Breastfeeding in the United States: 1999-2006

In April, 2008, the National Center for Health Statistics (NCHS), a department of the Center for Disease Control and Prevention (CDC) issued a report entitled Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Survey, 1999-2006. What did they find?

* The percentage of infants who were ever breastfed increased from 60% among infants who were born in 1993-1994 to 77% among infants who were born in 2005-2006.
* Breastfeeding rates increased among non-Hispanic black women from 36% to 65%
* Breastfeeding rates were significantly higher among those with higher income (74%) compared with those who had lower income (57%)
* Breastfeeding rates among mothers 30 years and older were significantly higher than those under 30
* There was no significant change in the rate of breastfeeding at 6 months of age for infants born between 1993 and 2004

Of note: for infants born in 2005-2006, the percent ever breastfed exceeded the Healthy People 2010 target of 75%.

Breastfeeding was defined as ever having been breastfed or received breast milk.
Ever breastfed was defined by the following question: “Was (your baby) ever breastfed or fed breast milk?”

My comment: It is very encouraging to learn that 77% of babies born in the United States between 2005 and 2006 were ever breastfed. However, we continue to fall short of the 50% goal of exclusive breastfeeding at 6 months. Why does this continue to be an issue?

Throughout most of history, breastfeeding was the norm, with only a small number of infants not breastfed for a variety of reasons. In the distant past, wealthy women had access to wet nurses, but with the industrial revolution this practice declined as wet nurses found higher-paying jobs. By the late 19th century, infant mortality from unsafe artificial feeding became an acknowledged public health problem. Public health nurses addressed this by promoting breastfeeding and home pasteurization of cows' milk.

After the turn of the century, commercial formula companies found a market for artificial baby milks as safer alternatives to cows' milk. During this same period, infant feeding recommendations became the purview of the newly organized medical profession. Partially due to the support of physicians and a vision of "scientific" infant care, the widespread use of formula as a breast milk substitute for healthy mothers and babies emerged in the first half of the 20th century.

Throughout the middle part of the 20th century, most physicians did not advocate breastfeeding, and most women did not choose to breastfeed. Therefore, an entire generation of women-and physicians-grew up not viewing breastfeeding as the normal way to feed babies. Despite the resurgence of breastfeeding in the late 20th century in the United States, breastfeeding and formula feeding continued to be seen as virtually equivalent, representing merely a lifestyle choice parents may make without significant health problems.

Currently, the World Health Organization (WHO) recommends that children breastfeed for at least two years. (1) The American Academy of Pediatrics recommends that all babies, with rare exceptions, be exclusively breastfed for about six months. (2) The United States Public Health Service's "Healthy People 2010" set national goals of 75% of babies breastfeeding at birth, 50% at six months, and 25% at one year. (3) Are these goals realistic? If so, how can we reach them?

One important question to ask is: Why do women stop breastfeeding? As in other published research, Ahluwalia, et al (4) found that the most common reasons for cessation included sore nipples, inadequate milk supply, infant having difficulties and the perception that the infant was still hungry after feeding. Something not explored in this article is the lack of support offered to women who do breastfeed whether amongst their communities, places of employment or the health care providers from whom they seek advice.

Though surpassing the goal of 75% of all babies ever breastfed is wonderful, it is vital we move on to the more difficult goal of still breastfeeding at 6 months.


References:
1. World Health Organization, United Nations Children's Fund, US Agency for International Development, Swedish International Development Agency. Innocent declaration on the protection, promotion and support of breastfeeding. New York: UNICEF, 1990.
2. American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100(6):1035-1039.
3. United States Department of Health and Human Services. Healthy People 2010. US Stock number 017-001-0547-9. Washington, DC: DHHS, 2000.
4. Ahluwalia IB, Morrow B, Hsia J. Why do women stop breastfeeding? Findings from the pregnancy risk assessment and monitoring system. Pediatrics 2005;116(6):1408-12

Perineal Massage

What is the perineum?
The perineum is the area between your vaginal opening and rectum. This is the area that stretches and may tear during delivery. If your health care provider cuts an episiotomy, this is the tissue that is cut. If you tear or an episiotomy is cut during delivery, this area may need stitches.

What is perineal massage?
Perineal massage is the practice of gently stretching and massaging the tissues that surround the opening of a pregnant woman’s vagina in preparation for childbirth. The intention is to attempt to prevent tearing of the perineum during birth or needing an episiotomy.

What are the benefits of perineal massage?
Several studies have shown that perineal massage when performed regularly during the last weeks of pregnancy can decrease your risks of tearing or getting an episiotomy during childbirth and may help you experience less stinging sensation as your baby’s head is delivering.

Who benefits most from perineal massage?
Perineal massage seems to work better for some women than others. Women who are having their first baby, women over 30 and women who have had an episiotomy before seem to have fewer and less severe tears when regular perineal massage is started at 34 weeks gestation.

How do you do perineal massage?
*Discuss with your health care provider before beginning.
*Begin at 34 weeks gestation.
*Wash your hands and cut your nails short.
*Relax in a comfortable and private location with your knees bent.
*Lubricate your thumbs and the perineum with natural oils (olive or almond), K-Y jelly or your body’s natural lubricant. Do not use petroleum jelly, baby oil or mineral oil.
*Place your thumbs 1.5 inches inside the vaginal opening. Press down and to the sides until you feel a slight burning. (If your partner is performing the perineal massage for you, follow the same basic instructions but he or she should use their index finger.)
*Hold this position for 1 to 2 minutes.
*Then, slowly massage the lower opening of the vagina in a U-shaped motion. Continue for an additional 8 minutes.
*Best results occur if you do perineal massage at least once every day for a total of 10 minutes.
http://www.midwife.org/siteFiles/news/sharewithwomen50_1.pdf

Are there any risks with perineal massage?
We don’t know of any risks associated with perineal massage. It is easy to do and most women don’t mind doing it. However, I have seen several women come to labor and delivery with bleeding from the perineum after massage was performed. Therefore, gentle stretching and use of a gentle lubricant are very important. Avoid the urethra (at the top of the vaginal opening) and do not massage if you have an active vaginal infection.

What are other interventions that decrease my risks of tearing during childbirth? Side-lying or upright pushing position, application of warm compresses to the perineum during labor, controlled delivery of the baby’s head, manual support of the perineum during the delivery of the head and avoidance of episiotomy have also been shown to decrease the risks of tearing during delivery.

References:

1. Perineal Massage in Pregnancy. J Midwifery Womens Health. 2005;50(1):63-4 http://www.midwife.org/siteFiles/news/sharewithwomen50_1.pdf

2. Beckman MM. antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2006(1): CD005123 http://www.cochrane.org/reviews/en/ab005123.html

3. Albers LL. Minimizing genital tract trauma and related pain following spontaneious vaginal birth. J Midwifery Women Health. 2007 May-Jun;52(3):246-53 http://www.medscape.com/viewarticle/558117_12

4. Hastings-Tolsma M, Vincent D, Emeis C, Grancisco T. Getting through birth in one piece: protecing the perineum. MCN Am J Matern Child Nurs. 2007 May-Jun;52(3):158-64 http://www.ncbi.nlm.nih.gov/pubmed/17479052?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

5. Stamp G, Kruzins G, Crowther C. Perineal massage in labour in prevention of perineal trauma: randomised controlled trial. BMJ. 2001 May 26;322(7297):1277-80 http://bmj.bmjjournals.com/cgi/content/abstract/322/7297/1277

6. Labrecque M, Eason E, Marcoux S. Randomized trial of perineal massage during pregnancy: perineal symptoms three months after delivery. Am J Obstet Gynecol. 2000 Jan;182(1 Pt 1):76-80. http://www.ncbi.nlm.nih.gov/pubmed/10649159?dopt=Abstract

A Walk to Beautiful - Ethiopian Women Seek Fistula Repair and Hope

PBS will air A Walk to Beautiful, a documentary about five women and their journey from their rural Ethiopian villages to the Addis Ababa Fistula Hospital. It is a journey of healing and hope: Healing of their untreated obstetric fistulas, hope of returning to a “normal” life.

Ethiopian women frequently marry as children and become pregnant early in puberty. Because of poor nutrition, excessive hard labor, and their young age, many will suffer from an obstructed labor due to a small pelvis. If so, it is common for the baby to die and the woman to suffer from birth injuries, such as the formation of a fistula.

A fistula is a passageway between two organs that shouldn’t be connected. After a traumatic vaginal delivery, fistulas can form between a woman’s vagina and bladder (causing spontaneous leaking of urine from the vagina) or between her rectum and the vagina (causing spontaneous leaking of stool from the vagina).

The World Health Organization (WHO) estimates that at least 2 million women live with untreated obstetrical fistulas around the world. In Ethiopia, just 10% of births are attended by either a local midwife or another medical professional that are trained to repair damaged vaginal tissues. Those who have difficult deliveries may develop a fistula because of un-repaired injuries. In Ethiopia if a girl or woman suffers this injury, her life as a wife, mother – and human being – is often over. Her husband typically removes her from the household or leaves her because of embarrassment. She may be banished by her family and shunned by the community.

The Addis Ababa Fistual Hospital was established by Australian obstetrician, Catherine Hamlin, and her husband Reginald in 1974 to operate on women with fistulas. Since, they have opened three additional “mini-fistula hospitals” have in Ethiopia with plans to build two more. Theirs is a story of restoring health and hope to the women of Ethiopia.

A Walk to Beautiful airs on PBS on May 13, 2008 at 8:00 http://www.pbs.org/wgbh/nova/beautiful.

Read more about the Addis Ababa Fistual Hospital at http://www.fistulafoundation.org/hospital/history/.

More on Physician Fatigue and Patient Safety

One of my first blog entries referred to physician fatigue and patient safety. The American College of Obstetricians and Gynecologists (ACOG) released a statement on February 1, 2008 about this very issue: Committee Opinion #398. ACOG believes it is prudent for physicians to consider adapting their sleep habits to coincide with the sleep guidelines from the National Highway Traffic Safety Administration. Below I've listed these recommendations.

• Structure work to take advantage of circadian influences
• Recognize that the drive to sleep is very strong between 2 am and 9 am, and especially between 3 am and 5 am; avoid unnecessary work during these times
• Apply good sleep habits which includes a quiet, dark room with adequate ventilation and comfortable temperature
• After a night shift, go immediately to sleep to maximize sleep length
• Arrange for backup during the time that sleep impairment is likely
• Recognize behavioral changes, such as irritability, that may indicate dangerous levels of fatigue
• Use naps strategically

I think it wise for all of us to follow these recommendations to the best of our ability. This will be difficult for new mothers, especially those who exclusively breastfeed. However, when possible, sharing night time feeding duties should be considered. This is another reason to support prolonged maternity leave with pay for new mothers.

New Recommendations Issued for Seafood Consumption During Pregnancy

The National Healthy Mothers, Healthy Babies Coalition published "New Seafood Recommendations during Pregnancy" on October 4, 2007.

Fish is the dietary source with the highest levels of long-chain omega-3 essential fatty acids. Docosahexaenoic acid (DHA) and eicospentaenoic acid (EPA) are the omega three fatty acids found in fish. DHA is concentrated in nerve cell membranes and is essential for development of the fetal nervous system. Research has concluded that the potential benefits from DHA in pregnancy for the developing fetus include improved visual, cognitive, motor and behavioral skills in the newborn that have been shown to last into childhood and may impact lifelong health and mental capacity.

There is concern about trace levels of methyl mercury in fish. However, recent studies indicate that the nutritional benefits of fish consumption during pregnancy greatly outweigh potential risks from trace amounts of mercury in fish. Ocean fish, including salmon, chunk-light tuna, sardines and makerel are natural sources that meet the need for DHA and EPA in pregnancy.

Recommendations
1. Pregnant, breastfeeding and postpartum women are recommended to consume a minimum of 12 ounces of seafood per week, or DHA fortified eggs. Six ounces can come from albacore tuna.
2. Consumption of ocean fish rather than fish oil supplements is the best public health approach. Whole fish, but not fish oil supplements, has been linked to a reduction in preterm labor. If a pregnant woman cannot consume whole fish, a number of public health bodies endorse fish oil supplements instead. The European Commission recommends a minimum of 200 mg/day of DHA supplements for pregnant and lactating women.

My comments
Not all polyunsaturated fatty acids have the same benefits. I frequently have patients ask if ground flaxseed, flaxseed oil, canola oil and walnuts are a good source of omega-3 fatty acids. These foods contain ALA (alpha linoleic acid) which must be converted by the body to DHA and EPA. The conversion is inefficient estimated at only 2 to 15 percent. Therefore, fish and fish oil remain the best sources of omega-3 fatty acids.

Not only are omega-3 fatty acids necessary for the neurodevelopment of the fetus, they also play a very important anti-inflammatory role in the mother. They have been proven to have a cardiovascular protective effect. In addition, regular consumption of EPA and DHA have a protective effect against depression, including postpartum depression.

Links

Other links with information on safe and sustainable seafood consumption:

1. FDA: What You Need to Know About Mercury in Fish and Shellfish
http://www.cfsan.fda.gov/
2. Environmental Defense's Seafood Selector
http://www.environmentaldefense.org/page.cfm?tagID=1521
3. Monterey Bay Aquarium's Seafood Watch
http://www.mbayaq.org/cr/seafoodwatch.asp

Elective Cesarean Sections and Newborn Respiratory Conditions

Elective cesarean sections before 39 weeks gestation significantly increase the risk of breathing difficulties in the newborn. This was the result of a study published on January 12, 2008 in the British Medical Journal.

The authors reviewed the outcome of 2687 infants who were delivered by an elective cesarean section at the University Hospital in Denmark between 1998 and 2006 and compared them to 31,771 with an intended vaginal delivery (vaginal delivery or those that labored and ended with an emergency cesarean section) after 40 weeks gestation.

Those infants born by elective cesarean section in the 37th week of life were four times more likely to be admitted to the intensive care unit due to respiratory difficulties than those who had intended a vaginal delivery. There was a threefold increase in those electively delivered in the 38th week. A twofold increase was seen during the 39th week, though this finding was not statistically significant.

Authors' conclusions:
1. It is already known that elective cesarean section at any gestational age before 40 weeks has been associated with increased risk of neonatal respiratory illness. This has been attributed to the lack of physiological changes related to labor.
2. This study adds that babies delivered by elective cesarean section at 37 to 39 weeks gestation are at a twofold to fourfold increased risk of respiratory morbidity compared with babies delivered by intended vaginal delivery. A reduction in neonatal respiratory conditions may be obtained if elective cesarean section is postponed until 39 completed weeks of gestation.

Article: Risk of respiratory morbidity in term infants delivered by elective cesarean section: cohort study. BMP 2008;336:85-87 (12 January), doi:10.1136/bmj.39405.539282.BE


My comments: Approximately 30 percent of babies born in the United States today are delivered via cesarean section. It is becoming increasingly more common for women to request a cesarean delivery without ever attempting a vaginal delivery. Once more, because of the potential for uterine rupture with subsequent pregnancies and labor, the old adage has resurfaced: "Once a c-section, always a c-section". Woman are routinely discouraged of attempting a vaginal delivery after cesarean section. We have to remember that a cesarean delivery is still major abdominal surgery that increases a woman's risk for increased blood loss, infection and other conditions that are rarely part of a recovery from a vaginal delivery. In addition, the baby is more likely to suffer from respiratory morbidity if born before 40 weeks gestation.

Many women have difficulty with the physical stresses late in the third trimester. This can be a time of increased back pain, swelling and overall fatigue. However, these are not reasons to proceed with an elective cesarean before 39 weeks gestation. As one can see from the research above, unless there is a severe medical condition of either the mother or the fetus necessitating earlier intervention, elective cesarean sections should not be performed until the 39th week of gestation due to potential respiratory morbidity of the newborn.

My recommendations given good health of mom and baby:
1. Ask questions.
2. If possible, consider a vaginal delivery
3. If elective cesarean is chosen, it should be done after the completion of 39 weeks of pregnancy.
4. Make certain you have a conversation with your obstetrician about the possible risks associated with an elective cesarean section.

Breastfeeding May Protect Against Some Allergies and Skin Conditions

According to an article published in the January, 2008 edition of Pediatrics, the official journal of the American Academy of Pediatrics (AAP), exclusive breastfeeding for the first four months of life for those children at high risk of developing atopic disease (eczema, asthma and food allergies) decreases the incidence of such diseases in the first two years of life. The authors also cite evidence that exclusive breastfeeding for at least the first three months of life protects against wheezing in early life.

Asthma, eczema (atopic dermatitis) and food allergies, otherwise known as atopic diseases, have dramatically increased over the past several decades in children 4 years and younger. The incidence of asthma has increased 160% and the incidence of eczema and peanut allergy have at least doubled.

Children who have closely related family members with atopic conditions are at a higher risk of developing them. Although it is clear that atopic diseases run in families, early infant nutrition may have an important influence on the development of such conditions. Therefore, for those children at risk of developing these diseases through a genetic predisposition, it may be more important to exclusively breastfeed them early in life.

Another interesting point discussed in the report: At this time there is no sufficient evidence that avoidance of certain foods by pregnant women or those that are breastfeeding can prevent atopic dermatitis in infants. This is contrary to a prior recommendation made by the AAP.

Though somewhat technical, this article is an excellent review of atopic disease in children and the nutritional options during pregnancy, lactation and the first year of life. It includes pertinent definitions and a synopsis of the most recent research available on

• The role of dietary restriction for pregnant and breastfeeding women on the development of atopic disease
• The role of human milk and exclusive breastfeeding on the development of atopic disease
• The role of hydrolyzed formula on the development of atopic disease
• The role of introduction of complementary (solid) foods on atopic disease

PEDIATRICS Vol. 121 No. 1 January 2008, pp. 183-191

Antidepressants during Pregnancy

Depression is prevalent in the United States. The lifetime risk of depression in all women ranges from 10-25%. The most common time for a woman to have depression is during her reproductive years.

About 10% of pregnant women experience depression. Many of them receive antidepressants from their health care provider, particularly selective serontonin-reuptake inhibitors (SSRIs), the most commonly prescribed antidepressants. While SSRIs have not been previously associated with causing a significant amount of birth defects more recent studies have suggested that taking SSRIs while pregnant may be associated with an increased risk of birth defects, especially of the heart.

However, in two studies recently published in the New England Journal of Medicine investigators did not find such associations.

In the first study, investigators interviewed 9622 mothers of children with birth defects and 4092 mothers without birth defects born between 1997 and 2002 from 8 different states. Three percent of the participants reported having used SSRIs at some time before or during their pregnancy. They did not find an association between SSRIs and heart defects. They did, however, find an association with three other conditions and the use off SSRIs: two neurologic conditions (anencephaly and craniosynostosis) and an abnormality of the abdominal wall (omphalocele). When comparing the risks of these birth defects in the general population (who did not take SSRIs before or during pregnancy) with those who did take SSRIs the increased risks were small.

In the second study, investigators interviewed 9849 mothers of children with birth defects and 5860 mothers of children without birth defects born between 1993 and 2004. All the mothers had taken SSRIs during the first trimester (the first 13 weeks of pregnancy). Their findings were a little different. They did not find an association between all SSRIs and heart defects, omphalocele or craniosynostosis. They did, however, find an association between sertraline (Zoloft) and omphalocele and heart defects. Taking paroxetine (Paxil) was also associated with an increased risk of heart defects. Once again, the increased risks were small.

We have to keep in mind that these studies were performed by interviewing mothers, therefore the investigators were relying upon the mothers' memories. This may have introduced a bias into the data collected.

So, what is the bottom line? We don't have perfect information on these or most other medications during pregnancy. Therefore, the decision to start or continue SSRIs during pregnancy must be based upon potential risks and benefits of treating versus not treating. We must also keep in mind that untreated depression during pregnancy can have a very serious effect on both mother and infant. And, even though there may be an increased risk of some birth defects associated with specific drugs, the risk is still very small. Ultimately, the decision to treat or not treat depression with SSRIs during pregnancy is best made by the individual woman together with her well-informed health care provider.

N Engl J Med 2007;356:2684-2692
N Engl J Med 2007;356:2675-2683

Patient Safety: Physician Sleep Hours

How many hours of sleep did your doctor get last night?

Did you know that 100,000 patients die each year due to medical errors? Could doctor fatigue play a role in these deaths? Here are three studies that have been published about resident physicians in training and sleep deprivation as it applies to their on-the-job performance:

1. After 24 hours of wakefulness, cognitive function deteriorates to a level equivalent to having a 0.1% blood alcohol level. These doctors would be considered too unsafe to drive, yet could still treat patients for 12 more hours. (Nature, 1997; 388:235)

2. Well-rested physicians outperform their sleep-deprived colleagues in tests of memory, mathematical skills, visual attention, concentration, electrocardiogram interpretation and anesthesia monitoring (West J Med, 1990; 152:82-86)

3. Forty-one percent of resident physicians attribute their most serious mistake in the previous year to exhaustion. (JAMA, 1991; 265: 2089-94)

These articles all pertain to physicians-in-training. Because of the concerns for patient (and resident) safety the Accreditation Council of Graduate Medical Education (ACGME) - the body responsible for certifying medical residencies in the US - implemented in 2003 work rules to limit the number of hours residents can work to 80 hours per week. In addition, after 24 hours of "in-house call" they cannot accept new patients.

A New England Journal article published in 2004 concluded that interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns (first year residents) work per week can reduce serious medical errors in the intensive care unit. (N Engl J Med. 2004 Oct 28;351(18):1838-48)

However, these work hour restrictions do not pertain to practicing physicians who have already completed their residency. So, it may be a very important question for your doctor the next time you see her/him: "How many hours did YOU sleep last night?"

Your health may depend upon it.

Welcome

Welcome to the first MaternaCare 101 blog entry.

I am a board certified, practicing obstetrician and gynecologist. I also practice integrative medicine offering advice on conventional, alternative and complementary treatments. With MaternaCare 101 I hope to share with you new and interesting information about a broad spectrum of women's health issues as they pertain to pregnancy. This will include planning a pregnancy, the pregnancy experience, delivery and postpartum.

I am also a mom. My three sons are 23, 19 and 17 years old. They have always known me not only as their mom but as a serious student or professional. I hope MaternaCare 101 can become a forum for women to discuss the struggles of working mothers (and we all work, no matter at home or otherwise) and provide a community of support.

If you have any topics of interests, please expound but please keep the content family-friendly.
I invite your questions or concerns.

Well, here we go....