Thursday, November 20, 2014

Breastfeeding Problems Linked to Mom's Post-Birth Meds?

"Evidence-based care acknowledges that, sometimes, having no intervention is safest, and, sometimes, having interventions is safest.... Advocating for evidence-based practices and interventions is not an ideology that interventions are bad. It's taking an objective look at scientific research and actually applying it to individuals, rather than basing care on outdated traditions, fear, and the ridiculous idea that women shouldn't be involved in their own health care." - ImprovingBirth.Org

A new study is out that takes a look at the effect of intramuscular injections mothers receive immediately after birth and their effect on breastfeeding. These are injections that occur during the third stage of labor (before or after delivery of the placenta) that are intended to help the uterus begin to contract down to normal size. This helps prevent postpartum hemorrhage.

The International Breastfeeding Journal notes:
Existing RCTs found no links between uterotonics administered in third stage of labour and breastfeeding. These trials were published ten and twenty years ago, and, to our knowledge, more recent trials have not examined the impact of uterotonics on breastfeeding. In the absence of trial data, observation studies and biological mechanisms assume greater importance.
This Brown and Jordan article notes the background information on the literature:
Analysis of a large birth cohort (n=48,366) indicated that intramuscular injection of oxytocin, with or without ergometrine, in the third stage of labor reduced breastfeeding rates at 48 hours by 6-8% (adjusted odds ratio [OR]= 0.75, 95% confidence interval [CI] = 0.61-0.9 1; adjusted OR=0.77, 95% CI=0.65- 0.9 1), consistent with other observational studies. A randomized controlled trial (n = 132) of active management of the third stage with intravenous ergometrine indicated an increase in supplementation and cessation of breastfeeding by 1 and 4 weeks postpartum, mainly because lactation was inadequate for the infants' needs.
The medications this 2014 Brown and Jordan study looked at included oxytocin and ergometrine. The study gave mothers who had a vaginal birth within the past 6 months a questionnaire that asked about whether they received uterotonic injections, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological. 82% of the mothers had received active management of the third stage, and 17% received physiological management.

Here are the study results:
No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty.
What this means is that their study might imply that uterotonic injections during the third stage of labor do not affect breastfeeding initiation, but may affect breastfeeding duration.

As with all research, we can say that this study showed an association between the injections and the cessation of breastfeeding due to physical reasons, but we cannot necessarily say it is causation. It is an important point to keep in mind when reading about research.

There is a great deal of evidence for the benefits of uterotonics for prevention of postpartum hemorrhage. Randomized control trials and metasyntheses of research by organizations such as the World Health Organization and the Cochrane Library have found that administration of oxytocin or other uterotonic are highly effective at reducing postpartum bleeding and prolonged third stage, with no apparent side effects for the baby. Ergometrine is associated with nausea for the mother.

The data for this study was collected by self-report on a questionnaire filled out by the mothers. Of course there are data collection errors, like selection bias and recall bias, involved in this type of study. It is not secondary data analysis (e.g. they did not look at medical charts to determine if an injection was received and then link it to data for the mother showing whether she stopped breastfeeding at a certain point in time). It is not a prospective randomized control trial (the gold standard of research, though not always possible).

Interestingly, they removed mothers who had intravenous oxytocin from their statistical analyses, as they were likely to have been receiving it during labor for induction, and also more likely to have an epidural. However, when they did analyze this small sample, they found that the finding was still significant: women who had the intramuscular injection compared to those receiving it intravenously were less likely to be breastfeeding at 2 and 6 weeks. So what is it about the injection, then?

Also, their psychological questions on reasons for stopping found that mothers who had an active third stage were significantly more likely to say they stopped breastfeeding for reasons of pain and/or embarrassment. Why would receiving uterotonics after labor contribute to difficulty latching or embarrassment? Perhaps they are correlated but not causational.  Or perhaps the medication affects the baby's ability to latch. The authors suppose the two are related: mothers who have trouble latching will be more embarrassed to nurse in front of others. This is all conjecture.

Brown and Jordan note in their discussion section that active management may not reduce postpartum hemorrhage for women at low risk of hemorrhage. This is a good argument for more risk assessment antenatally and upon birth admission. Many obstetric hemorrhage initiatives in the U.S. include this as a recommendation for hospitals. There is always the argument, however, that even low risk women sometimes hemorrhage after birth (there are instances of low risk home birth mothers transferring due to excessive bleeding). In rural or resource-poor settings, it may be beneficial to standardize receipt of prophylactic uterotonics when transfer could be life-threatening.

Furthermore, when care is not standardized, more health care mistakes are made. This is what the field of quality improvement in healthcare has found, and the reason standards of care are emphasized. It also means that everyone is doing the same thing, which reduces the receipt of poor care one place and better care at another. Standardization of care has been shown to reduce life-threatening errors in healthcare. There are times when we have to weigh the pros and cons (e.g. prophylatic uterotonics can reduce morbidity and mortality associated with hemorrhage, but may decrease breastfeeding success and duration). I work with a lot of doctors and nurses in my job in healthcare quality improvement, and I've learned a lot about the capabilities of the providers in our healthcare system. I've seen how changes are made in a system.

As a doula and a social researcher, I am also a strong proponent of patient-centered care. I think that care should also focus on what is right for each individual. Sometimes that means asking the patient what they want, though they may defer to the care provider to make the decision. The care provider may then decide that the pros outweigh the cons.

Another point is that women are more and more high risk for OB hemorrhage in industrialized countries. With the increase in medical conditions, inductions, cesarean sections, pitocin augmentation, use of pain medication and analgesia, advanced maternal age, etc., more women are going to be high risk and therefore more will receive active management of the third stage. So a great intervention would be to recognize that more women need assistance with breastfeeding in the first 2 - 6 weeks so that they can overcome latch issues, embarrassment, perceived low milk supply, and so on.

Moreover, how do we know that the women who have physiologic third stages are somehow different than the women who do not? Since active management is, at the moment, is the norm, and is in the population in this study, the women who "choose" to have no uterotonic injections may already be better informed on breastfeeding, better linked-into breastfeeding help networks, etc.

I did find their explanation of the interaction and possible mechanism behind uterotonics and breastfeeding. The authors speculate:
It is possible that disruption of neuroendocrine/paracrine pathways may lead to suboptimal latching, nipple trauma, pain, and feeding difficulty.
They explain a bit more in the discussion how ergometrine and oxytocin may disrupt hormone balance.

More research is needed on active management of the third stage and its effect on breastfeeding!

I definitely think this article contributes to what a lot of lactation professionals have been noticing, however: Interventions during labor have an effect on breastfeeding success, and we know that epidurals and pitocin augmentation during labor are associated with breastfeeding issues. But does the post-delivery dose have a large enough effect to change practice?

I don't think this particular research article should lead to full-scale changes in recommendations or standards of care at this time. I was inspired to write this article for just that reason - those who may think this is definitive evidence that we should stop promoting prophylactic uterotonics. We do a lot of things prophylactically in our lives. A prophylactic is something that is designed to prevent something from occurring. I think that a lot of birth and breastfeeding advocates are quick to judge all medical interventions as bad, and also to believe research that reinforces their beliefs, and not believe research that does not (well, most people do that). I have taught to be critical of research and to examine it from all sides.

I also think its unfair to blanket statement that all physicians and hospital medical professionals are the only ones to use interventions that may be harmful. Sometimes medical professionals close their eyes to the evidence of harm from routine interventions, but sometimes natural birth advocates (doulas, midwives) do to. 

"Midwives are often quick to criticize medical birth attendants for unwise interventions that disrupt normal birth and may cause harm. But how many of us are guilty of the same thing?" - Gail Hart

Even home birth midwives sometimes use supplements, herbs, etc that have not been tested or approved for effectiveness and safety. Doulas, too, make suggestions for some interventions for pregnant women and babies that we don't know are entirely safe or efficacious. We all have to pay close attention to good, solid evidence, and keep in mind that sometimes things are true even if they contradict what we believe. 

If you're interested in learning more on how to be a critical reviewer of research, I suggest you peruse Science and Sensibility's series of posts on "Understanding Research."

Brown, Amy and Sue Jordan (2014) Breastfeeding Medicine. Vol 9, No 10. DOl: 10.1 089/bfm.2014.0048

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