Wednesday, November 4, 2015

A Very Informative Video on Circumcision

So, I've just recently discovered Ryan McAllister, PhD and his videos on birth and circumcision, and I highly recommend you view his video on Child Circumcision (aka genital cutting). It is a lecture to a room of anthropology students, and he comes at the topic from an accessible academic perspective.

If you're ever wanted to know more about why you should think about or question circumcision or no, this is a great overview video (with a brief hard-to-watch clip of male genital cutting near the beginning).

He makes a number of excellent points. He covers culture, medicalization, the biology of the penis and the procedure, informed consent issues, ethics, the science behind common reasons for removing the foreskin, and more.

I love the comedic clip's quote... "so you can have this chopped off or you could wash it?"

The whole video really makes you question, do the supposed pros outweigh the known cons?

Note that this presentation includes graphic material to convey more complete information about the topic.

One thing he doesn't really touch on is the fact that the obstetricians who perform this procedure are also keen to have parents circumcise because it is a relatively quick and easy surgery that they make money from.

Ryan is the director of

One of NotJustSkin's primary missions is to educate the public about violations of informed consent or bodily integrity. In the U.S., male genital cutting, more often called circumcision, is commonly practiced even though parents rarely receive the information that would be required to give informed consent to any other procedure. Circumcision is the only procedure where a doctor can legally amputate part of a non-consenting child without any medical reason.

I was not an intactivist before viewing this video, but I may be one now...

To add, being a feminist from a Jewish background, I also encourage a perusal of an article called "Circumcision: a Jewish Feminist Perspective."

This is the first of Ryan's videos that I came across, but I plan to post on his other content, as well.

Wednesday, October 14, 2015

New National Recommendations for Safe Reduction of Primary Cesarean Births

In recent years, several national partners including ACOG, AWHONN, SMFM, CDC, HRSA and others came together as the National Partnership for Maternal Safety and have worked with the Council on Patient Safety in Women’s Health to create several “bundles” of recommendations to improve the outcomes and safety of pregnant women.

A bundle is a checklist of specific changes that, if followed, will lead to improvement.

Bundles are a collection of succinct evidence-based components that when implemented together should have a positive impact on outcomes and safety for pregnant women. The bundles have four domains, Readiness, Recognition and Prevention, Response, and Reporting/Systems Learning. The bundles provide the core elements that every hospital can implement for every woman, every time. Birth facilities are encouraged to expand on the core component by developing policies, protocols and standardized practices that best meet local needs and are evidence based.

The first bundle that was released by this partnership focused on obstetric hemorrhage, one of the leading causes of maternal mortality. It has since been followed by other bundles focusing on high impact, high volume health and safety issues such as hypertension in pregnancy and safe reduction of primary cesarean births.

Below, I share with you the new national patient safety bundle recommendations for supporting intended vaginal births. You may click the image to enlarge. Lowering the primary cesarean section will increase maternal safety by decreasing morbidity from unnecessary surgeries and the consequences of prior cesarean delivery in future pregnancies.

Safe Reduction of Primary Cesarean Births: Supporting Intended Vaginal Births

Every patient, provider, and facility

  • Build a provider and maternity unit culture that values, promotes, and support spontaneous onset and progress of labor and vaginal birth and understands the risks for current and future pregnancies of cesarean birth without medical indication.
  • Optimize patient and family engagement in education, informed consent, and shared decision making about normal healthy labor and birth throughout the maternity care cycle.
  • Adopt provider education and training techniques that develop knowledge and skills on approaches which maximize the likelihood of vaginal birth, including assessment of labor, methods to promote labor progress, labor support, pain management (both pharmacologic and non-pharmacologic), and shared decision making.

Every patient

  • Implement standardized admission criteria, triage management, education, and support for women presenting in spontaneous labor.
  • Offer standardized techniques of pain management and comfort measures that promote labor progress and prevent dysfunctional labor.
  • Use standardized methods in the assessment of the fetal heart rate status, including interpretation, documentation using NICHD terminology, and encourage methods that promote freedom of movement.
  • Adopt protocols for timely identification of specific problems, such as herpes and breech presentation, for patients who can benefit from proactive intervention before labor to reduce the risk for cesarean birth.
to every labor challenge
  • Have available an in-house maternity care provider or alternative coverage which guarantees timely and effective responses to labor problems.
  • Uphold standardized induction scheduling to ensure proper selection and preparation of women undergoing induction.
  • Utilize standardized evidence-based labor algorithms, policies, and techniques, which allow for prompt recognition and treatment of dystocia.
  • Adopt policies that outline standard responses to abnormal fetal heart rate patterns and uterine activity.
  • Make available special expertise and techniques to lessen the need for abdominal delivery, such as breech version, instrumented delivery, and twin delivery protocols.
Every birth facility
  • Track and report labor and cesarean measures in sufficient detail to: 1) compare to similar institutions, 2) conduct case review and system analysis to drive care improvement, and 3) assess individual provider performance.
  • Track appropriate metrics and balancing measures, which assess maternal and newborn outcomes resulting from changes in labor management strategies to ensure safety.

I listened to the organization's conference call presentation on this new bundle. Chair of the workgroup. David Lagrew, noted:
- that 53% of disparity in cesarean section rates is related to labor induction and early admission.
- rates vary from provider to provider, so individual provider data tracking is helpful to make change
- He also emphasized creating a Culture of Supporting Intended Vaginal Delivery:
To be successful, one must achieve development of a culture in which the clinical providers, administrative support and public: 1) appreciate the true value of achieving a vaginal delivery; 2) respectfully acknowledges the desires of the patient and 3) maintains educational processes, facilities, equipment and staff expertise which can maximize the chance of successfully obtaining vaginal delivery which is safe for mother and infant(s).
Co-presenter Lisa Kane Low noted these recommendations:
- don't admit women prior to 6 cm (especially first time moms) for active labor
-in-house persons, e.g. laborists, available without other demands, are associated with an increase in spontaneous vaginal deliveries
- make doulas part of the team
- look at Bishop score to schedule inductions and reduce inductions prior to 41 weeks.
- have specialized providers available for breech version, instrumental delivery, and twin delivery

Keep an eye out on the Safety Actions Series website if you'd like the slides and recording from this call. Listen especially to the Q&A and discussion at the end!

The California Maternal Quality Care Collaborative will be coming out with a toolkit for this topic, as they have in the past for previous topics, so I will be excitedly waiting for that!

Additionally, here is the list of resources that the Council includes as part of this safety bundle:

Wednesday, September 30, 2015

Healthy Pregnancy Spacing

What is the "ideal" spacing of pregnancies?

Socially, there may be a wide range of opinions on the subject of how far apart your children should be. Theories abound as to the ideal spacing for the parents' sanity (condense the amount of time you're in diapers), the mental health of the children (will they get along if they're too close/too far apart?), and so on.

We know that many women "plan" to have their kids a certain number of years apart, others try to rely on natural family planning methods which sometimes lead to close pregnancies, and some women actively try to have several children within a limited time period.

Some couples decide to have or end up having several children close together, either because they had trouble conceiving at first, because they don't use a highly effective form of birth control, because they are reaching the end of their reproductive years, or because it is the norm in their social or religious community.

Often it is social/parenting reasons that dictate pregnancy spacing, and many women do not take into account the health impacts of pregnancy spacing. I believe it is my public health duty to tell you that the healthiest thing you can do is to wait at least 18 months to 2 years before conceiving the next baby.

Here's why:

Benefits of Spacing of 18+ months

It has been repeatedly demonstrated that adequate birth spacing reduces adverse events for both mothers and infants. Research on several populations found that the risk for adverse birth outcomes is lowest when the interpregnancy interval was 18-23 months. These studies controlled for maternal reproductive risk factors.

Adverse birth outcomes for the infant included low birth weight, preterm birth, and small for gestational age. There is also limited evidence that risk of autism increases.

Adverse outcomes for the mother include increased risk of uterine rupture in women attempting a vaginal birth after previous cesarean delivery and uteroplacental bleeding disorders (placental abruption, where the placenta detaches from the uterine wall, and placenta previa, where the placenta covers the cervical opening).

The benefits of waiting at least 2 years between births also extend beyond the pregnancy and birth outcomes. Closely spaced pregnancies often don't give the mothers body enough time to recover from the physical and metabolic stress of pregnancy and breastfeeding, which can deplete some nutrients. Furthermore (and this may not be relevant to your situation), for resource-poor families, two young children very close in age often leads to a time, energy, and resource disparity where one child suffers the consequences. There are some studies that show short interpregnancy interval length is associated with increased child mortality.

While you can tandem nurse an older and younger child, your milk does change during pregnancy and it may be best to finish you are prepared to possibly finish your breastfeeding relationship with your elder child before becoming pregnant.

If you had an adverse birth outcome with your previous birth (for example, low birth weight or premature baby), it is even more important to actively plan for your next baby, rather than leaving it to chance and potentially having a short birth interval. (The buzz word in public health is Interconception Care)

Consequences of (Too) Long Birth Intervals (5 years)

It is worth noting, however, that long birth intervals (~5 years) are associated with an increase with of preeclampsia (hypertension in pregnancy). Limited evidence shows an association with preterm birth and low birth weight, as well.

There are also hypotheses that waiting too long between pregnancies puts your body back into a state of a first time pregnancy, and the physiological changes caused by pregnancy that may help with pregnancy and labor may disappear.

I hope this helps you think about your pregnancy spacing and family planning! With all that in mind, I'll let you figure out where in that 2-5 year window is the best time for your family to deal with the practical demands of a growing family.


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