion that the term “gestational diabetes” is useless, one can wonder if it is really harmless. Today we understand that our health is to a great extent shaped in the womb.(31) Furthermore we can interpret more easily the effects of maternal emotional states on the growth and development of the fetus. In the current scientific context we can therefore claim that the main preoccupation of health professionals who meet pregnant women should be to protect their emotional state. In other words the first duty of midwives, doctors and other practitioners involved in prenatal care should be to avoid any sort of “nocebo effect”.

There is a nocebo effect whenever a health professional does more harm than good by interfering with the belief system, the imagination or the emotional state of a patient or of a pregnant woman. The nocebo effect is inherent in conventional prenatal care, which is constantly focusing on potential problems. Every visit is an opportunity to be reminded of all the risks associated with pregnancy and delivery. The vocabulary can dramatically influence the emotional state of pregnant women. The term “gestational diabetes” is a perfect example.

When analyzing the most common reasons for phone calls by anxious pregnant women, I have found that, more often than not, health professionals are ignorant of or misinterpret the medical literature, and that they lack of understanding and respect for one of the main roles of the placenta, which is to manipulate maternal physiology for fetal benefit.

Prenatal care will also be much cheaper on the day when the medical and scientific literature will be better interpreted!

Michel Odent

Références :
1 - Odent M. The Nocebo effect in prenatal care. Primal Heath Research Newsletter 1994; 2: 2-6.
2 - Odent M. Back to the Nocebo effect. Primal Heath Research Newsletter 1995; 5 (4).
3 - Odent M. Antenatal scare. Primal Heath Research Newsletter 2000; 7 (4).
4 - Odent M. The rise of preconceptional counselling vs the decline of medicalized care in pregnancy. Primal Health Research Newsletter 2002;10(3)
5 - Wen SW, Liu S, Kramer MS, et al. Impact of prenatal glucose screening on the diagnosis of gestational diabetes and on pregnancy outcomes. Am J Epidemiol 2000; 152(11): 1009-14.
6 - Vambergue A, Valat AS, Dufour P, et al. Pathophysiologie du diabète gestationnel. J Gynecol Obstet Biol Reprod (Paris) 2002 ; 31(6 Suppl) : 4S3-4S10.
7 - Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values. Am J Clin Nutr 2002; 76(1): 5-56.
8 - Ahern JA. Exaggerated hyperglycemia after a pizza meal in well-controlled diabetics. Diabetes Care 1993; 16: 578-80.
9 - Romon M, Nuttens MC, Vambergue A, et al. Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women with gestational diabetes. J Am Diet Assoc 2001; 101(8): 897-902.
10 - Odent MR, McMillan L, Kimmel T. Prenatal care and sea fish. Eur J Obstet Gynecol Biol Reprod 1996; 68: 49-51.
11 - Chipkin S, Klugh S, Chasan-Taber L. Exercise and diabetes. Cardiol Clin 2001; 19: 489-505.
12 - Wojtaszewski JP, Nielsen JN, Richter EA. Invited review: effect of acute exercise on insulin signaling and action in humans. J Appl Physiol 2002; 93(1): 384-92.
13 - Dye TD, Knox KL, Artal R, et al. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997; 146(11): 961-5.
14 - Kim C, Newton R, Knopp R. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25: 1862-8
15 - Symonds EM. Aetiology of pre-eclampsia: a review. J R Soc Med 1980; 73: 871-75.
16 - Naeye EM. Maternal blood pressure and fetal growth. Am J Obstet Gynecol 1981; 141: 780-87.
17 - Kilpatrick S. Unlike pre-eclampsia, gestational hypertension is not associated with increased neonatal and maternal morbidity except abruptio. SPO abstracts. Am J Obstet Gynecol 1995; 419: 376.
18 - Curtis S, et al. Pregnancy effects of non-proteinuric gestational hypertension. SPO Abstracts. Am J Obst Gynecol 1995; 418: 376.
19 - Jarrett RJ. Gestational diabetes : a non-entity ? BMJ1993 ; 306 : 37-38.
20 - Roberts RN, Moohan JM, Foo RL, et al. Fetal outcomes in mothers with impaired glucose tolerance in pregnancy. Diabet Med 1993; 10(5): 438- 43.
21 - Lao TT, Ho LF. Impaired glucose tolerance and pregnancy outcome in Chinese women with high body mass index. Hum Reprod 2000; 15(8): 1826- 9.
22 - Tan Y, Yeo GS. Impaired glucose tolerance in pregnancy_is it of consequence ? Aust NZ J Obstet Gynaecol 1996; 36(3): 248-55.
23 - Ramtoola S, Home P, Damry H, et al. Gestational impaired glucose tolerance does not increase perinatal mortality in a developing country: cohort study. BMJ 2001;322: 1025-6.
24 - Jensen DM, Sorensen B, Feilberg-Jorgensen N, et al. Maternal and perinatal outcomes in 143 Danish women with gestational diabetes mellitus and 143 controls with a similar risk profile. Diabet Med 2000; 17(4): 281-6.
25 - Hellmuth E, Damm P, Moldted-Pederson L. Oral hypoglycaemic agents in 118 diabetic pregnancies. Diabetes Med 2000; 17(7): 507-11.
26- Gabbe SG, Gregory RP, Power ML, et al. Management of diabetes mellitus by obstetrician-gynecologists. Obstet Gynecol 2004; 103(6): 1229-34.
27 - Jovanovic L, Ilic S, Pettitt D, et al. Metabolic and immunologic effects of insulin lispro in gestational diabetes. Diabetes Care 1999; 22: 1422-7.
28 - Pettitt D, Ospina P, Kolaczynski J, et al. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Diabetes Care 2003; 26(1): 183-6.
29 - Nachum Z, Ben-Shlomo I, Weiner E, et al. Twice daily versus four times daily insulin regimens for diabetes in pregnancy: randomized controlled trial. BMJ 1999; 319: 1223-7.
30 - Langer O, Conway D, Berkus M, et al. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med 2000; 343: 1134-8.
31 -La banque de données du Primal Health Research Centre est spécialisée dans les études explorant les conséquences à long terme de ce qui se passe au début de la vie.
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Wednesday, January 16, 2008

Home Delivery

I just heard about another upcoming documentary about home birth, Home Delivery. It follows three very different women birthing at home in New York City. There's a short trailer on the movie's website.
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A night as a newborn nurse

I recently came across the House of Harris blog, and a recent post about her work as a newborn nurse was outstanding. There are probably a lot of health care workers like her who want births to be better, who want to give the mother and baby a gentler experience.
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Tuesday, January 15, 2008

Why Come to The Trust Birth Conference, by Sarah Buckley

Carla Hartley, director of Ancient Art Midwifery Institute, has brought together an amazing group of speakers who are not only passionate and articulate, but who are at the forefront of knowledge and activism.

At the Trust Birth conference you will be inspired and informed, with practical ideas that you can take back to your own community and professional work.

Be informed by the hard evidence from Henci Goer, whose ability to summarize and critique the medical studies is among the best in the world.

Be challenged by Michel Odent, who asks if humanity can survive our current obstetric practices.

Be trusting of birth and its safety for mother and baby, as Sarah Buckley gives you the medical evidence and the amazing hormonal story of why birth is safe and intervention is risky.

Be nourished in your practice by Jan Tritten, editor of the wonderful magazine Midwifery Today who will share ‘The wisdom of the grandmothers’: what midwives all over the world know about the safety, sacredness and importance of birth.

Be entertained by Heather Cushman-Dowdee, aka Hathor the Cowgoddess, whose antics have given a laugh and a dose of sanity to mamas all over the world.

Be inspired by Debby Takikawa and her film What Babies Want, which distills the evidence for gentle treatment of babies – and support for parents.

Be moved by Rachel Correa, whose profound story of homebirth and stillbirth was a highlight of the recent Australian Homebirth Conference.

Be activated by Heather Brock’s workshop on getting our post-birth bodies in shape, including our pelvic floor and abdominals. (They must be here somewhere!)

Be educated outside the box with midwife Gail Hart’s workshop as she discusses whether Gestational Diabetes is a scare tactic or a legitimate concern.

Be amazed by Lennon Clark as she describes the ability of babies to communicate their elimination needs, which can eliminate the need for diapers and help save the earth!

Be pushed in your ideas around pushing in labor, as a panel of midwives discusses the “P’ word: is is useful, and whether our bodies can do it for themselves.

Be immunized against false information on immunization, as Kristi Zittle shares wisdom about the risks of immunization and the benefits of natural immunity

Be compassionate as you hear the lovely Marcy Axness shares stories, research and soul perspectives on post natal depression.

Be expanded in your mind and pelvis as Gloria Lemay shares her amazing pelvic perspective, in "Pelvises I have known and loved” (based on one my all-time favourite articles).

Be safe or not: what does safety in birth mean, and how does it apply to birth choices? Join Rixa Freeze who is writing her PhD on the unassisted birth movement.

Be adventurous and discover more about why women stay at home alone, choosing unassisted birth. Panel with Rixa and other freebirth advocates and mamas.

Be thrilled to meet some of your heroes and heroines in the birth movement.

Don’t forget to bring your books for signing, or buy copies at the conference!

Be reinvigorated when you leave, filled with wisdom and inspiration to continue the important--perhaps the most important--work for mothers, babies, fathers and families everywhere.
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Monday, January 14, 2008

Alternative to La Bassine

I've heard good things about the La Bassine waterbirth pool, but the price tag can be prohibitive for women on a strict budget. I found a similar inflatable pool for about half the price, the Sevylor Electra Round.

Similarities: Both have upright I-beams and an inflatable floor.
Differences. The Sevyor holds 72 gallons, La Bassine 100 gallons. The Sevyor is round, rather than slightly oval, and doesn't have handles inside.

This might be a good alternative for people wanting something a bit more sturdy than your standard fishy pool. Sometimes the horizontal rings give way under pressure, creating a lovely flood in the living room. Not fun.

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Singing in labor

Those of us familiar with unmedicated labors are used to hearing women vocalize during contractions. We often talk about women's "birth songs," although frankly that phrase is often a euphemism for sounds that are more like a bellowing cow or roaring lion or some scary monster from a b-grade science fiction movie. Eric described my pushing vocalizations as "coming from the belly of the best."

But...sometimes women actually do sing--and I mean SING--during labor. Bellies and Babies recently posted a video of her friend singing during her labor, accompanied by her husband on a guitar. It's beautiful. Supposedly she had a couple contractions during the video, but I had a hard time telling when!

Singing during labor makes a lot of sense. It makes us take nice, deep abdominal breaths, and then sloooooowly release the air as we sing. It also ensures that we keep the mouth, throat, and neck relaxed, which is great for keeping the pelvic area loose as well.
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Friday, January 11, 2008


I've been updating my links and blogroll. Please let me know if any of the older links are broken, or if you have a website or blog that you find interesting or informative.

Now a few shameless plugs:
  • A good friend has a fantastic food blog called Balance. I've always wanted to make a Buche de Noel and now I know how.
  • Another friend started selling her jewelry on Etsy. Check it out!
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Tina Cassidy's birth story

I've been following the birth story of Tina Cassidy's second baby. If you read her recent book Birth: The Surprising History of How We Are Born, you will remember that her first birth ended in a cesarean. She's been writing the story in installments (we're on number 7 and labor still hasn't started yet!) and I am interested to see how it turns out.
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More food for thought

Thank you, Kneelingwoman, for your detailed, thoughtful, and honest post. I have too many thoughts swirling around in my head to get them all out right now, but I love how you (and many of the commentors, too., even the ones raising gentle dissent) have raised so many complex issues. We all have one common goal--the wellbeing of mothers and babies--although the means to that end may at times conflict and at other times intersect. And that's okay, too, as long as one group's means doesn't wreak wholescale havoc on the bodies, spirits, or emotions of the mothers and babies it affects. I don't want fewer options and choices; I want more. I want every birth choice, from repeat cesarean to unassisted birth, to be chosen freely and in the spirit of love and confidence, not fear.
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Thursday, January 10, 2008

Gloria Lemay responds

Here is a response to the Good Morning America piece on UC from Canadian midwife* Gloria Lemay. She originally posted it on the main ICAN list.

“The baby could be born in a breach [sic] position, or with the umbilical cord wrapped around its neck. The mother could suffer from significant tearing or from a maternal hemorrhage and bleed to death in as little as five minutes.”

Dear Women,

The above quote is by a physician who was interviewed by Good Morning America for a program about Unassisted Birth on Jan 8, 2008.

I think it’s very important to address the statement that a woman can hemorrhage and bleed to death in as little as five minutes. This is a very horrifying comment for a doctor to make and, for anyone who doesn’t really know birth, it could be enough to send them running for the hospital.

First of all, yes, it’s possible to hemorrhage and bleed to death quickly in birth IF YOU HAVE A SURGICAL WOUNDING. Women die from bleeding in cesareans and with episiotomies. The closest to death that I have ever seen a woman in childbirth was in a hospital birth where the ob/gyn cut an episiotomy, pulled the baby out quickly with forceps and then left the family doctor to repair the poor woman. We were skating in the blood on the floor and desperately trying to get enough IV fluids into her to save her life while the family doctor tried to suture the episiotomy wound as fast as he could. I have never seen anything like that in a home birth setting or a hospital birth that didn’t involve cutting.

Think about it--would any midwife ever go to a homebirth if it was possible for the mother to die from bleeding in five minutes? I know I wouldn’t go if that could happen. We had a visit here in Vancouver BC from an ob/gyn from Holland back in the 1980’s. Dr. Kloosterman was the head of Dutch maternity services for many years and he was a real friend to homebirth and midwifery. He told us that you have AN HOUR after a natural birth before the woman will be in trouble from bleeding. Does this mean that you wait for an hour to take action with a bleeding woman? No, of course not. If there’s more blood than is normal, you need to call 911 and transport to the hospital within the hour, but you’re not going to have a maternal death before an hour is up. I have had 10 transports for hemorrhage in the many homebirths that I have attended (over 1,000). Two women have required transfusions. The other 8 recovered with IV fluids, rest and iron supplements. Of course, no one wants to see blood transfusions in this day and age. We also don’t like to see a woman anemic after having a baby because it makes the postpartum time very difficult. The most important action after having a baby is to keep the mother and baby skin to skin continuously for at least the first 4 hours.

What doctors won’t tell you is that the most severe cases of postpartum anemia are in women who have had cesareans. Major abdominal surgery results in anemia. I have a friend who is a pharmacist in a hospital. He spends most of his days trying to figure out individual plans to help cesarean moms get their hemoglobin counts up. He finds these cases of severe anemia in post-operative mothers very distressing.

I hope this information is helpful to you.

As far as the other nonsense this person is trying to frighten you with:

1. Significant tearing—if you look with a mirror at your vulva after birth and there seems to be skin that “flaps” away from the rest of the vulva structures, you can always go into the emergency ward and have someone suture the wound. Tears do not bleed like cuts do. This should not dissuade anyone from staying away from the place where the scalpels reside.

2. Breech position—you’ll know if your baby is breech. When the membranes release, you will see black meconium coming out the consistency of toothpaste. With a head first baby, the meconium colours the water green or brown but with a breech, the meconium is being squeezed directly out without mixing with water. The other way that you should suspect a breech presentation is if you have a feeling from about 34 weeks of pregnancy on that you have “a hard ball stuck in your ribs.” Breech presentations are about 3 percent of births.

3. Cord wrapped around the neck—the smart babies put their cords around their necks to keep them out of trouble. If you have a baby with the cord around the neck, it can be unwrapped very easily either during or right after the birth. The most important thing is to keep the cord intact.

Gloria Lemay, Vancouver BC Canada
Advisory Board Member, ICAN
Contributing Ed. Midwifery Today Magazine
Teaching midwifery on the internet at
Speaking at the Trust Birth Conference, Redondo Beach, CA in March 2008

* Gloria Lemay cannot officially call herself a "midwife," according to British Columbia ruling. Only midwives belonging to the BC College of Midwives may use that title. She is allowed to advertise as a "birth attendant."
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Wednesday, January 09, 2008

UC on Good Morning America

Good Morning America recently had a short segment about unassisted birth. They featured one woman, Christina Schaefer, who had a UC with her fourth baby. What the show didn't have time to tell was her back story.

Her first baby was born via cesarean section after an induction for mild preeclampsia. From the October 21, 2007 article "No doctor, no midwife: I'll give birth at home alone" in the New York Post's Page Six Magazine:

"Christina, a stay-at-home mom, wasn't looking to buck the system when she first got pregnant after three years of marriage. 'I really had no idea what to expect. I trusted my doctor. Whenever I'd go to see my OB, my blood pressure would rise, and I was concerned about preeclampsia,' she says, referring to the potentially fatal pregnancy-related condition. A little over a month before her first child, Cade, was due, Christina was admitted to the hospital with mild preeclampsia, and the doctor decided to induce labor. 'After giving me a dose of a drug called Pitocin, breaking my water and screwing an internal fetal monitor into my baby's scalp, they realized he was stressed, so they told me they were going to do a C-section. They didn't ask my permission. As soon as they stopped the Pitocin, the baby was no longer stressed, but they did the C-section anyway. I think if they had just let things progress normally, I could have had a vaginal birth,' Christina says."

Her next two births were hospital VBACs with CNMs. She wanted to do the same for her fourth baby, but the hospital had changed its VBAC policy. She was informed that she would have to have a repeat cesarean section. She pled her case before the hospital, but was told, "It's all about liability."
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Support Waterbirth International

Passing along a message I received from Barbara Harper of Waterbirth International:

Waterbirth International needs your help!!

For twenty plus years WBI and Barbara Harper have been guiding mothers and their providers, providing education and birth pools all over the world. Waterbirth International is facing the very difficult truth that the Gentle Birth World Congress--a fabulous success in every way for international and local attendees--drained all of our resources. We may have to close the doors permanently by January 31st. We need to raise $200,000 in donations to cover the debts from the Congress.

With such a large sum to raise, we need each of you to support this cause. When you support waterbirth, you are making a statement that you want and need options, choices and more control.

Can you help us stay open to take the next phone call?
- to convince the an obstetrician to incorporate waterbirth into his/her practice.
- to work with the nurse midwives to install pools in their facilities.
- to educate an entire hospital on the benefits of allowing women freedom of movement in the water.

We have freely given these services over the past 20 years. We want to continue to give them freely, but we need your help to keep the phones turned on and the volunteers working.

How much is it worth to see waterbirth become the norm in the US, like it is in the UK? I think we only need a few more years to make that happen.

Women really do want waterbirth to be an available choice in every hospital. They need choices now, more than ever.

If we need to call every single waterbirth parent personally, we will. We don't want 25 years of pioneering work to end and the vision of safe and beautiful waterbirth to go away. Please do the following:

~DONATE any amount you can
~Become a MEMBER of Waterbirth International
~Buy a birth pool for your local midwives
~Buy a birth pool for yourself
~Buy a birth video and donate it to your local library
~Spread the word around the world
~Post this message on other sites and blogs
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Tuesday, January 08, 2008

Vision of Unity

I have been disturbed by all of the antagonism, fighting, gossip, and divisiveness that envelops childbirth. So many of the choices surrounding birth are framed in terms of polarized debates: home versus hospital...midwives versus doctors...epidural versus "natural" childbirth...assisted versus unassisted. Rarely does either party walk away having accomplished anything positive. We wield studies and statistics like clubs, hoping that we can intimidate each other into submission by sheer force or volume or rhetorical ingenuity. We hurl horror stories at each other: woman catches fire during her cesarean! baby dies during a breech homebirth! two best friends die after their cesareans! woman loses both arms and legs after giving birth in a hospital!

I cannot take part in this violent war of words. Mothering has transformed me. I never knew that I could love so passionately and so completely. Happy Sad Mama's words echo my own feelings: "I love my kids so much, so intensely much, and I am so grateful for them that my image that flies past the blackness of my eyelids when I think too hard about this love is of me lying, face-down, on the ground reaching up for them. I want them so intensely interwoven with me, I feel absolutely addicted to them and entranced by them and I just can't imagine that everyone else in the world feels this way because I am almost CRAZY with the love and addiction for them."

When I was pregnant with my daughter, I felt an intense inner need to give birth to her at home, in privacy. When a reporter from Grazia magazine was interviewing me last spring, I unexpectedly broke into tears as I was telling her how I had wanted Zari to be born in an atmosphere of love, knowing only the warmth of her parents' arms. I am not a crier, usually. I didn't cry at my daughter's birth. I was calm. Intensely happy, of course, too, as you can see in the videos right after her birth.

I feel a kinship with Sarah Buckley in this regard. She too felt a strong inner pull that her fourth baby needed to be birthed at home, into the presence of her own family: "Our baby’s birth was to be witnessed only by the family--there had been a strong feeling from the start that this was what this baby wanted....There was also a simple, domestic feeling to this pregnancy--no need for outside activity or people--and I felt keenly this baby’s love of family." The birth story is definitely worth reading, by the way.

Love is a tremendous motivating force. I challenge you to join me in transforming our verbal swords into plowshares. Let's turn the endless debates into something more beautiful and more useful: a Vision of Unity.

by Jeannine Parvati Baker

Like many of us, I have been praying with my ears, listening to midwives all around the world.
How can we (wo)manifest the vision of unity that would serve families?
Meditating upon the divisions between birth attendants, a vision came to me.
I saw a circle wherein the tribes called to heal the Earth by healing birth sat together.
It was a medicine wheel, with all styles of midwifery and obstetrics represented.
Across the wheel from me sat a medical doctor.
To each of my sides were medwives and CNM's, seated across from one another.
We defined the cardinal points in the wheel, but were not the whole circle.
From where I sat, I could see directly what was behind the doctor, and visa versa.
To either side I had an oblique angle to view my sister medwives and CNM's.
Then I realized why we needed one another. It is to keep us honest.
I can see what is the shadow of obstetrics, as the good doctor can see the shadow freebirth casts.
Nurses and medwives add to the bigger picture across the wheel from one another.
No one can turn around and see ones own shadow alone. This is how we serve one another.
All of us who attend birth are holograms in this circle of life. Each has the whole truth about birth within.
When we bring our versions of the truth together, there is a finer resolution and
multi-dimensional viewing into the great round of being.
In my vision, we are sitting in birth's circle, representing our various tribes.
Not my circle, not yours, but birth's circle.
Each tribe, each perspective, is precious to birth.
Together the living oracle will be voiced through all of us.
Let it be the voice of what the Earth needs through each of us.
Remembering this always: What we do to one, we do to all.

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Saturday, January 05, 2008

Oughta be in Ottawa

We had a blast spending our Christmas break in Ottawa with my in-laws. All but one of Eric's siblings and their families came home to visit. He's the oldest of seven, so the house was packed to the brim with Zari's cousins (currently there are 14 and 2 more on the way). Ottawa had record-breaking snowfalls while we were there. Zari discovered the joys of eating snow. She figured out that it was most efficient to stick her head right into the snowbank, but licking the snow off her mittens was also a favorite activity. Or I should say, "favourite," as a nod to Canadian spelling. We took several days to drive out, visiting different family members on the way. Coming back home, though, we bit the bullet and did it all in one long day: just over 15 hours with stops.

Favorite memories of the trip:
~ Watching New Year's Eve fireworks from Victoria Island at 18:57 to celebrate Ottawa's being chosen the capitol of Canada in 1857 by Queen Victoria. Winter fireworks are definitely way more beautiful than summer ones. The explosions, coming from Parliament Hill and a railroad bridge, were mirrored in the river. The sky was overcast and we had a deep snow cover, so everything was very bright even though it was night.
~ Sledding off the deck in the backyard. The snow was so deep that we built a sledding hill in the back yard and sent the little kids down it.
- Ice skating at the local ice arena. I put Zari in the Fauxhawk (front carry). After a while she wanted out, so then Eric and I held her between us and pulled/pushed her along as she kicked her legs.

Here are some pictures from our time in Ottawa:

Zeke's new competition
Pink puffball
Christmas Eve pinata smashing and floor hockey
Zari's serious face
I made newborn size leather shoes for one SIL who just had twins
and another who's pregnant with her third.
Newspaper pirate
Playing in a "tent" with her cousins
Trying on Eric's ski boots
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GBS-Positive Treatment Plan

Reposted with permission from Barb Herrera of Ama Mama.

GBS-Positive Treatment Plan from Ama Mama Holistic Health Care

This plan was developed by a pregnant woman in San Francisco who tested positive for Group Beta Streptococcus. She was planning a home birth and wanted to avoid hospitalization and antibiotic treatment. She successfully eliminated the bacteria from her genital and anal tracts.

We received this plan in 2001. At the time, this client's midwife has used this treatment method successfully with two additional GBS-positive mothers and was working with a fourth woman who had elected to use this same method. This method purportedly takes approximately three (3) weeks to obtain negative cultures, but each successive culture showed less GBS growth.

After this course of treatment is completed, you and your midwife can then perform a culture weekly to see if the bacteria levels are decreasing. The reading closest to time of delivery is purportedly the most reliable. It is recommended that, if this course of treatment proves successful at eliminating GBS from the vaginal/rectal tract, the regimen be continued until delivery to decrease the likelihood of GBS being present in your vaginal tract at the time of delivery. You may also want to consider separate cultures for the vagina and rectum; the risk of neonatal GBS infection is less if GBS is present only in the rectum (and not the vagina) although extra precautions remain necessary.

We at Ama Mama offer this information as a prenatal alternative to women who have tested positive as a GBS carrier. It is not endorsed or recommended by Ama Mama or the Center for Disease Control. It is suggested that you take the following supplements and remedies, as directed, for three weeks. As with any treatment, please discontinue use and contact your health care provider immediately if any adverse effects are noted. Thank you.

1. Twice a day, with breakfast and dinner:
Acidophilus or pro-biotic supplement: 4 billion cells per dose
Echinacea: Two 350 mg (each) capsules
Garlic: Two 580 mg (each) capsules
Vitamin C: 500-2000 mg (0.5-2 grams), with 200 mg bioflavonoids
Grapefruit seed extract: 15 drops

2. Once per day for 3 days, once per week thereafter: Homeopathic Streptococcynum 200X

3. Once per day (until finished): Herbal-C suppositories, by Bezweken
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Nursing self-portrait

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Tuesday, January 01, 2008

Group B Strep information

Since GBS came up in the comment section of an earlier post, I thought I would dedicate a new post to the topic.
First, let's do the numbers:
Courtesy of Stephanie Soderblom--numbers come from this article and the CDC

* 15-40% of women are suspected to be colonized.
* 98-99% of babies born to colonized women will not become infected.
* Of those infected with early onset, 15% will die.
* Of those infected with late onset, 50% did not contract it from their mother but rather from other sources such as hospital personnel.

Taking "worse case scenario" (ie. assuming 40% of women are colonized, and 2% of those babies will become infected)--if we did not screen, did not give antibiotics, did nothing at all...
* .0225% (1 in 4444) babies would die of early onset GBS

Next, some articles:
* Mothering magazine has an article overviewing GBS and IV abx treatment.
* Prenatal screening for group B streptococcal infection: gaps in the evidence (editorial in the International Journal of Epidemiology)

Finally, I have included several research abstracts from an alternative treament for GBS colonized mothers: chlorhexidine vaginal washes. These have been found to be as effective as IV antibiotics at preventing GBS infections in babies. A vaginal wash is much easier to administer than antibiotics, less invasive, and carries fewer side effects.

Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.

Matern Fetal Neonatal Med 2002 Feb; 11(2):84-8. Facchinetti F, Piccinini F, Mordini S, Volpe A. Department of Gynecology, Obstetrics and Pediatric Sciences, University of Modena and Reggio Emilia, Italy.

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.
CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine.

Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labor.
Lancet 1992 Jul 11;340(8811):65-9. Comment in: Lancet. 1992 Sep 26;340(8822):791; discussion 791-2. Lancet. 1992 Sep 26;340(8822):792..

Conclusion: Chlorhexidine reduced the admission rate for infants born of carrier mothers to 2.8% (RR 1.95, 95% Cl 0.94-4.03), and for infants born to all mothers to 2.0% (RR 1.48, 95% Cl 1.01-2.16; p n 0.04). Maternal S. agalactiae colonization is associated with excess early neonatal morbidity, apparently related to aspiration of the organism, that can be reduced with chlorhexidine disinfection of the vagina during labor.

Vaginal Flushing vs. IV Antibiotics
Facchinetti F, Piccinini F, Mordini B, Volpe A. “Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.” J Matern Fetal Med 2002 Feb;11(2):84-8.
Department of Gynecology, Obstetrics and Pediatric Sciences, University of Modena and Reggio Emilia, Modena, Italy.

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.
METHODS: This was a randomized controlled study, including singleton pregnancies delivering vaginally. Rupture of membranes, when present, must not have occurred more than 6 h previously.. Women with any gestational complication, with a newborn previously affected by group B streptococcus sepsis or whose cervical dilatation was greater than 5 cm were excluded. A total of 244 group B streptococcus-colonized mothers at term (screened at 36-38 weeks) were randomized to receive either 140 ml chlorhexidine 0.2% by vaginal flushings every 6 h or ampicillin 2 g intravenously every 6 h until delivery. Neonatal swabs were taken at birth, at three different sites (nose, ear and gastric juice).
RESULTS: A total of 108 women were treated with ampicillin and 109 with chlorhexidine. Their ages and gestational weeks at delivery were similar in the two groups. Nulliparous women were equally distributed between the two groups (ampicillin, 87%; chlorhexidine, 89%). Clinical data such as birth weight (ampicillin, 3,365 +/- 390 g; chlorhexidine, 3,440 +/- 452 g), Apgar scores at 1 min (ampicillin, 8.4 +/- 0.9; chlorhexidine, 8.2 +/- 1.4) and at 5 min (ampicillin, 9.7 +/- 0.6; chlorhexidine, 9.6 +/- 1.1) were similar for the two groups, as was the rate of neonatal group B streptococcus colonization (chlorhexidine, 15.6%; ampicillin, 12%). Escherichia coli, on the other hand, was significantly more prevalent in the ampicillin (7.4%) than in the chlorhexidine group (1.8%, p < 0.05). Six neonates were transferred to the neonatal intensive care unit, including two cases of early-onset sepsis (one in each group). CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine. Vaginal Disinfection with Chlorhexidine During Childbirth
Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M. “Vaginal disinfection with chlorhexidine during childbirth.” Int J Antimicrob Agents 1999 Aug;12(3):245-51.
Department of Gynecology and Obstetrics, Aker Hospital, University of Oslo, Norway.

The purpose of this study was to determine whether chlorhexidine vaginal douching, applied by a squeeze bottle intra partum, reduced mother-to-child transmission of vaginal microorganisms including Streptococcus agalactiae (streptococcus serogroup B = GBS) and hence infectious morbidity in both mother and child. A prospective controlled study was conducted on pairs of mothers and their offspring. During the first 4 months (reference phase), the vaginal flora of women in labour was recorded and the newborns monitored. During the next 5 months (intervention phase), a trial of randomized, blinded placebo controlled douching with either 0.2% chlorhexidine or sterile saline was performed on 1130 women in vaginal labour. During childbirth, bacteria were isolated from 78% of the women. Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18% (chlorhexidine), (P < 0.000 1, 95% confidence interval 0.12-0.22). The lower rate of bacteria isolated from the latter group was accompanied by a significantly reduced early infectious morbidity in the neonates (P < 0.05, 95% confidence interval 0.00-0.06). This finding was particularly pronounced in Str. agalactiae infections (P < 0.0 1). In the early postpartum period, fever in the mothers was significantly lower in the patients offered vaginal disinfection, a reduction from 7.2% in those douched using saline compared with 3.3% in those disinfected using chlorhexidine (P < 0.05, 95% confidence interval 0.01-0.06). A parallel lower occurrence of urinary tract infections was also observed, 6.2% in the saline group as compared with 3.4% in the chlorhexidine group (P < 0.01, 95% confidence p interval 0.00-0.05). This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine. Vaginal Chlorhexidine during labor
Burman LG, Christensen P, Christensen K, Fryklund B, Helgesson AM, Svenningsen NW, Tullus K. “Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labour. The Swedish Chlorhexidine Study Group.” Lancet 1992 Jul 11;340(8811):65-9. Comment in: Lancet. 1992 Sep 26;340(8822):791; discussion 791-2. Lancet. 1992 Sep 26;340(8822):792.
National Bacteriological Laboratory, Stockholm, Sweden.

Streptococcus agalactiae transmitted to infants from the vagina during birth is an important cause of invasive neonatal infection. We have done a prospective, randomised, double-blind, placebo-controlled, multi-centre study of chlorhexidine prophylaxis to prevent neonatal disease due to vaginal transmission of S agalactiae. On arrival in the delivery room, swabs were taken for culture from the vaginas of 4483 women who were expecting a full-term single birth. Vaginal flushing was then done with either 60 ml chlorhexidine diacetate (2 g/l) (2238 women) or saline placebo (2245) and this procedure was repeated every 6 h until delivery. The rate of admission of babies to special-care neonatal units within 48 h of delivery was the primary end point. For babies born to placebo-treated women, maternal carriage of S agalactiae was associated with a significant increase in the rate of admission compared with non-colonised mothers (5.4 vs 2.4%; RR 2.31, 95% CI 1.39-3.86; p = 0.002). Chlorhexidine reduced the admission rate for infants born of carrier mothers to 2.8% (RR 1.95, 95% CI 0.94-4.03), and for infants born to all mothers to 2.0% (RR 1.48, 95% CI 1.01-2.16; p = 0.04). Maternal S agalactiae colonisation is associated with excess early neonatal morbidity, apparently related to aspiration of the organism, that can be reduced with chlorhexidine disinfection of the vagina during labour.

Chlorhexidine Gel
Kollee LA, Speyer I, van Kuijck MA, Koopman R, Dony JM, Bakker JH, Wintermans RG. “Prevention of group B streptococci transmission during delivery by vaginal application of chlorhexidine gel.” Eur J Obstet Gynecol Reprod Biol 1989 Apr;31(1):47-51.
Department of Paediatrics, University Hospital, Nijmegen, The Netherlands.

In a prospective study in 227 parturients, carriership of group B streptococci was established to be 25%. In carriers, transmission of streptococci to the newborn occurred in 50%. 10 ml of a chlorhexidine gel containing hydroxypropylmethylcellulose was introduced into the vagina during labor in 17 parturients, who were known to be carriers of group B streptococci from the first trimester of pregnancy. In none of the newborns from these mothers colonization by group B streptococci did occur. Vaginal application of chlorhexidine may prevent transmission of group B streptococci, and serve as an alternative to intrapartum prophylaxis using antibiotics. A large multicenter randomized controlled study should be performed to confirm this hypothesis.

Chlorhexidine before rupture of membranes
Christensen KK, Christensen P, Dykes AK, Kahlmeter G. “Chlorhexidine for prevention of neonatal colonization with group B streptococci. III. Effect of vaginal washing with chlorhexidine before rupture of the membranes.” Eur J Obstet Gynecol Reprod Biol 1985 Apr;19(4):231-6.

A single vaginal washing with 2 g/l of chlorhexidine was performed before rupture of the membranes in 19 parturients who were urogenital carriers of group B streptococci (GBS). Two (11%) of the infants became colonized immediately after birth, in contrast to 16 of 41 (39%) infants to controls (P = 0.02). A significant reduction of GBS colonization of the ear (P = 0.02) and umbilicus (P = 0.01) was noted. Taken together, 2 of 57 (4%) cultures obtained at birth were positive in the chlorhexidine group, in contrast to 30 of 123 (24%) among the controls (P less than 0.01). These findings raise hope for the design of a simple washing procedure which might prevent serious infections in the early neonatal period with GBS but also with other chlorhexidine-sensitive organisms.
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