April 9, 2008
Volume 10, Issue 8
Midwifery Today E-News
“Malaria in Pregnancy”
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In This Week’s Issue:

Quote of the Week

"Baseball and malaria keep coming back."

Gene Mauch

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The Art of Midwifery

Although malaria was eradicated from the US in the 1950s, it is infrequently diagnosed in people who have never left the US. It can be spread through blood transfusions, organ transplants and shared needles. In other cases, babies can get it during pregnancy or delivery from mothers who have traveled in areas where malaria is present.

Unless you are working in a country that has endemic malaria or with women who are from or have visited such a country, malaria is not likely to be an issue when caring for pregnant women. In rare cases, though, a woman could become infected from a mosquito that got the disease from a local person who did fit one of those categories. In addition, a 2003 study of travelers from Israel and the US showed that one-third of them developed malaria more than two months after traveling, even when they took anti-malaria medications.

Some knowledge of the disease will help midwives to identify malaria in the event that they encounter one of these cases, either in work abroad or in their local areas.

Cheryl K. Smith
Excerpted from "Malaria in Pregnancy," The Birthkit, Issue 55, Fall 2007
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Research to Remember

Malaria during pregnancy poses substantial risk to the mother, her fetus, and the neonate; the infection contributes to as much as 15% of maternal anemia, 14% of low birth weight infants, 30% of preventable low birth weight, 70% of intrauterine growth retardation, 36% of premature deliveries, and 8% of infant mortality.

Emerg Infect Dis, May 2007

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Malaria in Mothers and Babies

A new malarial infection or relapse during pregnancy can pose substantial risks to mothers and their unborn babies, including maternal anemia, spontaneous abortion, intrauterine growth restriction, low birth weight, prematurity and even death. Women in their first or second pregnancies are at highest risk. Newly infected women are at a higher risk as well, since their immunity to malaria is not well-developed.

In addition, pregnancy commonly causes women who had previously suffered from malaria to relapse. This is believed to occur as a result of the natural immune system suppression that occurs during pregnancy.

Treating such women is harder than treating women who are not pregnant, because high doses of antimalarial drugs are known to be teratogenic (causing birth defects). In addition, as mentioned above, many of the drugs used most commonly to treat malaria are no longer effective. Newer drugs have not been thoroughly tested on pregnant women, so adverse effects are not known.

In the case of a woman who has immigrated to the US or another country where malaria is not endemic, diagnosis can often be difficult because of the nonspecific clinical symptoms and because clinicians do not consider it as a possibility. In addition, immigrants may have some immunity and not show symptoms for months after arriving in the country.

Infants in endemic countries appear to be protected from malaria for the first three to six months of life. Various theories have been postulated including immunities contained in colostrum and breast milk. Nevertheless 75,000–200,000 neonatal deaths annually can be attributed to malaria in sub-Saharan Africa.

In newborns, signs and symptoms of malaria include fever, poor appetite, irritability and lethargy. It also can mimic sepsis (blood poisoning), further obscuring the diagnosis. Malaria infection can also occur in the placenta.

Cheryl K. Smith
Excerpted from "Malaria in Pregnancy," The Birthkit, Issue 55, Fall 2007
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Read Gentle Birth, Gentle Mothering by Dr. Sarah J. Buckley for information that will help you make intelligent, informed choices. Dr. Buckley combines the best medical evidence with her experience as a mother of four to give you advice and information that will help you have a safe, natural birth and start you on the road to gentle parenthood. Topics covered include epidurals, Caesareans, ultrasound, prenatal diagnosis, attachment parenting, extended breastfeeding, co-sleeping, doing without diapers, yoga and gentle discipline. Order the book.

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"Globally, temperature increases of 2–3 degrees C would increase the number of people who, in climatic terms, are at risk of malaria by around 3–5%, i.e., several hundred million. Further, the seasonal duration of malaria would increase in many currently endemic areas."

— Climate change and human health: risks and responses. Summary. World Health Organization 2003. www.euro.who.int/document/gch/climchsum0903e.pdf

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Web Site Update

Read this article excerpt from the most recent issue of Midwifery Today (Spring 2008) newly posted to our Web site:
Midwives Honor the Sensuality of Pregnancy and Birth—by Shafia M. Monroe
"People have often said to me, 'You must really love babies to be a midwife.' And 'Wow, how you can stand all that blood?' Of course midwives love babies. We work hard to provide care to ensure that a woman has a healthy pregnancy and thus a vigorous baby. But in actuality, midwives love women. We love to see them happy during their pregnancy, supported during their labor, honored in birth, sustained while breastfeeding and nurtured as new mothers."

Read this article recently posted to our Web site:
Saving Lives—by Sister MorningStar
"My own work in rural villages and with closely knit groups like immigrants, Mennonites, ethnically displaced peoples and back-to-earth subcultures taught me that many wimyn have retained their instinctual nature to birth upright, vocalize, immediately embrace their young and prefer a piece of their own placenta for life-threatening complications like postpartum hemorrhage."

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Question of the Week

Q: In a recent episode of "Baby Story," a mom in labor was offered Ambien, a hypnotic, so she could sleep until she went into hard labor. Does anyone have experience with this or other drugs in its class being used during labor? Does it pass into the baby? Isn't this just going back to the era of twilight sleep (scopolamine—a hypnotic—and morphine)?

— Anonymous

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: How long can a baby be on breast milk only, with the addition of no solid food or liquids? I don't want to feed my baby anything but breast milk until I have to, but am not clear whether there is a maximum after which it becomes less healthy to do so.

— Anonymous

A: Babies are meant to feed solely on breast milk for the first six months. This can also mean seven, eight or nine months or longer if there are food allergy tendencies and depending on the individual baby's readiness for solids. Introduction of solids is an "introduction" and should be based on the baby's readiness.

Readiness can be seen in diminished tongue reflex—when baby pushes food out of her mouth with her tongue, baby's ability to sit up well and, often, a developed pincer grip. Teething, which begins in the middle of the first year, and developing the ability to chew are also signs of readiness.

— Audrey Stone, La Leche League
Brooklyn, New York

A: My first daughter was eleven months old before she had anything but breast milk. My second daughter was eight months. Third daughter was nine months. Fourth daughter was seven and a half months and my fifth daughter and last child was almost ten months old. All were healthy and happy babies.

— Jan L., Retired La Leche Leader
Kokomo, Indiana

A: It is best to let the baby set the pace. Some babies will want solids earlier than six months; some later. As mother's milk contains proteins from all the foods in her diet, the breastfed baby is able to eat whatever it wants as it has been exposed to all those different proteins.

Babies can feed themselves; they will usually play with the solids before eating much of them. This is normal learning behavior. Some experts feel that difficulty with solids may be because babies prefer to feed themselves and don't like being fed, particularly commercial baby foods that are without interesting consistency or flavor.

Weaning from the breast can take years; this is also normal. Keep nursing as much and as often as baby wants during this transition time.

— Nikki Lee, RN, BSN, Mother of two, MS, IBCLC, CCE, CIMI
craniosacral therapy practitioner

A: Breast milk is the main source of nutrition for the first year of life. The introduction of solids is appropriate when the baby has all the signs of readiness, such as no tongue thrust, can sit up on his own, has the pincer grasp, and most importantly is INTERESTED in table food. I am a La Leche League Leader and with this guidance I felt confident delaying solids until my children developed to this point. In both cases it was after nine months of age. Even then, I introduced foods, rather than replacing meals.

— Paula Santi
Walnut Creek, California

A: The information that we manage here in Venezuela, at the level of "enlightened pediatrics" and breastfeeding consultancy, is that six months of exclusive, on-demand breastfeeding is the appropriate time span. In that time, the digestive tract of the babies mature enough to begin the gradual introduction of complementary foods without difficulties. From then on, a transition process begins whereby mother's milk slowly goes from being the main source of food to becoming a complement of the other foods.

We encourage mothers to continue giving breast milk as the only milk for their babies until they are at least two or three years old. My personal conviction, after a good number of readings and research, is that if you're going to give any raw milk to a baby/toddler at all, it ought to be human milk (preferably his/her mother's!).

— Alejandro Araujo
Birth Facilitator and Breastfeeding consultant

A: Breast milk should remain baby's main food source until approximately 12 months of age, and should be offered before any solids. Personally, I exclusively breastfed my second child until she turned eight months, then she began to eat "finger foods" so we skipped the need for any mashed foods altogether.

— L. Short
4th year student
Bachelor of Nursing/Bachelor of Midwifery
Melbourne, Australia

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.

Think about It

According to the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) updated monograph, "Postpartum Mood and Anxiety Disorders: Case Studies, Research and Nursing Care," up to 14.5 percent of new mothers suffer postpartum depression. Even more alarming though, it notes, a woman is more likely to develop a severe mental disorder during the first few months after the delivery of her child than any other period in her lifetime.

Could this be related to the fact that we have turned birth into a traumatic and/or unnatural experience? I wonder how common these mental disorders are among women who have peaceful, natural births.

Cheryl Smith, Managing Editor
Midwifery Today

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