|May 29, 2002|
Volume 4, Issue 22
|Midwifery Today E-News|
“HIV and Breastfeeding”
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Midwifery Today Conferences
CHINESE MEDICINE IN BIRTH CARE:
Chinese Traditional Medicine to Change Breech Presentation
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The three-day conference will have components of Midwifery Today conferences as well as the presentation of several papers. Chinese doctors have been asked to arrange for midwives to be present as well as doctors, and it has been noted that we are interested in Chinese medicine. A hospital focused on the practice of Chinese medicine is located across the street from Shamin Island, where our venue is located.
INNOVATIVE MIDWIVES: Midwifery Today literally searches the world for them. Then we bring those midwives to you for the most in-depth learning experiences.
Eugene, OREGON, Five-Day Intensive Workshops: August 26-30, 2002
Choose from one of two intensive workshops:
The Hague, THE NETHERLANDS, "Revitalizing Midwifery": November 13-17, 2002
A two-day midwifery education conference precedes three days of international conferencing.
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week
"We cannot prepare for the future without embracing the meaning and the relevance of the baby's perspective on life."
- Michel Odent, MD
2) The Art of Midwifery
Doula trick of the trade: In an effort to encourage the laboring mom to make noise and keep her noises low and deep, I began modeling that sound. We usually end up humming and moaning together. Once that ritual is established, it almost becomes like singing or a meditative mantra. The last mom whose birth I attended said she vividly remembers being surrounded in a gentle bubble of vibration from our sounds. Not only does it help relax mom, but it seems to frighten the nursing staff to the point where they just sit back and watch in amazement!
- Kathleen Hickey
DOULAS: We encourage you to continue to send in your favorite tricks of your trade!
3) News Flashes
Two recent studies confirm that breastfeeding makes babies more intelligent and healthier. One of the studies shows that babies breastfed for up to nine months have higher IQs. It is not clear which nutrients may play a role, but human milk contains docosahexaenoic acid and arachidonic acid -- fatty acids that seem to be important in brain development. The American Academy of Pediatrics recommends that babies should get nothing but breastmilk for six months and advises women to breastfeed to some extent for a full year. The World Health Organization recommends that mothers should breastfeed babies for two years.
- Reuters, May 8, 2002
4) HIV and Breastfeeding
Response to notation by Karen Ehrlich about studies on HIV-positive women and the effects of breastfeeding on transmission [Issue 4:20]:
While the results from these studies are provocative, they must be looked at in a larger context. We do know that breastmilk from HIV-positive women contains the virus and that populations of HIV-positive women who breastfeed have higher rates of transmission of the virus to their babies through breastfeeding. The two articles by Anna Cousoudis, et al. are actually reports of data from two different points in the same study. The results show that at six months infants breastfed exclusively for three months or more have no greater risk of HIV infection than those never breastfed - 19.4% in both groups. Infants who had mixed feeding of breastmilk and other fluids or formula or foods had a higher risk of infection (24.7%). By 15 months the percentages were 24.7% for those exclusively breastfed for at least three months and 35.9% for mixed feeders (vs. 19.4 never breastfed). It is clear that exclusive breastfeeding is better than mixed feeding, but after six months babies in the exclusive breastfeeding group became infected (increase from 19.4% to 24.7%). The mothers and the infants did not receive any antiretroviral medications.
This is a small study in which only 103 women exclusively breastfed to at least three months and 156 women never breastfed. In addition, the 95% confidence intervals are large. Both these facts mean the data can more easily be flawed than if the study were larger and the confidence intervals small.
The authors made several interpretations of their results. One very important interpretation is the authors' statement that the WHO, UNAIDS, UNICEF recommendations for infant feeding be reinforced in developing countries, with added emphasis on encouraging HIV-positive women who have no access to safe alternatives to exclusively breastfeed. Another conclusion is that other studies must be done to confirm the results before they should influence any policy changes. And finally, on the basis of their data (which needs confirmation) a recommendation can be made to HIV-positive women with no access to safe breastmilk substitutes to exclusively breastfeed for at least three months but not longer than six months.
The WHO, UNAIDS, UNICEF current policies for infant feeding are as follows: Exclusive breastfeeding should be promoted, protected and supported for six months for women who are known to be HIV negative and whose HIV status is unknown. For HIV-positive women the use of breastmilk substitutes is recommended where "acceptable, feasible, affordable, sustainable and safe"; otherwise exclusive breastfeeding is recommended for the first months.
Other risk factors have been suggested to increase the risk of transmission of HIV during breastfeeding. Cracked nipples, engorgement and mastitis can increase the risk of exposure to maternal blood during feedings. Oral thrush in the infant may be another factor.
All of the above has been focused on developing countries. Another recent study in Kenya reports a higher mortality in HIV-positive women who breastfed. The Coutsoudis et al. study showed no increase in mortality in women who breastfed compared to those who never breastfed. A further and refined look at all these issues must be done before conclusions can be drawn and recommendations made.
What about the developed world? Currently the standard of care includes a regime of antiretroviral drugs for HIV-positive women during pregnancy and birth, antiretroviral medication for the baby to six weeks of age and breastmilk substitutes for infant feeding. Here the risk of maternal to child transmission of HIV is less than 2%.
Could those women with undetectable viral loads who continue to take antiretroviral medications postpartum safely breastfeed? No information exists about the effects of long-term exposure of the infant to the drugs through breastmilk or if the mother taking the drugs while breastfeeding eliminates the risk of transmission to the baby. Does exclusive breastfeeding provide any protection against HIV infection to the infant exposed at birth? It is just not known.
Given the above, where breastmilk substitutes are safe and readily available, I regrettably could not recommend to an HIV-positive woman that she breastfeed. Of course, it is her decision. It is my job to give her all the known and unknown information, to the best of my ability, and it is my job to support her in whatever decision she makes.
References: Coutsoudis, Anna, et al. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. The Lancet: (354), August 7, 1999. pp 471-476. Coutsoudis, Anna et al. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS, 15 (3) 2001. pp 379-387. Coutsoudis, Anna. Promotion of exclusive breastfeeding in the face of the HIV pandemic. The Lancet: (356), November 11 2000. pp.1620-1621. Coutsoudis, Anna. Shaffer, Nathan. Numazaki, Kei. Correspondence, HIV infant-feeding patterns and HIV-1transmission The Lancet: (354) November 27 1999. pp.1901-1904. Effect on Breastfeeding on Mortality among HIV-Infected Women. WHO Statement, June 7 2001. Found online www.who.int/HIV_AIDS/MCTC/
- Nancy Miller, CNM
5) Check It Out!
CONFERENCE AUDIOTAPES FOR THIS WEEK'S THEME
THE SCIENTIFICATION OF LOVE
Dr. Michel Odent discusses peak experiences and their effect on human health and well being. An informative, inspiring and deeply thought-provoking book!
BIRTHSONG MIDWIFERY WORKBOOK 3rd ed., by Daphne Singingtree
Designed to help you learn the basics about birth and midwifery.
6) Midwifery Today's Online Forums
I am a first-year midwifery student at The National College of Midwifery. I am looking for a 2-3 month apprenticeship opportunity in Mexico or Central America. My preference is a medium volume clinic (10-15 births a month). My Spanish is minimal but I am very eager to learn. Any information is greatly appreciated.
Go to our forums to share your thoughts and experience.
SEND YOUR RESPONSE to email@example.com with "Question of the Week" in the subject line.
7) Question of the Week Responses
Q: I am seeking insight about having a VBAC after four c-sections. Does anyone have experience with a situation like mine? I labored with all but one of my babies and was labeled CPD. All my labors were augmented. We are considering having another baby.
- NV, midwife
A: I've had eight homebirths after three cesareans. All went well.
A: I had an emergency c-section at 36 weeks, another that was planned in advance (before I became informed) and an ectopic rupture, for which I was opened up through the convenient previous scar. I was induced with Pitocin with the third, vaginal birth successful, then a spontaneous natural birth with a midwife attending with my fourth. We'll have another, at home.
A: My favorite VBAC story is about the woman who had had four previous c-sections. For her fifth pregnancy four years ago (before everyone got so hyper about VBACs) we discovered that she had gestational diabetes. She was very careful about her diet. She started taking red raspberry leaf, black cohosh and evening primrose in tincture form at 36 weeks. At 37 weeks she went into spontaneous labor. We were not doing continuous monitoring of VBACs then. When she reached 5 cm, she got into the tub for comfort. An hour later she was fully dilated with the head on the perineum. She birthed a 6 lb. 10 oz.-girl in the tub. The baby was about two pounds smaller than her previous smallest baby.
In January she had another successful VBAC despite pregnancy-induced hypertension and gestational diabetes. Because of these and the cultural changes and fears about VBAC, she was continuously monitored and augmented with Pitocin. Active labor lasted about an hour and she had another beautiful girl, weighing 6 lbs. 3 oz. No herbs this time around.
The answer to your question is yes, you can VBAC after four c-sections. Watch your diet. Even if you are not diabetic in the pregnancy, eat well and emphasize balanced meals. Avoid sugar. Get enough rest and help at home. Remember that the good Lord made your body to have babies. Trust in birth.
- Tricia Shute, CNM
A: While apprenticing with an experienced midwife, we had two clients who had had multiple c-sections and both delivered vaginally at home in very efficient, uncomplicated births. The first woman had had four c-sections, starting with the first baby diagnosed as cephalopelvic disproportion. With her fifth baby she had an eight-hour labor and delivered her biggest baby yet - a baby girl just over 8 pounds. What made her situation more significant was that this woman's mother-in-law was at the time a state legislator who had not supported the legalization of midwifery in our state a few years earlier, although we are legal and VBACs are included in our scope of practice. I don't know that she has changed her opinion on legalization, but the birth made a favorable impression on her.
The second woman had had 13 pregnancies (2 miscarriages, 7 cesareans for failure to progress, 2 vaginal births all in hospital) and successfully gave birth at home in less than five hours to a healthy 8+ pound baby boy! No complications whatsoever. What a triumph!
- Dotti Kirkpatrick, registered midwife
A: I had one mother who gave birth vaginally after four c-sections and another after three. Both had good deliveries. Remember that the labor probably will be long and slow because the uterus is finding its own way again. Stay hydrated and eat! Get as much rest as possible. Most important, do not allow yourself to be induced or your labor augmented! Let your body do its work in its own way and work with it. Use water, massage, whatever to stick with it. Be sure to have only those with you who believe you can and will give birth. You CAN!
- Judy, CPM
A: A lady came to me with her seventh pregnancy; the first five had been c-sections - the first for "CPD" with an 8 lb 1 oz baby, the next four repeats because of doctor preference. The sixth baby was an 8 lb. 3 oz. VBAC. She had VBACs at home with me for babies seven and eight, with weights of 8-12 and 8-7. The labors were pokey, and I had to camp out for about 24 hours each, but once she was dilated she had no difficulty pushing the baby out and no problems with bleeding, etc.
Baby nine weighed 9 lbs. Her contractions were not good quality and irregular but she was complete after 12 hours of active labor. After pushing with contractions (which were not very strong and 5-12 minutes apart) for 2 hours without real progress, we elected to transport due to failure to descend (despite all kinds of positions) and maternal exhaustion.
I was shocked when we reached the hospital (one I had not transported to before) when they told her they were going to "give her some IV fluids and let her rest a bit before letting her push her baby out! I was glad they were going to give her a fair chance. When she was given Pitocin I got very worried, knowing her uterus was quite worn out. But after about 3-4 hours she had a c-sec. for "failure to progress." Her uterus was found to be total mush. Nonetheless she had a very healthy, big baby and had her tubes tied.
This woman was 39, obese, on a poor diet and didn't exercise. She had had all nine babies one to two years apart. So she had a lot going against her, yet things still went amazingly well for her. (I don't like to have clients who don't take better care of themselves and do a lot of teaching, but when you don't meet them until baby number seven, sometimes they think they already know it all! I did have her using lots of red raspberry and a good prenatal which I think helped some.)
- Esther RN, CPM
A: I have attended home VBACs after only one cesarean, as have many; but I know of one woman who has had eight babies including traumatic cesareans, and she now has peaceful homebirths. She is truly a birth goddess and is out to revolutionize birth with her own stories as well as her outspoken unashamed glorious writings which can be found at http://www.birthlove.com I highly recommend you consult with her; she would be happy to share her wide knowledge of this issue.
I am an apprentice at a birthing center in Manila, Philippines and would like to get a U.S. license when I return. I am interested in locating a school to get my academic learning achieved. Ideally I would like to do all or part of that learning by extension so I could begin my studies while still in Manila and continue while again living overseas. Are there any good options to doing my schooling in this manner?
In Australia we have some of the highest rates of obstetric intervention in the world: 21.9% caesaraean and 25.9% induction in 1999. You can guess that our obstetric system is dominated by the medical model and obstetricians! But you can help us change that. We have formulated a National Maternity Action Plan (NMAP) demanding that every woman in Australia have the option of one-on-one midwifery care, similar to what our neighbours in New Zealand are enjoying. Our document tells Australian politicians why and how to do it here. It's a great summary of the benefits of midwifery care. We are asking for support and endorsement from as many groups and individuals as possible. All you have to do is read the Adobe document found at
and send your e-mail endorsement to the convenors as listed. If you are a member of an organisation, you can ask that your organisation formally endorse us also. We figure that a flood of endorsements from Australia and overseas will help the state and federal governments see the light. We would like to have them all in by late June. Thank you from all of us in Australia!
- Sarah Buckley, for the NMAP
As a family physician who practices obstetrics, I've enjoyed receiving your e-mail newsletters and updates and quote your sources frequently when asked to justify my "midwife-like" techniques and tendencies. I am therefore dismayed at the sense of hostility I got while reading a recent issue, in regard to your allopathic medical colleagues. Allopathic obstetricians (meaning those with medical degrees, as we who do deliveries are all obstetricians of a sort, are we not?) have very heartily admitted and agreed with the results of the study you quoted from ACOG regarding VBAC. Please remember that the "us versus them" mentality is not productive. All of "us" want to see healthy happy mothers and babies - just like all of "you."
- Shenary Fote MD
A reader asked why evening primrose oil is not recommended for VBACs [Issue 4:21]. When there is *any* question about potential scar integrity (i.e., if pregnancies have been very close together after a c-section and/or if the incision was not the basic low horizontal), it is not advisable to do *anything* to push the body toward softening any faster than it does on its own. My point is that anything that softens the cervix has the potential to soften the scar. Again, this is a "use your judgment" issue. We have to remember that our herbs and oils can have medically significant effects, that they are not safe in every single instance. Is it possible that not using something to "help" the uterus along may mean a VBAC mom may have to transport? Yep. But there's also a risk that helping the uterus along will make for a much more emergent transport later. If nothing else, the whole Cytotec debacle highlights the need for us to respect the natural process and respect our limitations.
Re the tiny mother [Issue 4:21]: The woman I described was having her first baby, not her second, which made it an even bigger
- Cynthia B. Flynn, CNM, PhD
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