Kangaroo Mother Care Saves Lives

Read the full article here — premature babies on their mothers’ chests have better outcomes than those placed in incubators. This is particularly important in low-income countries who simply don’t have the resources to have all the “bells and whistles” that can help preemies survive and thrive.

Fantastic Kangaroo Care and Skin-to-Skin Contact Resources

One of my friends emailed this to a childbirth educators list I’m on, and I thought it was fantastic, so wanted to share with others.

First, is a Power-Point presentation (in pdf format) from  Dr. Bergman on the importance of skin-to-skin contact for full-term newborns, and even greater importance of kangaroo care for preemies. Drawing on developmental curves of other mammals, Dr. Bergman points out that humans are basically born immature — dogs, cats, monkeys, etc., are all born more highly developed (as measured by percentage of brain growth, etc.); and preemies are born more on the “marsupial” level of immaturity and prematurity. Animals are born with brains that are 80% of the size of adult brains; humans are not. Based on brain development (as a percentage of the adult size, compared to newborn/adult brains of animals), humans don’t reach the 80% marker until about a year after full-term birth. When born premature, they are even less that. The presentation presents powerful and compelling arguments for attachment parenting concepts (such as, sleeping with the baby, carrying the baby in an infant carrier on the mother or father, breastfeeding on demand, skin-to-skin contact, not crying it out which can be harmful, etc.), and even stronger arguments for “kangaroo care” for preemies.

The second resource is the Kangaroo Mother Care website which has even more links, stories, research, etc., on kangaroo care and premature birth. Dr. Bergman draws a distinction between “Kangaroo Care” as practiced in U.S. hospitals (“This has been defined as “intra-hospital maternal-infant skin-to-skin contact”. KC is generally started later, and on stabilised prematures, and is used an adjunct to technological care”) and “Kangaroo Mother Care” which in part includes NEVER separating the mother and the baby — if the baby needs additional care, then technology is brought to him, rather than him taken away from the mother to go to the technology.

Dr Nils Bergman was the Doctor who introduced Kangaroo Mother Care (KMC) to South Africa. He has recently published the results of a strict scientific trial (in Acta Paediatrica) comparing skin to skin immediately after birth to incubator care . What he found was that skin to skin care was much better for the newborn than the incubator. Babies were warmer and calmer, breathed better and had a more stable heart rate with skin to skin care.

Surprisingly, the smaller the baby was-down to 1200grams- the more stable they were, and the more unstable in the incubator! This is opposite to what people think!

In fact there is other research suggesting that the incubator is harmful! Babies’ brain development requires skin to skin contact and being held and carried, and eye to eye contact to form the right brain pathways. Depriving babies of this skin to skin care makes alternative stress pathways which can lead to ADD, colic, sleep disorders etc.

Surprisingly incubators are still used for the very reason of stabilizing the baby when they in fact do the opposite!

There is a lot of information on the website, and I can’t do it justice, so just explore it for yourself, share with friends, and remember for future reference. Although the following story is anecdotal (although if a doctor wrote it, it would not be a mere “anecdote” but would be a “case study”), this woman saved her baby’s life by instinctively picking her up and putting her on her chest. The baby was born at 24 weeks gestation, weighing 20 oz (566 grams), and doctors didn’t believe she would live — her heart was beating only every 10 seconds and she wasn’t breathing.

She said: “I didn’t want her to die being cold. So I lifted her out of her blanket and put her against my skin to warm her up. Her feet were so cold.

“It was the only cuddle I was going to have with her, so I wanted to remember the moment.” Then something remarkable happened. The warmth of her mother’s skin kickstarted Rachael’s heart into beating properly, which allowed her to take little breaths of her own.

Miss Isbister said: “We couldn’t believe it – and neither could the doctors. She let out a tiny cry.

The baby was eventually taken and put on a respirator, but “Her heart rate and breathing would suddenly sometimes drop without warning” — which reminds me of one of the graphs in either the PDF or the website — that the baby’s heart rate and breathing and temperature were all more stable and regular when on the mother than in an incubator.

I don’t think that this doctor is suggesting that the only thing a premature baby needs, no matter how early it is born, is to be put on his mother’s chest — after all, he pointedly says that technology needs to be brought to the mother-baby when needed. But what if the interventions that are currently being done on premature infants are actually harmful, or at least, would be more helpful if the baby is on his mother’s chest (unless that is totally impossible). Yes, I’m sure there is a ton of research showing that babies receiving the current standard of care do better than babies in a “control group” — but what if standard interventions done on the mother’s chest were vastly superior than standard interventions done in a plastic box?

As an example of what I’m angling at, consider a hypothetical research project: babies are born, and divided into two groups — the first group is put in an orphanage where their physical needs are met (they are fed, clothed, and given diaper changes) but are basically kept in cribs all the time. The second group is put in a different orphanage where their physical needs are met and they also receive some social interaction, playing with other orphans and also sometimes the caregivers who are not as overwhelmed and busy as in the first orphanage. Obviously, the second group is likely going to do much better. However, neither of these settings is natural or normal — consider that there is also the possibility of babies not taken from the mother at all, but are given the level of maternal care and attention that you and I take for granted — breastfed, lovingly held and cared for, played with on a one-to-one basis, read to, etc. (in addition to the basic physical needs being met). Don’t you think that this third group would greatly excel either of the first two groups? Of course! So, is it not possible that our current standard of care, while better than that of the 70s or 80s, still pales in comparison to what might be possible if the technology (breathing assistance, drugs, fluids, nourishment, etc.) were done in the context of kangaroo care, rather than KC being more or less an afterthought?

“First, do no harm.” If, as that newspaper article demonstrated, it could shown that a mother’s natural inclination is to hold her premature infant on her chest, and that it holds some benefit to the baby (in this case, warming her, starting her breathing, and regulating her heartbeat), then that should be promoted — not necessarily at the expense of technology that has also been proven beneficial, but in conjunction with that technology to attain even better outcomes.

Several months ago, Reality Rounds posted a couple of heart-wrenching posts. She got a lot of flak, too, for it — all of it undeserved. I’m linking to them so that you can get a better idea of what’s involved in extremely preterm birth care; but, as my mother always says, “If you don’t have something nice to say, don’t say it at all.” First, “For they know not what they do” — which describes the extreme fragility of tiny babies, and the great caution the NICU team must employ not to hurt the baby as they try to help and save the baby:

We do everything.  Dry the infant with towels.  Careful.   Not too rough.  Do not want the gelatinous, friable skin to break and bleed unto the blankets. Listen for heart sounds.  Heart rate is barely 60 beats per minute.  No need for chest compressions.  We breathe air and oxygen into the tiny lungs.  Careful.  Too much air can blow a hole in the tiny lungs.  Too much oxygen can cause lung damage and blindness. We walk the wire.

It must be so extremely difficult to do everything that can be done to save the babies, knowing that it is hurting them physically (needles hurt! and worse for preemies — not to mention everything else). I liken it to what nurses in burn units must go through, as they try to save people who are badly burned — knowing that what they are doing, while necessary, is torture. And that even in the best of circumstances, the patient will endure untold pain, and be scarred for life — perhaps even unrecognizably scarred, perhaps losing fingers or toes or arms or legs. And perhaps when all is said and done and the patient is released to go home, he may even wish himself dead. Yet some people beat the odds and their injuries are not as life-altering or as scarring as they might have been; and many people are glad to be alive. But some people die in burn units, in spite of all the care given; and nurses and doctors must occasionally feel guilty that they did not “let nature take its course,” because then the person’s pain would have been shorter — when people die despite the best care given them, and die in pain, we can say in retrospect that it “would have been better” for them to have had no care at all and died quickly, than to have had their pain dragged out over days and weeks. But until we have a crystal ball to know which ones will have good results and which will not, we have to take care of them all.

The second post is NICU is a war zone — stressful for the parents, stressful for the baby, stressful for the workers. Finally, “Is letting a 21-week baby die health care rationing?” which includes the following paragraph on “Benevolent Injustice”:

I have cared for many infants at the edge of viability.  It is always emotionally draining.  There is no justice to it.  The extreme measures involved to keep a 22-23 week infant alive is staggering, and it is ugly.   I once had a patient who had an IV placed on the side of her knee due to such poor IV access.  When that IV infiltrated, I gently pulled the catheter out, and her entire skin and musculature surrounding the knee came with it, leaving the patella bone exposed.  I have seen micro-preemies lose their entire ear due to scalp vein IV’s.  I have watched 500 gram infants suffer from pulmonary hemorrhages, literally drowning in their own blood.  I have seen their tiny bellies become severely distended and turn black before my very eyes, as their intestines necrose and die off.  I have seen their fontanelles bulge and their vital signs plummet as the ventricles surrounding their brains fill with blood.  I have seen their skin fall off.  I have seen them become overwhelmingly septic as we pump them with high powered antibiotics that threatened to shut down their kidneys, while fighting the infection.  I have seen many more extremely premature infants die painful deaths  in the NICU, then live.

I do not claim any knowledge much less prowess in the field of premature birth. I do not blame anyone for allowing their extremely preterm baby die a natural death, rather than be subjected to these procedures. Nor do I blame parents who request that “everything” be done to save their babies. But care for premature babies is heart-wrenching either way, and painful. But what if there is a better way? I don’t know if this Kangaroo Mother Care extends to the micro-preemies, or there is some sort of cut-off point where it no longer helps — previously, I quoted that “babies down to 1200 grams” did better with KMC — which is about 2.5 pounds, and probably all late-second or early-third-trimester, much bigger than 20-23 week babies, for the most part (which is primarily the focus of the above blog posts). But what if current care is like the hypothetical orphanage study above — better than nothing, but not as good as kangaroo care in conjunction with life-saving interventions.

Sr Agneta Jurisoo studied what little literature was available on KMC during 1987. The following year she and Dr Bergman arrived at a small mission hospital in Zimbabwe, where premature births were common. There were no incubators, poor transport over great distances, and overloaded referral centres: only one of ten premature babies survived.

In the absence of incubators, they started a care plan in which the mother became the incubator. Instead of waiting for the baby to “stabilise”, the mother was used to stabilise premature infants immediately after birth. It was immediately clear this was highly effective, no matter how small or how premature, stabilisation took a mere six hours. With this care, now five of ten very low birth weight babies survived.

One problem is that current care is so entrenched, that it is very scary (and may even seem to be malpractice) to make the huge paradigm shift from taking the baby away from the mother for care, to putting the baby on the mother for care. Obviously, doctors and nurses are trained to take care of the baby alone, in an incubator — much like doctors are trained to have the mother on her back with her legs in stirrups when she gives birth. It can be very disorienting to have the baby come out “the wrong way” when the mother is on hands-and-knees or is squatting or kneeling. In the same way (only much, much bigger), it will take someone with a lot of guts to bring the NICU to the mother-baby pair, instead of taking the baby to the NICU. Who am I kidding? — it is a big shift to have full-term healthy babies put directly on the mother’s chest and kept there, instead of being put almost immediately into the warmer. Technology is very deeply entrenched in normal births and normal postpartum, and much more so in premature births! But “first do no harm” — first make sure that what you’re doing that is not physiologically normal (taking the baby from the mother) is going to first be not harmful, and second be beneficial. Certainly, there are times when babies need immediate surgery or other care that is not feasible or practical to be done on the mother. But I think steps need to be taken to keep mothers and babies together, if possible.

Abortion and Preterm Birth — a new study

Sidney Midwife, one of the blogs I read, had this as her most recent post: Study Showing Abortion-Premature Birth Risk Points to Cerebral Palsy. Since this is National Infant Mortality Awareness Month, and since premature birth increases infant mortality, this newest study has implications for this topic.

When I read about the study, I read the article, and then decided to find the abstract. Since the article mentioned that the study was published in the BJOG, and mentioned the study’s lead author, I had a good head-start. So, I went to the BJOG website, did a search for the author’s name, and came up with a pod-cast. Then the abstract. Then — wishful thinking! — I clicked on “fulltext,” fully expecting to go to a login screen, where I would have to pay $38 to view the report. What a pessimist realist! But, lo and behold, the full study is available! [Yeah, I’m a nerd — excited about being able to read a full study. :-)]

Here is the abstract:

Background History of induced termination of pregnancy (I-TOP) is suggested as a precursor for infant being born low birthweight (LBW), preterm (PT) or small for gestational age (SGA). Infection, mechanical trauma to the cervix leading to cervical incompetence and scarred tissue following curettage are suspected mechanisms.

Objective To systematically review the risk of an infant being born LBW/PT/SGA among women with history of I-TOP.

Search strategy Medline, Embase, CINAHL and bibliographies of identified articles were searched for English language studies.

Selection criteria Studies reporting birth outcomes to mothers with or without history of induced abortion were included.

Data collection and analyses Two reviewers independently collected data and assessed the quality of the studies for biases in sample selection, exposure assessment, confounder adjustment, analytical, outcome assessments and attrition. Meta-analyses were performed using random effect model and odds ratio (OR), weighted mean difference and 95% confidence interval (CI) were calculated.

Main results Thirty-seven studies of low–moderate risk of bias were included. A history of one I-TOP was associated with increased unadjusted odds of LBW (OR 1.35, 95% CI 1.20–1.52) and PT (OR 1.36, 95% CI 1.24–1.50), but not SGA (OR 0.87, 95% CI 0.69–1.09). A history of more than one I-TOP was associated with LBW (OR 1.72, 95% CI 1.45–2.04) and PT (OR 1.93, 95% CI 1.28–2.71). Meta-analyses of adjusted risk estimates confirmed these findings.

Conclusions A previous I-TOP is associated with a significantly increased risk of LBW and PT but not SGA. The risk increased as the number of I-TOP increased.

To be honest, the study does not even mention cerebral palsy, nor does it mention infant mortality — those are conclusions drawn by other readers of the study, based on the known facts of the risks of preterm birth and low birthweight. For instance, this cerebral palsy website says, in part,

Extremely low birth weight infants are 100 times more likely to develop CP than a full term infant. In one large overview of 6399 very low birth weight children that survived neonatal intensive care, childen that were evaluated up to age 3, the rate contracting CP was 77 per 1000. 2.5 per 1000 is the normal rate.

The CDC says,

Being born preterm is the greatest risk factor for infant mortality (death within the first year of life). Recent analyses of infant death data by CDC researchers demonstrate that preterm-related deaths accounted for more than 1/3 of all deaths during the first year of life, and more infants died from preterm causes than from any other cause.

Thinking of this sad topic always brings to mind a woman’s blog I read over a year ago. I forget how I even stumbled across it — some word search on Google or WordPress or something. Anyway, she told the story of her pregnancies. Midway through her first pregnancy, she found out that the baby had some defect of some sort — I can’t remember what it was, if it was genetic like Down Syndrome or physical like spina bifida  (probably neither one; it may have even been lethal) — and chose to terminate the pregnancy, rather than to give birth to a deformed child. The abortion took place sometime around 20-24 weeks. Then she got pregnant again; tests showed that everything was fine for this baby, and then a few weeks of gestation after the time of the first abortion, she went into preterm labor that was not (could not be?) stopped, and her baby died. I wondered at the time if her first abortion caused (or at least was a factor in) the early birth of her second baby — that her body having been forced to open too soon for the abortion (an induction abortion, I think, rather than a D&C or D&X), was traumatized by it, and opened too soon during the second pregnancy. This study strengthens that thought. I wonder if women are given true informed consent prior to undergoing abortions, that if they have an abortion, they might later put a wanted child at risk of preterm birth, cerebral palsy, or even death.

Here is a good article that includes more information on preterm birth, including other causes and factors.

September is National Infant Mortality Awareness Month

Infant mortality is how many live-born children die within 365 days of their birth. It is not necessarily a measure of how good a country’s prenatal or birth skills are, since many children die from car accidents and household accidents and such every year. It can be a useful comparative tool (for instance, is a country better off at keeping its infants from dying from gunshot wounds, or drowning, or cancer, or…?), but it is far from perfect. Especially, as I recently noted, if other countries use different data for their official statistics — for instance, not counting births prior to 26 weeks as live births.

GA 17-47

Still, as you can see, from the chart, there is a huge drop in infant mortality for babies born in each different gestational age bracket, up until “term.” This means a huge difference for babies — the longer they stay in until term, the better their outcomes will be. Here is a partial chart, which shows mortality by gestational age at birth:

imr by gest week

Again, there is a precipitous decline in infant mortality nearly every preterm week, with a majority of babies who were born prior to 24 weeks gestation dying, and a bit better than 50/50 at 24 weeks, with steep drops after that, for each week of gestation. Obviously, the longer these little “buns” can “bake,” the better. That is one reason why this midwife’s work is so astounding and beneficial. Some excerpts from this article include:

Lubic and her team of midwives run a birthing clinic in one of the city’s poorest areas. After 800 babies in eight years, they have never lost a child in childbirth, and has cut the rate of premature births – the biggest risk factor for infant mortality – in half

Her approach is simple. She believes low-income women, many on Medicaid, need the prenatal education that midwives provide. Everything from posture, to nutrition, to how the baby grows…

“Do you think it boils down to just the time you spend with them,” Andrews asked Lubic.

“I think so,” she replied. “I’m convinced that’s what it is. It’s time, respect, its treating people with dignity.”

Here is another chart I put together from the CDC statistics — comparing preterm birth rates by race (black and white only, to keep it simple):

IMR by gest week and race

Up to half of all births (and therefore half of the deaths) in the early weeks were babies born to black women; even though the rate decreased, so that black babies were born at half the rate of white babies by 27 weeks, that’s still disproportionately high. “Preterm birth is the leading cause of death and disability among African American infants.” However, while death rates are still disproportionately high for black babies at term, compared to white babies, they are less dramatic, since the percentage of term births is closer to the national population average (about 13% African-American).

Midwives have better results than doctors, with so-called disadvantaged populations in the U.S., though. Ruth Lubic may may have achieved phenomenal results, but she is not an exception to the rule that midwifery results in better outcomes. So, one question is, why do doctors put up such roadblocks to increasing midwifery care? These are CNMs not CPMs that were studied in this link — yes. But there are still significant difficulties for any midwife to practice. Many are legally restricted, or are politically restricted, from increasing their sphere of influence. For instance, some would want to attend home births, but if they do that, their hospital privileges will be terminated. We don’t see this in Canada, where, in fact, midwives are required to attend both hospital and home births. Obstetricians still attend about 90% of all births in this country, whereas in most other developed countries, midwives are the norm, and OBs are called in only when necessary.

But there is a factor for preterm birth that it not frequently talked about. That factor is previous induced abortion. First, according to the Alan Guttmacher Institute, black women obtain abortions at five times the rate of white women. Although African-Americans comprise only about 13% of the U.S. population, they have 21.4% of all preterm births. This may explain some of the disparity noted above.

Now, for the studies. I did a search through Google Scholar for “‘induced abortion’ and ‘preterm birth'”, and went through the first one hundred studies returned (ten pages, with ten results apiece). Not all of the studies returned were actually about this topic — many only included the search terms tangentially, with the studies themselves being about things as diverse as periodontal disease and smoking — not really about abortion at all. Here is what I found:

  • this abstract from a French study from 1995: “Previous induced abortion was associated with an increased risk of preterm birth (OR 1.4; 95% CI 1.1–1.8); the risk of preterm delivery increased with the number of previous induced abortions (OR 1.3; 95% CI 1.0–1.7 for one previous abortion and OR 1.9; 95% CI 1.2–2.8 for two or more). The relationship was the same for very preterm and moderately preterm deliveries and for spontaneous and indicated preterm deliveries”
  • History of induced abortion as a risk factor for preterm birth in European countries: results of the EUROPOP survey, March 2004 (full study): “Previous induced abortions were significantly associated with preterm delivery and the risk of preterm birth increased with the number of abortions. Odds ratios did not differ significantly between the three groups of countries. The extent of association with previous induced abortion varied according to the cause of preterm delivery. Previous induced abortions significantly increased the risk of preterm delivery after idiopathic preterm labour, preterm premature rupture of membranes and ante-partum haemorrhage, but not preterm delivery after maternal hypertension. The strength of the association increased with decreasing gestational age at birth.”
  • From the Journal of Reproductive Medicine, Feb. 2009: “Induced and spontaneous abortion are associated with similarly increased ORs for preterm birth in subsequent pregnancies, and they vary inversely with the baseline preterm birth rate, explaining some of the variability among studies.”
  • From October 2005, Obstetrical and Gynecological Survey: “A history of induced abortion correlated with an increased risk of very preterm birth (odds ratio, 1.6; 95% confidence interval, 1.2-2.1). There was little change when controlling for maternal characteristics or without adjusting for a history of preterm deliveries. In addition, the association remained the same when women with previous preterm delivery were excluded. The risk tended to increase with the number of previous induced abortions. The adjusted risk of preterm delivery associated with induced abortions tended to be highest for extremely preterm deliveries. The major complications leading to very preterm birth were premature rupture of membranes and idiopathic spontaneous preterm labor, and these occurred more often in connection with extremely preterm birth. Hypertension and fetal growth restriction were more common when infants were born at 28 to 32 weeks gestation. An association between previous induced abortion and very preterm delivery related to fetal growth restriction was apparent in infants born at 28 to 32 weeks gestation.
    “This study shows that a history of induced abortion increases the risk of very preterm birth, particularly extremely preterm deliveries. It appears that both infectious and mechanical mechanisms may be involved.”
  • And again from the Alan Guttmacher Institute, from 2000, a Danish study: “Danish women whose first pregnancy ended in abortion are about twice as likely as those who did not terminate their first pregnancy to subsequently deliver an infant at less than 37 weeks’ gestation, according to results of a population-based cohort study; they have a somewhat elevated risk of having a subsequent delivery at 42 or more weeks of gestation. Analyses of the same cohort also suggest that women who have undergone abortion have twice the risk of other women of later bearing a low-birth-weight infant…
    “When age, residence, interpregnancy interval and number of previous miscarriages were taken into account, women with one previous abortion were 1.9 times as likely as women in the comparison group, those with two previous abortions were 2.7 times as likely and those with three or more previous abortions were 2.0-2.2 times as likely to have a preterm birth. In general, the risk varied slightly according to the method of abortion used, but it was sharply higher (odds ratio, 12.6) among women who had had two abortions by dilation and evacuation. Increases in the risk of preterm birth were significant mainly among women whose interpregnancy interval was 12 months or more; the pattern of risk among this subgroup was similar to the overall pattern. Previous abortion also was associated with a doubling of the odds of very preterm delivery (before 34 weeks’ gestation).”
  • The abstract of this study on precancerous changes in the cervix and subsequent preterm birth matter-of-factly states, “However, because many of the known risk factors for preterm birth, such as sexually transmitted disease, smoking, or prior induced abortion, also are associated with an increased risk of precancerous changes in the uterine cervix, it has been difficult to determine the degree risk due solely to cervical treatment from the degree of risk due to the other risk factors for preterm birth.”
  • The abstract of this Danish study begins, “We have previously shown that induced abortions result in a slightly increased risk of spontaneous abortion and preterm delivery in subsequent pregnancies.” [The study looked at whether the increased risk was perhaps due to a complication from the abortion, but they found that was not the case.]
  • This 2007 study looked at cervical length/shortening in women with multiple prior induced abortions, and found that, “A cervical length of < 25 mm on transvaginal ultrasound is predictive of preterm birth in women with more than one prior induced abortion. Women with multiple prior induced abortions and a short cervix have a 3.3-fold greater chance of spontaneous preterm birth compared with those with a cervical length of 25mm.”

And now more articles and studies that some might question due to pro-life bias, but I think worth reading nonetheless: Endeavour Forum, “Induced Abortion and Later Risk of Preterm Birth,” “Does Induced Abortion Account for the Racial Disparity in Preterm Births, and Violate the Nuremburg Code?“, Open Letter to the U.S. Surgeon General, and AAPLOG’s “Induced Abortion and Subsequent Preterm Birth: General Comments and Summary of the Pertinent Literature.”

In the interest of fairness, not all studies noted the above — perhaps the differences may be part of the reason why midwives have much lower rates of preterm birth among at-risk populations than doctors have. This 1998 study from Hong Kong looked at 118 teenage girls who had had one or more induced abortions.  However, the study was small, and the “control group” (i.e., those who had not had a prior abortion) had a higher-than-average rate of preterm birth, which is more common among teenagers than the pregnant population at large.  It also notes that D&C abortions had been shown to increase rates of future preterm births, and most of these young ladies had suction or medical abortions.

Another Chinese study, this time published in 2001, noted that prior induced abortion (the abstract didn’t note the type of abortion performed) “did not significantly increase the risk of LBW or preterm birth,” although the authors cautioned that this was with a low-risk population, and may not be generalizable.

Next, yet another study from China, this one from 2004, which also found no difference, although there were some odd things I noticed in the discussion. The study looked at mifepristone-induced abortions (RU-486), surgical abortions, and no abortions. Most of the drug-induced abortions were early, about 7 weeks or so; with the majority of the surgical abortions (roughly 60%) performed after 7 weeks but still within the first trimester, and almost all of those were vacuum aspiration abortions. About 1/4 of women who had had drug-induced abortions also had D&Cs performed, and the study said, “The lower risk of preterm delivery among women with a previous mifepristone abortion compared with women with no abortion was confined to women who had mifepristone abortions without postabortion curettage.” I assume that is because the authors recognize and agree that a D&C increases the chance of future preterm birth. Even though this study seems to say that early abortions don’t play a role in future preterm birth, it says, “An early induced abortion with mifepristone and misoprostol without postabortion curettage may produce less trauma to the cervix and the uterus than the mechanical dilation of the cervix and curettage of the uterine wall that takes place in first-trimester vacuum aspiration or postabortion curettage.” That sounds logical — artificially or mechanically dilating the cervix sounds like it could be traumatic to the cervix, and scraping the walls of the uterus sounds fairly traumatic as well. The study noted that many other studies have found an association between prior abortion and subsequent low birthweight or preterm birth; and suggested that, “The age range of the women, the exclusion of women with previous spontaneous abortion and chronic diseases, and the low prevalence of smoking during pregnancy may have contributed to the low rates of preterm delivery and low birth weight in our study. Moreover, the study was undertaken in affluent cities in China; a large number of the participating women were professionals, and they had a level of education well above the Chinese average.

Finally — and the study I think most interesting, since it was 1) the only one that was not Chinese, in case ethnic or cultural differences come into play, or there was somehow biased research in China; and 2) it may actually give a clue as to how to reduce subsequent preterm birth and/or low birthweight in women who have already had abortions — is from this abstract. It said, preterm birth and low birthweight “appeared to be more common, but after logistic regression analysis, we found no evidence of adverse pregnancy outcomes. Induced abortion is not an independent risk factor for adverse obstetric outcome. Marked health behavioral pregnancy risks are associated with prior induced abortions. Health counseling of these women is a challenge, but this objective has not yet been achieved.” And perhaps it is in this that midwives excel, as mentioned above — in getting pregnant women to change their behavior, since they tend to view the pregnancy as a whole-woman condition, not a medical condition, as a life-changing, life-involving event, that needs to be supported with healthy practices, including nutrition and other lifestyle alterations. Midwives are more likely to actually sit down with their clients and talk with them, not just to them, and counsel them. You know how sometimes parents can talk and talk and talk to their kids, and not get any effective behavior changes? And them somebody else comes along, and connects with the kids, and has them eating out of his or her hand, obeying the slightest whim, just because they now want to? We’re human. We need human connections. We’ll do things for people we like and feel a connection or bond with, that we won’t do for others. Perhaps midwives befriend their clients, rather than remaining clinically cold and aloof. Perhaps that is how they get the better outcomes with the same (or worse) at-risk clientele.

Let’s get something straight, shall we?

In the wake of Dr. George Tiller’s murder in Kansas, I’ve been in some conversations, read other blogs without joining in, and was apprised of conversations other people had had, that discussed the nature of the abortions he performed. One man said that “6,000 women will die every year” because Tiller won’t be able to perform “life-saving abortions” on them. Many other people apparently think that most if not all of post-viability and/or third-trimester abortions Tiller performed were to save the life of the mother. This is not true.

Here is the link to the Kansas Department of Health and Environment’s abortion reports, from 1998-2008. I’ve only looked at a few of them, and as far as I know they don’t mention Tiller by name, but I believe he was the only person in Kansas who regularly performed abortions after fetal viability. The Data Summaries appear to be pretty standard, and starting around page 10 have tables showing abortions performed at 22 weeks or more — where the women were from (Kansas or another state), before or after fetal viability, the reason for the abortion, etc. I looked at the 2001 document (just picked that one at random) and was surprised at several things, which may be of interest to you, regardless of where you fall on the pro-choice/pro-life spectrum.

Let me insert here, that it is a “spectrum”, as polarizing as this debate can get. Few people who call themselves “pro-choice” will literally agree that women should have the right to have an abortion at 39 weeks 6 days for any reason; and few people who call themselves “pro-life” believe that there should be no abortion ever, not even to save the life of the mother in the case of a pre-viable fetus. (I have read a few comments or seen a few polls that way, which is either not consistent with a pro-life stance [sacrificing two lives when one could be saved], or they define “abortion” in such a way that they don’t consider that removing a tubal pregnancy is an actual abortion, because the purpose of the surgery is not to kill the baby, but rather to save the mother’s life, and the death of the baby is an unfortunate and unavoidable end result of saving the mother’s life, since the baby is pre-viable.) Most people are in-between, with lots of shades of variation.

So, there is a wide spectrum, but the abortions I think of when I think of Dr. Tiller are the post-viability and/or third-trimester abortions.  “Viability” is the point after which the fetus could live outside the mother’s womb, and this varies depending on the technology of the country and the particular hospital. In America, it’s generally agreed to be about 24 weeks, which is when 50% of all babies survive, albeit with many babies suffering from defects (including things like cerebral palsy, blindness, mental retardation, etc.) due to being born too soon. [Those of you who work with L&D or the NICU or know first-hand statistics can fill in some of the gaps, or correct any mistakes.] The rate of survival goes up and the risk of defects goes down the longer the baby stays in, so delaying birth if possible is always a good thing from that standpoint; and by the beginning of the third trimester, the baby has a good hope of survival with much lower risk of long-term negative side effects. Obviously, the likelihood the baby will survive if born prior to 24 weeks is low, but the youngest surviving baby I’ve heard of is Amillia Taylor, who was born at 21 weeks 6 days of gestation; she turned two last fall, and is starting to walk and talk. Considering that she had less than half the typical womb-time of most babies, this is miraculous; and adding in the nearly 5 months she ought to have gotten before being born, she would be about 18-19 months old, so not even totally off the developmental charts for a baby born at a normal gestational age.

So, back to the 2001 report, dealing with abortions at 22 weeks or greater (on the edge of viability, or beyond) — 1) 585 abortions were performed on out-of-state women, with only 50 done on Kansas women. 2) 385 post-viability women were from out of state. This makes me wonder just how dangerous the woman’s condition was that she could go off to another state for health care, rather than going to her nearest hospital. To those of you who work L&D and particularly antepartum, trying to keep pregnant women safe and alive who are suffering certain health complications — does it sound even remotely safe for you to pack up these women and transport them from all over the country to Kansas for an out-patient procedure, under the “medical care” of the woman’s family or friends? I’ve read numerous blog posts from you, in which you detail working with patients on magnesium drips — how you have to watch them carefully, taking reflexes every hour, among other things, to make sure that they are being treated properly. Does it sound right to you to send off sick women for an out-patient procedure without medical care? Or does it give you the heebie-jeebies? 3) There were no abortions performed to save the woman’s life; all post-viability abortions were done to “prevent substantial and irreversible impairment of a major bodily function” should the pregnancy continue. In fact, I just looked at all the data summaries, and not one case was done to save the woman’s life. But in many cases, these babies are viable, meaning they have a reasonable chance of living outside the womb, if they were allowed to be born alive by induction or C-section, if the pregnancy did indeed need to be terminated for maternal health reasons. (Since there is no break-down of abortion data, we can’t say from here how many abortions were down at 24 weeks, and how many were done at 30 weeks [when there is at least a 90% viability rate, with a low rate of long-term complications due to prematurity] or beyond. 4) There were no “emergency” abortions — which is a good thing, because the abortion procedure Tiller employed took 3 days to complete, usually starting with an injection of digoxin into the baby’s heart to stop it from beating and thus kill him or her, and inserting laminaria into the woman’s cervix to slowly dilate it, before administering some drug (perhaps Cytotec) to induce labor and the woman would give birth to the dead baby. This blog goes more in depth into the data summaries, adding up all the reasons of all the years.

All pregnancies are terminated at some point. The majority of them end somewhere between 37-42 weeks with the birth of a live baby, either by C-section or vaginal birth. There is no doubt that some pregnancies should be terminated early, but whether this ends in the birth of a dead or live baby is where the point of contention lies. What is the reason to ensure that the baby will not be born alive (which is the point of a post-viability abortion, and the only difference between an abortion and a preterm induction)? Except for having limited medical attention over the course of the dilation, and giving the baby a lethal injection prior to birth, Tiller’s procedure is basically an induction — the mother gives birth vaginally to the baby at whatever stage of gestation she is, whether 22, 24, 27, 30, or 36 weeks. If she can give birth vaginally to the baby at that stage (which she obviously can without damaging her “health” or “major bodily function”… since that is exactly what she did), why kill it first?

I will also take another side-track to define “health” and “major bodily function” the way either the United States or the Kansas Supreme Courts do, and that is to include “mental health” as a “major bodily function” and “finances” as an aspect of her “health.” Of course, most people who use the terms “major bodily function” and “health” do not think that finances are an aspect of health, nor that “mental health” is a “major bodily function.” I have to tread lightly here, because I don’t want to seem like a jerk about mental health. I’m not; but I have a major problem with the way the courts have defined it, and more importantly with the way elective abortions have been shoehorned through that loophole. If you want an actual psychiatrist’s take on Tiller’s “diagnoses” of these women, click here to watch an interview with Dr. McHugh, who reviewed the redacted medical records and noted a paucity of actual clinical diagnostic information, and said, “he had mostly social reasons for thinking that the late term abortions were suitable. That the children … would not thrive. That the woman would have her future re-directed. That they wouldn’t get a good education after they had a child. That they would be always guilty in some way about having that child. That they had been abused already and that this — to have the baby would be another form of abuse. These … are not psychiatric ideas… These were social ideas. …. There was nothing to back these things up in a substantial way.”

In response to one hard-headed abortion advocate I was discussing this issue with, I emailed a group of pro-life Maternal-Fetal Medicine specialists with the following letter:

I’m currently in the middle of a debate on a pro-life blog with an abortion proponent who is insisting that the sort of late-term abortions the late Dr. Tiller did were medically justifiable, although he can come up with no such medical reason, and a L&D nurse I know said she could think of none — saying if the mother’s life or health is in danger, they induce or C-section the mom, thus saving both. I’ve asked if he could give evidence of any OB doing what Tiller did (i.e., kill a baby who could be born alive, particularly leave a woman who supposedly needed an abortion to preserve her life or health in a hotel for 3 days with her friends), rather than at least keep the mom in a hospital. He claims that Tiller’s way must be okay since, “you can’t point to even a single case of his way being condemned by any authority.” So, I guess I’m asking for authoritative voices who have condemned Tiller’s method of terminating the pregnancy in such a way as to kill the baby, rather than preserve his or her life. If you could particularly point me towards sources that authoritatively declare that the proper way to end a pregnancy if a woman’s life or health is on the line does not include out-patient procedures, nor injecting digoxin into the fetal heart, but in trying to preserve both mother and baby.

To which they responded:

Kathy,

1)       Dr. George Tiller was a family practice doctor. He had NO training in high risk pregnancies, fetal or maternal problems.

2)       There is no need after 23-24 weeks to ever perform an abortion in the way that Dr. Tiller did, to save or protect maternal life or health in any way. If life or health is threatened all trained obstetricians and maternal-fetal medicine physicians can and would simply deliver the baby and place the baby in a neonatal intensive care unit. It happens every day, many times, all over the United States .

3)       Sometimes before 23-24 weeks (rarely) a pregnancy has to be delivered because the mother’s life is clearly in danger. In this case, the labor can be induced, the baby delivered and the baby will not survive because of the early gestational age, but this can be done without intent of killing the baby.

4)       The only reason abortions were done by Dr. Tiller was because the mother did not want a LIVING baby born. He induced their labor and delivered the baby, almost always killing the baby first, before inducing the labor, to achieve the real purpose for which woman came to him: they did not want to deliver a living baby.

5)       If a mother’s life or health was really at risk from her pregnancy it would at least border on malpractice, if not be frank malpractice, for a family practice doctor without any special training in high risk obstetrics to induce the labor in such a woman in the outpatient setting. This alone should make it clear to anyone familiar with medical practice that none of the abortions he did were MEDICALLY necessary, at least not with the need to kill the baby before delivery.

You won’t find any “authoritative” voice that will say exactly what you are looking for. It would be like looking for an authoritative source that says if you jump out of an airplane and want to survive you need a parachute. In other words, it is so obvious, and there is no other way it is normally done, that you don’t need an authoritative source to state this in so many words. Any one in medicine who works in obstetrics would have to admit this.

On the other hand, every single text book on obstetrics or maternal-fetal medicine can be scoured and you will not find any description stating that killing a fetus before delivery is necessary to save the life or health of the mother, in any circumstance. This should be evidence enough. . …

Nathan Hoeldtke, MD for the Pro-Life Maternal-Fetal Medicine Group.

For those of you who may still have reservations, thinking there must be some reason for late abortions to be necessary sometimes to save a woman’s life or health, or that ACOG would have some position statement either endorsing or censuring it, let me direct your attention to something. The American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG) wrote a brief one-paragraph statement about how ACOG arrived at its stance on partial-birth abortion (which is not precisely what was under consideration in the majority of this post — PBA was outlawed in Kansas at some time during Tiller’s career, so he switched from that to digoxin-induction as his method of abortion; but I think it has bearing on the topic). Basically, a select panel met to formulate a policy statement, came to the conclusion that there were no circumstances in which PBA was necessary to save the life or health of the woman… and then the ACOG board unilaterally added the statement that it “may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman. . .” The AAPLOG response to the actual ACOG position statement is here, in which they blast the leadership for issuing such a position without any evidence, saying it “lacks scientific credibility.” If you’re surprised that ACOG would take such a position without evidence… remember their stance on elective C-sections, as well as on home birth.

So if you’re in a conversation about late-term abortion and somebody says that they’re necessary to save a woman’s life or health, or that Dr. Tiller in particular saved women’s lives by performing late-term abortions nobody else would do, ask them, “Where’s the evidence for that?”

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Oral Hygiene, Preeclampsia, Preterm Birth

I’d previously read that gingivitis is associated with higher rates of preeclampsia, but that it was not known if it was a “cause and effect” or just an association. If gingivitis causes preeclampsia, then better oral hygiene might prevent some cases of preeclampsia; but if it’s just an association — that women who are predisposed to either gingivitis or preeclampsia, or just are in poorer health or have an underlying health condition — then combatting gingivitis would do nothing.

In that vein, I was intrigued when I read this article, which said that bacteria has been found in the amniotic fluid of women who have given birth prematurely. One possible pathway given was that a kind of bacteria normally found in the mouth (and harmless there) may make its way into the bloodstream, and from there through the placenta into the baby’s amniotic fluid. This might weaken the amniotic sac, or perhaps cause some sort of uterine infection or fetal infection, or something that would account for the preterm birth. This is a new discovery, because this bacteria does not respond to traditional culturing, but instead requires examining DNA.

I wonder if preeclampsia might also be a manifestation of some sort of infection, perhaps transmitted through the weakened areas of the mouth when gingivitis occurs — the puffy and bleeding gums just seem like wide-open places for bacteria to cross into the blood-stream.

As an aside, I had two heart surgeries as a young child, and am supposed to take antibiotics for life whenever I have dental work done. It’s to prevent this sort of thing from happening — nasty oral bacteria (that may do nothing worse than cause bad breath, plaque or cavities when kept in the mouth) upon entering the bloodstream move to the weakest point, which for heart patients would typically be the heart. Southern humorist Lewis Grizzard eventually lost his life because of this — after four heart surgeries. In a pregnant woman, the baby may be “the weakest point” which is attacked, or at least may be the area with the least defenses. Antibiotics are given with the hope and assumption that if the dental patient’s mouth is pricked or otherwise open and/or bleeding, and oral bacteria enter the bloodstream, that the prescription antibiotics will prevent these bacteria from setting up a heart infection.

When I was pregnant the first time, I didn’t know about the gingivitis-preeclampsia risk, much less this newly released bacteria-preterm birth link. But I did know about the possibility that always exists (no matter how small) for oral bacteria to enter the bloodstream through an open sore in the mouth. I assume the risk is much greater when, say, the pick that cleans your teeth and may have untold numbers of bacteria on it jabs into the gum and more or less “injects” the bacteria below the surface. However, when my gums bled during pregnancy — which is not uncommon — I was concerned and wondered what to do about it. Sometime in the past, I had read that gingivitis might be caused by a lack of vitamin C, or at least, that taking vitamin C would stop it. You’re not supposed to take large amounts of vitamin C while pregnant because the baby might develop scurvy (although I think this is mostly talking about large doses around the time of birth, causing the baby to develop scurvy after birth when he’s withdrawn from the maternal vitamin C; and I’ve read one doctor who prescribes large doses of vitamin C, and his protocol for dealing with this is to give the baby vitamin C as well, and then gradually wean him off of it), so do your own research before doing anything! So I took a couple of grams of vitamin C for a few days, in addition to whatever was in my prenatal vitamin, whenever my gums started bleeding, and usually within a day it would stop. I only had to do this a few times during pregnancy.

Op-Ed Piece on Elective Cesareans

This opinion piece was written by the CEO of UnitedHealthcare of New Jersey, a health insurance carrier, on elective C-sections and NICU admissions, etc., which I’ve blogged about previously, and I’ve seen it blogged about extensively on other blogs.

I’ll pull a few quotes from here, but I urge you to read the whole thing [any bold or italics will be mine]:

It turns out that in an audit of all UnitedHealthcare-insured ba bies admitted to the NICU in one market, 48 percent of all newborns admitted to NICU were delivered by elective admission for delivery including scheduled C-sections (cesareans), many taking place before 39 weeks of pregnancy, or full term.

Note that “elective admission” includes scheduled C-sections as well as inductions of labor — inductions which may ultimately have failed and then required a C-section to complete the birth of the baby. While I find it extremely interesting, not to mention unsettling, that almost half of the NICU admits were due to “elective admission” for birth (I would assume from the language that these are all not medically necessary; although I could be wrong in that), I will point out that “full term” is not usually defined as 39 weeks of pregnancy, but rather 37 weeks — although not too many years ago it was 38 weeks. Still, in another way of looking at it, I only consider “full term” to be when labor begins spontaneously — there is so much we don’t know about labor and birth and a baby’s maturity, that to cause the baby’s birth prior to natural onset of labor is to risk prematurity — regardless of the week of gestation.

When we shared this startling data about C-sections and health problems in newborns with a pilot group of physicians and hospitals, they significantly reduced the number of elective admissions for delivery prior to 39 weeks, including C- sections. The result: There was a 46 percent decline in NICU admis sions in three months, a decline that has held stable for more than a year. That’s almost half the number of newborns with potential health problems, almost half the number of distraught parents, almost half the number of potential tragedies. The cost savings to these hospitals, the parents and the health-care system is enormous.

Reducing elective admissions prior to 39 weeks significantly reduced the number of babies that needed to have intensive care in a hospital setting. Not only does this translate into significant cost savings (which is of high importance to an insurance provider, naturally), but think of how many lives have been altered, perhaps tragically, by these unnecessary inductions and C-sections which led to many days or even weeks in the NICU, for no medical reason!

There is evidence that reducing the overall number of Cesarean deliveries would significantly reduce health risks for mothers and their newborns. More than 1.2 million C- sections are performed annually in the United States at a cost of more than $14.6 billion per year, according to the federal Agency for Healthcare Research and Quality (AHRQ). While some women do need C-sections because of fetal distress and other medical issues, AHRQ says that more than half of all Cesareans are medically unnecessary.

My thanks to Empowering Birth for originally blogging about this article, thus bringing it to my attention.