July 18, 2001
Volume 3, Issue 29
Midwifery Today E-News
“Folate Metabolism”
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THIS WEEK'S ISSUE

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Quote of the Week:

"So many servants of birth insinuate rules and regulations, the 'standards of care,' between the birthing woman and the power of birth. In this fashion, they destroy her faith in herself."

- Ellen C. Waff


The Art of Midwifery

I gently wrap one of my soft rebozos [rectangular shawl] around the laboring woman's head, covering her eyes and ears and assuring that she can breathe freely through her nose. I first bring the ends of the rebozo toward the back of her head and then bring them forward to form a second layer. I hold the ends of the rebozo in one hand and generally rest my other hand on her shoulder or place it at her back to avoid the phantom hand syndrome in which she wonders what I am "saying" with my free hand or where it is while she is without visual/auditory stimuli. Sometimes just a few moments are the most restful break from the sights and sounds surrounding her. I don't use it just when the stimuli is negative. I offer it as a gentle reprieve from all external stimuli and an opportunity for my gorda to go within. It is especially lovely if she is sitting on a birth ball at the same time and can gently sway to her own rhythm.

- Joni
Guadalajara, Mexico

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News Flashes

A study showed that consumption of formula instead of human milk in infancy increases diastolic and mean arterial blood pressure in later life. Researchers measured blood pressure at 13-16 years in teenagers born prematurely and assigned them at random to different diets for an average of 30 days. Two diet comparisons were donated banked human milk versus preterm formula, and standard term formula versus preterm formula. Each diet was used as the sole food or as a supplement to mother's milk according to the mother's choice.
The lower blood pressures in children born prematurely who were fed breastmilk provide evidence of programming of a cardiovascular risk factor by early diet.

- The Lancet, Vol. 357 No 9254, Feb. 2001


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Folate Metabolism

In response to an inquiry about cleft lip/palate [Issue 3:27]

While the entire question of folic acid supplementation has been shown to have an association with reduced rates of cleft lip and palate (CLP) in some studies, there is nowhere near the kind of solid evidence to connect reduced CLP and folic acid supplementation as there is between folic acid and neural tube defects. Also, there have not been any large-scale, properly conducted studies on CLP prevention using folic acid supplementation of the size and validity of those that have been done with neural tube defects and folic acid. There is also some question about whether cleft lip with cleft palate is the same thing, genetically, as cleft lip alone. It is possible CL, but not CLP, can be prevented by folic acid supplementation or perhaps vice versa. So at this point, in assessing the literature, it is impossible to conclude that any lack of folic acid had anything to do with your son's condition or that you could have done anything to prevent it.

That being said, the kind of embryonic processes that produce a properly sealed neural tube are very similar to those that produce a properly sealed lip and palate. Therefore, it is logical to assume that since folic acid supplementation prevents 50-70% of the neural tube defects, it should also prevent some forms of CLP. You should be taking folic acid before conception and in early pregnancy in order to prevent neural tube defects anyway so if you take it in an effort to also prevent CLP, you are doing the right thing, whether or not the reason is necessarily 100% correct.

Now as to what dose of folic acid is correct and if you should be on a higher dose: There are many enzymes involved in folic metabolism and well-known variants of these enzymes work less efficiently. One good example is the enzyme methylenetetrahydrofolate reductase, the subject of my PhD thesis in progress. In the province of Manitoba, Canada, 7% of the population (as assessed by analysis of 1000 anonymous consecutive newborn screening blood spots) is homozygous (has two genes for) the inefficient version of the enzyme. Such people need higher doses of folic acid to make up for the inefficiency and for such a person the amount of folic acid in the standard prenatal vitamin may not be enough.

I do not recommend going out and getting genetic screening for this particular variant because it is only one of several variants that can be present. What we do in the course of our research, if we discover that a person has the inefficient version, is check the outcome of the entire system working as a whole by three simple blood tests. If these are normal, we are not concerned about the homozygote being at risk for poor folic acid metabolism beyond recommending that they get these tests repeated at regular intervals by their own doctors. I personally think, without proof, that some women must have a more efficient version of another one of the enzymes because they appear to compensate for being homozygotes for the variant MTHFR without any extra supplements.

You can check red blood cell folate, which reflects how well you used and stored folate over the last three months in your blood. A result in the high normal range should reassure you that you are getting enough folic acid. If your result is low normal, you are likely not getting enough because the published normal ranges for this test are based on healthy men and women and do not take into account the extra needs of pregnancy.

You can also check your levels of serum homocysteine, an amino acid that is used up as folic acid is metabolised. A low normal serum homocysteine (less than 10umol/L value) means you are getting enough folic acid. A high normal range likely means you need more folic acid for the same reason as in the case of low normal RBC value. There is some evidence to suggest this is the most sensitive way to test your folic acid metabolism. (Homocysteine has also been rather strongly implicated in vascular disease during later life and less strongly implicated in placental malfunctions leading to complications of pregnancy. That is part of my thesis so I can hopefully give you a definitive answer on homocysteine and placental functioning in about three years time.) There are two excellent review articles on the topic of homocysteine and vascular disease at

www.heartcenteronline.com

and the American Heart Association's professional advisory statements at

www.americanheart.org/Scientific/statements/1999/019901.html

These papers explain all about testing homocysteine levels, vitamin cofactors, and who should or should not be evaluated.

A third test you can use checks your serum folate level, which reflects the free folate in your blood waiting to be used. Because at least one genetic variant causes very little folic acid to get into the blood, a normal result would reassure you about your own personal absorption of the vitamin.

Even doing these tests can be questionable, however. If you are pregnant, your levels will be altered by the hormones of pregnancy, making it difficult to interpret the results without expert guidance. They are also expensive tests to undergo simply for the purpose of easing your mind about your vitamin pill. Also, there does not appear to be any harm to taking up to 5 mg per day of folate (with one exception I will outline below). Our clinical geneticists now routinely recommend 5 mg/day preconceptionally for all female relatives of people with neural tube defects in their past pregnancy history. Excess folic acid is excreted in the urine and there are no reports in the literature that I have been able to find that show any ill effects on the children of women taking this dosage. Women with a previous baby with a neural tube defect and their female relatives have been taking this higher dosage for many years and delivering many normal healthy babies. If there was a danger, it should have become apparent by now. So if it will reassure you to take the higher dose without first doing blood tests, it is most likely a completely safe choice.

I found one report on much higher equivalent doses (the human equivalent of 23mg/day) in rat mothers causing rat pups to be born slightly below the median birthweight, but these baby rats quickly overcame the slightly low birthweights and reached normal rat pup values within a few weeks. This report does not really apply to humans, in my opinion, because rat embryos have a different enzyme complement for some of the enzymes involved in folic acid metabolism compared to humans. (If someone can find anything else I would love to hear about it for my thesis.)

I did mention one potential bad effect of taking folic acid. If a person is deficient in vitamin B12 either because of diet (as in vegans) or because of a genetic inability to absorb and use B12, taking folic acid can potentially mask the symptoms of B12 anemia until serious and permanent neurological damage is done. If you had the genetic version of inability to absorb B12 you would likely already know for other reasons. Even so, it does make sense to add a B12 supplement to your folic acid supplement if there isn't any in your prenatal supplement, especially if you are a vegan.

B6 is another vitamin involved in the whole system as an essential cofactor so adding B6 or having a supplement vitamin with B6 in it is probably a good idea as well. In my own work with women who had a baby with a neural tube defect and women who had normal outcomes after an elevated maternal serum screen, we found low dietary intake of B6 was very common. (See Bjorklund NK, Evans JA, Greenberg CR, "Folic acid supplementation: more work is needed," 2000; CMAJ, 163:1129)

- Natalie K Bjorklund
PhD Student, University of Manitoba
Biochemistry and Medical Genetics

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Midwifery Today's Online Forum

The midwife asked me what I was doing at home to try to bring on my labor. I told her nothing except taking evening primrose oil 3 times a day for the last 2 weeks (but that's mostly because my cervix tore last birth and I want to help the scar). I told her I felt that the baby was ready to come when it was ready to come. She said "ok".

I'm wondering in your opinions under the circumstances of the BPP and non stress tests looming over me, would I be wise to start the nipple stimulation, evening primrose oil as cervical suppository etc to try to "naturally" bring on labor? My only negative thought is that if the baby truly isn't ready, how much different are these measures than Pitocin?

- Dianne

To share your thoughts and experience, go to Midwifery Today's Forums. Click on "Aspiring Midwife Chat" and "Is natural induction really natural?"

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Question of the Week

Editor's Note: Because E-News readers held forth so generously about herpes, we will dedicate next week's issue to that subject and include the answers we've received to last week's question about the condition. If you have information about herpes and pregnancy/birth you would like to share, please write to mtensubmit@midwiferytoday.com Thank you!


Question of the Week Responses

Q: What is the cause of swollen legs postdelivery? One would think, were they swollen beforehand? Could it be: preeclampsia, too much intravenous fluids, inactivity? This problem seems to be more common in the ladies who have cesareans, forceps or ventouse, but I have seen it in normal births.

A: I have been massaging postpartum mothers at NY Presbyterian Hospital since 1990 and clearly there is significantly more swelling after cesarean birth. Gentle, therapeutic massage is a wonderful remedy for relief.

- Rochelle Aruti
Riverdale NY


Switchboard

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

~*~*~*~*

International Connections

I am an apprentice midwife and do a lot of traveling internationally. I am finding it hard to have adequate resources on hand simply because of the bulk weight of my books. Does anyone know where I might find the classic textbooks and references on CD-Rom? All suggestions welcome. Email me: mjfoxy7@yahoo.com

~*~*~*~*

On fibroids: I work at the A.R.E. (Edgar Cayce Foundation). One treatment we offer is castor oil packs. I have heard numerous accounts of women healing themselves of fibroids using castor oil externally, along with herbs and diet.

www.edgarcayce.org

- Angelica
Rainblurb@hotmail.com

I am 15 years old and have been seriously thinking about going to college to become a midwife after I graduate from high school. Although that is a couple years away I would like to learn more about midwifery. Are there many websites where you can actually learn more about the field of midwifery and what the jobs are of midwives? Is there any advice that you would have for an aspiring midwife?

- Anon.
[Ed note: We will forward your comments to this young woman when you write to mtensubmit@midwiferytoday.com]

====

More on government regulation of homebirth [Issue 3:27 & 28]:

I am thinking about Yvonne Cryns, Nan Koehler, Abby Odam, the granny midwives, and every other traditional birth attendant in this country who has been crucified by the AMA or another source. We live in a society that values regulations. Without these government regulations every birth attendant practicing in the home setting is potentially an outlaw in the AMA's eyes. Wonderful, loving, competent midwives have been jailed, lost their homes, spent thousands of dollars defending themselves, or were placed under house arrest while serving families competently. The AMA has a track record of prosecuting midwives in almost every state!

In the Netherlands, midwives enjoy a place of honor alongside the physician community. I envision homebirth as the norm for a percentage of our population in the United States. I envision midwives enjoying the status they once held and the freedom to practice as they once practiced prior to the AMA slander campaign of the early 1900s and the current atmosphere of prosecuting midwives when one bad outcome occurs. Bad outcomes unfortunately happen in the hospital quite frequently and it is legally permissible. It is not permissible at all at home, yet who can predict an amniotic fluid embolus?

I do not like regulations myself. I believe midwives deserve the status of independent practitioner and should "refer" medically unstable pregnancies. A doctor should not be dictating who can deliver at home and who cannot. Take the physician out as middleman!

In one sense, homebirth can never really be regulated. However, it can be made legal. It can be made available. When it is made legal it becomes even safer than it is because it takes out the fear of transferring to hospital in the "illegal" states. It becomes available to more women as "legality" opens the door for more midwives; then women who want a midwife have access. Laurie [Issue 3:28], you will find that you will strive for safety too when you become a midwife. One can walk the wondrous road of birth and allow it to unfold unhampered, watch the process and bless women and still be safe and be part of the "system" legally. There can also be those midwives who choose to stay out of the "system". I do not envision "rules and regulations" that contradict the heart and science of homebirth. I see homebirth as being allowed to flourish in the same manner as we currently practice. In Texas, we have been allowed to write our own protocols (just like each hospital).

No midwife deserves prison any more than a physician or nurse does. I see the midwife as part of the "birthing" team. I can choose to write my protocols as best fits my midwifery style. I can choose to offer VBAC at home or Breech if I am so qualified and have experience.

- Sandra Stine, CNM

More on Hyperemesis gravidarum:

Thank you so much for including hyperemesis gravidarum in your newsletter. I am a birth teacher and labor assistant (and former apprentice) who has experienced this nasty condition through three of my four pregnancies (the last three). I know a study of one is hardly significant, but the psychological stigma that hung over me during each "episode" was practically unbearable! The inferences that I was not wanting the babies, that I had a bad relationship with my husband, and worst of all that I was not even really experiencing the vomiting for any other reason than I wanted it to happen were all incredible to me and simply added to my stress. Pregnant women do not desire vomiting themselves to death! Even though I know my own circumstances, I felt quite exonerated by reading your included study!

What I would like to see addressed is treatment for the emotional/psychological problems that stem from this condition. Frankly, the few students and clients I have had who've experienced this and I lay in bed or on a couch for weeks and/or months (when we weren't hanging over the toilet bowl) crying and wishing it would end. By the time we had physically recovered, we were emotionally spent. Are there herbal remedies that might work specifically on this (creams, aromatherapy)? Also, has anyone ever looked at low pre-pregnancy weight or hormone levels as factors?

- Lori Stillwagon

As a past sufferer of severe and long-lasting morning sickness, I believe that if any real statistical connection were to be found between psychological problems such as "hysteria," "maternal overdependence," "pregnancy rejection" and HG, it is probably more sensible to assume that the HG is causing the psychological problems and not the other way around! Debilitating HG brings out depression, dependence, and ambivalent feelings about pregnancy in even the most sane of women. I would not be surprised if this psychological connection theory is nothing more than a case of chicken-and-egg reasoning.

- Anon.

Did anyone see the latest study in the New England Journal of Medicine on the safety of VBAC? I didn't get a chance to see the whole thing when it was reported in the newspaper or write the reference down. It didn't look good. It seemed to indicate that VBAC is too dangerous due to a high risk of uterine rupture. I also got the feeling that induction was the contributing factor but that the researchers weren't properly acknowledging that. Anyone have the reference or a conclusion or analysis?

- Amy V. Haas, BCCE
Fairport, NY

I have had some very helpful responses to my question about the use of wild yam and progesterone creams in pregnancy. Thank you to each of you who helped me!

- Elaine

In response to the question regarding retained placenta piece [Issue 3:28}:

How about *not* trying to sue somebody? That response is contributing to the ruin of healthcare in this country. And no, the placenta doesn't get weighed. Every woman's placenta is different sized (even from one birth to the next) so there would be no purpose to doing that. Practitioners check the placenta to see that it looks "complete" (not as easy as it sounds), but even the most careful of us will occasionally not see that a small piece is missing. Most women will expel it within a couple of days. And no, your placenta did not "poison your blood."

- Anon.

EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.


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