January 16, 2008
Volume 10, Issue 2
Midwifery Today E-News
“Prenatal Testing”
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In This Week’s Issue:


Quote of the Week

"Technological obstetrics makes the assumption that more knowledge is better, but, like Eve's apple, the knowledge that we gain through prenatal diagnosis can cast us from our pregnant paradise, with major and long-lasting sequellae for mother, baby and family."

Sarah Buckley


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The Art of Midwifery

In a recent survey, women were asked to rate their fear of birth before reading positive birth stories, and again three weeks after reading birth stories. Participants reported an average of 33% less fear after they read empowering birth stories.

Sheri Menelli
Excerpted from "Positive Birth Stories," Midwifery Today, Issue 84
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Research to Remember

An analysis of discussions at the first prenatal visit regarding prenatal testing between obstetric providers and pregnant women found that women who were older than 35 were counseled for over twice the length of time as younger women. The most common topics discussed during the visit were practical details of testing, its purpose and the fact that such testing is voluntary. In comparing the discussions of obstetricians with those of nurse-midwives and women, they found that the obstetricians were more likely to make a recommendation about getting the testing, and they were less likely to indicate that such testing was voluntary. The researchers concluded that the information provided was inadequate for ensuring true informed decision-making.

Obstet Gynecol 91: 648–655, 1998


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Prenatal Diagnosis

Prenatal diagnosis represents incredible and continuing advances in technology, yet a sleight of hand—a trick, perhaps—is being played on pregnant women. We are told that prenatal diagnosis will increase our choices, but, as these tests become more available, women are feeling that they have less choice to refuse the testing. We already are, through social attitudes, individually responsible for our children's development, and now we also are becoming responsible for producing a healthy baby at birth.

As one woman comments, "I knew it was my responsibility to make sure I was not going to give birth to a handicapped child. But that meant taking the risk of losing a healthy baby. I am responsible for that too."

Finally, as we look more deeply, the parallels between prenatal diagnosis and medicalised childbirth become increasingly obvious. Both industries are centred on high technology and its superior knowledge, and both consider women's own feelings and instincts about their bodies and their babies to be of lesser importance.

Women who choose either path are at risk of a cascade of intervention—from induction to caesarean or from screening to abortion—with pressure to conform to medicalised ideas of "the right decision" at each point. As one woman notes, "…once you've got onto the testing trap you have to get to the end."

Where does this end take us, as individuals and as a society? Does prenatal diagnosis represent liberation or the beginning of a slippery slope towards selecting babies on the basis of socially acceptable characteristics? How will the "new genetics" impact prenatal diagnosis, with the huge amount of information that will soon become available about our unborn babies? And does it…make every woman feel that her pregnancy is "tentative" until she receives reassuring news?

The answers to these and other questions are as yet unknown, but this technology is certain to become more sophisticated in the coming years and our choices more complex. Mother Nature, like many women who are enrolling in these tests, does not know whether to laugh or cry.

Sarah Buckley
Excerpted from "Prenatal Diagnosis," Midwifery Today, Issue 77
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Previously, genetic counseling and diagnostic screening only of women over 35 was the standard of care for predicting Down syndrome. Beginning in January 2007, the American College of Obstetricians and Gynecologists (ACOG) stated that all women regardless of age should be offered the opportunity for screening.

ACOG Press Release, January 2, 2007


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Web Site Update

Read this article excerpt from the current issue of Midwifery Today magazine (Winter 2007) newly posted to our Web site:
Finding Better Solutions to End Bullying: What an Organization Can Do — by Marinah Valenzuela Farrell
This final article in our series on bullying addresses what organizations can do to end bullying, as well as legislative solutions that have been proposed.

The program and registration form for the Hope and Healing Conference in Ann Arbor in May 2008 is now online in both Web page and PDF format. Start here.

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Question of the Week

Q: I am a 28-year-old woman and I've just been told that I have uterine didelphys—with two of everything (cervix, uterus and vaginal canal). According to the gynecologist I saw, I can become pregnant but she said there is a higher risk of premature birth and of a caesarean. Other than this I am perfectly healthy and have had no illnesses or anything.

While I am not planning to get pregnant in the next two years, I would really like to think about my options, to prepare myself when the time is right. I have always planned on having a homebirth with a midwife to assist. I really want the opinion of someone who is not solely from the medical side of things. I know the doctors tell me what they think is the right thing to do but I have always felt that birth is a more natural occurrence than what the majority of the medical society seems to believe.

— Deborah


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


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Question of the Week Responses

Q: My eight-week-old daughter's pediatrician wrote her a prescription for vitamin D—Tri-Vi-Sol. He said that breastfed babies don't get enough of it in this part of the country. Is this really necessary? Is there another way to get vitamin D that is effective?

— Danielle Kimball-Smith

A: Breastfed babies in Northern, less sunny latitudes will not as a group get enough vitamin D from breastfeeding because mothers in those areas are widely deficient in vitamin D3 (cholecalciferol). This can be true in any area, though, as humans heed warnings to stay out of the sun and use sunscreen to prevent aging and skin cancer, blocking the UV rays that are crucial for the conversion of vitamin D in the body.

An individual mother can have her vitamin D status tested and supplement with sunlight and vitamins instead of supplementing her baby, but this is best done proactively to avoid the baby having to wait for the mother to attain adequate levels of vitamin D. Food sources of vitamin D can be tricky, for example cod liver oil contains significant amounts of vitamin D but also contains vitamin A in amounts that make high doses unadvisable. Women are often surprised at how much vitamin D supplementation is necessary to bring levels up, and doses of 2000-8000 IU/day or higher doses every few days is often indicated, with retesting at intervals of no more than three months to track levels and adjust doses to avoid toxic levels. High dose vitamin D therapy should be managed by a knowledgeable health care practitioner.

Recent studies have demonstrated a higher risk of diabetes in the children of pregnant and breastfeeding mothers with deficient and insufficient vitamin D levels, and other current research supports vitamin D's role in many important areas including the immune system, cancer prevention, hormonal regulation, bone formation and metabolism.

— Eden G. Fromberg, DO, FACOOG, DABHM
SOHO OB/GYN, New York City

A: This was a topic of study recently in my nutrition class. The recommendations for breastfed babies are iron and vitamin D supplementation starting around 6 months of age. The theory is that breastmilk is an inadequate source of both of these nutrients and therefore they must be added to the infant diet. The issue with this is that breastmilk is designed for the human infant in perfect order, but strongly depends on the health and nutrition of the mother.

Some studies suggest that low iron levels in late infancy and toddlerhood in a breastfed child are completely normal; a physiological normalcy. Little to no research in this area supports the supplementation of iron. Vitamin D, however, depends both on the mother's nutrition and where she lives, as geography plays a huge role in vitamin D synthesis. In northern areas, especially where cold is an issue, the sun is not enough to maintain vitamin D levels and a supplement or spectrum lighting is essential. The question is, if the mother increases her intake of vitamin D (and I personally endorse supplemental calcium with vitamin D, especially during pregnancy and breastfeeding) will this also raise the vitamin D levels of the infant? Anecdotal information backs this practice both with iron and vitamin D supplementation and it makes good sense. If the child is ingesting milk based on the nutrition of the mother, who raises her blood iron and vitamin D levels then the levels in the breastmilk would also increase, therefore increasing the availability of these nutrients to the child.

It would seem that a nice sunny window to play by, increasing the mother's levels with good nutrition and supplementation if needed and nursing on demand would be all the child needed, unless other health concerns are present. I encourage you do your own research (which would include any information from your provider) and evaluate the needs of your child and then make an informed decision as to what is best.

— Chantel Haynes
Doula/Nursing Student, Minnesota

A: You can find a variety of information on this subject, including medical study results and the various factors related to vitamin D deficiency at: www.kellymom.com/nutrition/vitamins/vitamin-d.html

— Anonymous

A: I hope you get several responses to your question. I'll answer it the best I can with the knowledge I have. First, breastfed babies get the very best of everything they can possibly get, so keep that up. I can't imagine your baby would need anything else. If your doctor mentioned vitamin D, go for a walk around the block every day. Hey, it's good for both of you to get out. As little as 20 minutes or so is all it takes to get natural vitamin D for both of you. You didn't mention what part of the country you're from, however, that should have nothing to do with it. If it's cold, bundle up and get outside. The sun is best, but even if it's not sunny, people think the sun isn't getting through when in fact it actually is. And remember, as long as you're breastfeeding, keep taking those prenatal vitamins.

All the best to you and your sweet baby,

— Natalie


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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Think about It

In December 2007, the National Center for Health Statistics (NCHS) reported that:

The cesarean delivery rate rose again in 2006, to 31.1 percent of all births, a 3 percent increase from 2005 and a new record high. The percentage of all births delivered by cesarean has climbed 50 percent over the last decade.

The preterm birth rate rose slightly between 2005 and 2006, from 12.7 percent to 12.8 percent of all births. The percentage of births delivered before 37 weeks of gestation has risen 21 percent since 1990.

The low birth weight rate also rose slightly in 2006, from 8.2 percent in 2005 to 8.3 percent in 2006, a 19 percent jump since 1990.

www.cdc.gov/nchs/pressroom/07newsreleases/teenbirth.htm


Feedback

Re: E-News Issue 9:25, Miscarriage:

This is the first time in 16 years I have felt that someone actually understood the pain I felt when I experienced four back-to-back miscarriages. They were very painful and the last actually was far enough along to have a water sac. It was in every way a labor. However, I was dismissed to the waiting room where I later passed the baby. I wish more understood that the pain is real not just imagined.

So I say "Thank You" for lifting a burden off my shoulders.

MB


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