Sunday, September 26, 2010

Medicare funding: carrot or poisoned chalice?



Australian maternity activists have for many years fought for public funding to be made available to women who choose a midwife as their primary maternity carer. The little group in the picture above in 2003 walked in a rally in Melbourne, wearing T-shirts with the message 'Push for better birth'. (you may recognise some of the faces!)



This front cover of Birth Matters, the quarterly journal of Maternity Coalition (I was editor at the time) comes with discussion:
"We'll have voting rights soon."
"How long until we have rights in childbirth?"


Maternity Coalition had facilitated the writing and promotion of the National Maternity Action Plan (NMAP 2001) The key elements of NMAP were choice for women of primary care provider, and place of birth. NMAP called for public funding for basic maternity services to be linked to the individual woman/baby/birth, rather than the complex and fragmented system of item numbers for out of hospital care under Medicare, and all acute maternity care being provided in hospitals. Medical items required in pregnancy and birth would continue. The change that we sought was that midwives would be recognised as primary care providers, and women would have choice without financial disadvantage when they chose a midwife.


The culmination of political and professional efforts to 'reform' maternity services, over these past couple of years, are coming to a head. The Labor government declared that it had a mandate to reform health. The Minister, under direction of the Australian Medical Association, held out a conditional offer of Medicare to midwives - a golden carrot in her hand. Consumer and midwife groups applauded - they saw an end to privately funding their maternity care. Many midwives are still holding on to a hope that they will be eligible for a Medicare provider number.

The condition is HUGE: supervision of midwifery practice by a doctor.

But what looked enticing is now being recognised as a poisoned chalice. Take a sip, midwife, and you're finished. There is no sign yet of an answer to the question 'How long until we have rights in childbirth?'

For most of the past 20 years I have been working to achieve equity of public funding for those women who choose a midwife as their primary maternity carer, and recognition of the midwife as a provider of basic maternity services. Equity means even-handedness, fair play: that services provided by a midwife are entitled to the same public funding as the same services provided by any other maternity care professional. As it happens, the only other professional with the authority to provide professional services in pregnancy and birth is a doctor. The inequity, or lack of fairness in maternity, is that although the midwife is as capapble as the doctor of providing basic maternity services, only the doctor is entitled to public funding for her/his services. And this is in a country that has legislation protecting competition in trade (Trade Practices Act).

This Medicare reform package will not deliver even a pathway to those goals of equity and choice. It will set midwifery back, and I expect it will feed the ever-increasing caesarean and birth trauma rates.

For more reading on this topic:

MIPP - Midwives Victoria
Homebirth Australia
Maternity Coalition
NEW Maternity Coaliton blog

Thursday, September 16, 2010

UNASKED QUESTIONS ABOUT SYNTHETIC OXYTOCIN

[This newsletter has been reproduced unaltered, with permission. If you would like to subscribe to it, please contact wombecology@aol.com]

PRIMAL HEALTH RESEARCH
A NEW ERA IN HEALTH RESEARCH
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road, London NW3 2JR
michelodent@googlemail.com
Summer 2010 Vol 18. No1
**************************
www.primalhealthresearch.com
(Free access to the Primal Health Research Data Bank)
www.wombecology.com
(The importance of pre- and perinatal ecology)
BETWEEN THE MIDATLANTIC AND THE MIDPACIFIC CONFERENCES
(Topics for the future: see below)


UNASKED QUESTIONS ABOUT SYNTHETIC OXYTOCIN
A labouring woman was puzzled and even anxious when she received a drip of synthetic oxytocin, The midwife immediately reassured her that oxytocin is not like a drug: it is “natural”. Perhaps this is why we ignore many questions regarding what is undoubtedly the most common medical intervention in childbirth on all five continents. Today, all over the world, most women giving birth vaginally get such a drip (called Syntocinon or Pitocin) including those with an eventual operative delivery by forceps or ventouse. Most women who undergo a caesarean section during labour have had such a drip before the decision to operate, and this drip is usually continued for some hours after the surgery. Even during and after a pre-labour c-section, synthetic oxytocin is included in many hospital protocols to facilitate uterine retraction. Furthermore, the rates of labour inductions are currently high, and induction almost always involves the use of synthetic oxytocin.

Preliminary questions
This new situation raises important questions. We must first wonder why modern women need substitutes for the hormone that is naturally released by the posterior pituitary gland. Is it because their oxytocin system is disturbed? Is the capacity to effectively release oxytocin depleted from generation to generation, as a result of several aspects of modern life, particularly medicalised birth? This is a vital question for the future of civilisation, since the oxytocin system is involved in sociability, capacity to love, and potential for aggression. Is it mostly cultural conditioning in a context of industrialised childbirth? In this latter case the current situation might be reversible. If it is simply a matter of environment at birth, we need to improve our understanding of the birth process. In fact, we must explore the possible contribution of multiple factors.

Other questions address the substances that might cross the placenta and reach the unborn baby. For example, the kind of fluid used to transport synthetic oxytocin. In earlier times, glucose drips were routine during labour. These infusions were not benign because simple sugar molecules rapidly cross the placenta while the mother’s insulin—released in response—fails to reach the fetal bloodstream. There is thus a risk of excessive insulin production generated by the baby's pancreas in response to these circulating high blood sugar levels. Extensive research has confirmed the risks of neonatal hypoglycemia.(1 to 7) These studies led to the replacement of glucose drips during labour by other liquids, such as Ringer’s solution. The results of such studies also apply to labouring women without a drip of synthetic oxytocin if they are encouraged to consume sugar or soft drinks. This is not always understood by the natural childbirth groups. Furthermore, if labour progresses spontaneously, adrenaline type hormone levels are low, voluntary muscles are at rest, and these women don’t need added energy.8

Can synthetic oxytocin cross the placenta?

When we finally acknowledge that all over the world most women receive synthetic oxytocin while giving birth, we can no longer deny problems arising from the possible transfer of oxytocin via the placenta. One can wonder why it remains an unexplored issue. The main reason, as we have suggested, might be that oxytocin is not considered a “real” medication because chemically the synthetic form is no different from the natural hormone: it is a simple molecule (a nonapeptide). However, the problem is not simple because the amount of oxytocin reaching the maternal blood stream via an intravenous drip is enormous compared with the amount of natural oxytocin the posterior pituitary gland can release. Furthermore, natural oxytocin is released through pulsations, while synthetic oxytocin is delivered continuously. Another reason for ignoring this issue might be the discovery of enzymes that metabolize oxytocin (oxytocinases) in the placenta. This finding might have led to a hasty, tacit conclusion that synthetic oxytocin does not reach the baby.

Until now, there has been only one serious article published on this subject.9 A team from Arkansas concluded that oxytocin crosses the placenta in both directions—after measuring concentrations of oxytocin in maternal blood, in the blood of the umbilical vein and umbilical arteries, and also after perfusions of placental cotyledons. More precisely, the permeability is higher in the maternal-to-fetal direction than in the reverse. Eighty percent of the blood reaching the fetus via the umbilical vein goes directly to the inferior vena cava via the ductus venosus, bypassing the liver, and therefore reaching the fetal brain immediately: it is all the more direct since the shunts (foramen ovale and ductus arteriosus) are not yet closed.

Since there is a high probability that a significant amount of synthetic oxytocin can reach the fetal brain, we must investigate the permeability of the so-called blood brain barrier at this phase of human development. This “barrier” implies a separation of circulating blood from cerebrospinal fluid in the central nervous system. It restricts the diffusion of microscopic particles, including bacteria, and molecules such as oxytocin. However, Australian researchers presented evidence that the developing brain is more permeable to small lipid-insoluble molecules and that specific mechanisms, such as those involved in transfer of amino acids, develop gradually as the brain grows.10 Furthermore, it appears that the permeability of the blood-brain barrier can increase under the influence of oxidative stress11,12,13, that commonly results when a synthetic oxytocin drip is administered during labor.14 Therefore, we have serious reasons to be concerned if we consider the widely-documented concept of “oxytocin-induced desensitization of oxytocin receptors”.15,16,17,18 It is probable that, at a quasi-global level, we routinely interfere with the development of the oxytocin system of human beings at a critical phase for gene-environment interaction. Within the framework of accepted scientific knowledge, we must acknowledge the important role of oxytocin, particularly in sociability, the capacity to love (of others and love of oneself) as well as the potential for aggression (aggression towards oneself and towards others).19 Interfering in normal reproductive physiology raises critical issues. For example: “Is there a link between the increased incidence of disorders associated with documented alterations of the oxytocin system (such as autism20,21 and anorexia nervosa22,23) and the widespread use of intravenous drips during labour?” “What will be the impact on the evolution of our civilizations?” We may even wonder if the widespread use of synthetic oxytocin can induce an unprecedented cultural revolution.

Such questions should inspire a new generation of research.

Plastic related substances

Of course, one cannot ignore the toxic effects of phtalates, which are added to plastics such as polyvinyl chloride (PVC) to increase their flexibility, transparency, and longevity. The National Institute of Environmental Health Sciences and the National Toxicology Program began studying phthalates following a discovery that blood stored in PVC plastic bags for transfusions contained significant concentrations of phthalates.24 The most common phthalate is di-ethylhexyl phthalate, or DEHP. In bags for intravenous drips and tubing, additives like DEHP can make up 40 or 50 percent of the product.

There are several reasons why this issue is critical. The first is that the effects of phtalates on intellectual development have already been demonstrated, in particular by an authoritative South Korean study.25 The authors found that high urinary concentrations of phthalate metabolites were associated with lower intellectual quotients (IQ) among 667 children at nine elementary schools. Another reason for serious concern is that today most women spend hours with an intravenous drip while giving birth. There is an accumulation of data confirming the transplacental transfer of phtalates among mammals in general26,27 and humans in particular.28 Most babies probably receive some amount of phtalates during the critical period surrounding birth. Is this amount negligible or dangerous? What are the possible long-term consequences? It is essential to emphasize that these phtalates pass directly into the fetal bloodstream, with no possibility of degradation in the digestive tract. Very sensitive tests today can find a millionth of a gram, or even less, of certain substances in blood or urine. This measurement process is called biomonitoring. In July 2006, an expert committee of the National Academy of Sciences (NAS) published the results of a comprehensive study of biomonitoring. The committee stated that, “In spite of its potential, tremendous challenges surround the use of biomonitoring, and our ability to generate biomonitoring data has exceeded our ability to interpret what the data mean to public health.”

Today, even the experts confess that they are in the dark.

References
1 - Mendiola J, Grylack LJ, Scanlon JW. Effects of intrapartum maternal glucose infusion on the normal fetus and newborn. Anesth Analg. 1982 Jan;61(1):32-5
2 - Lucas A, Adrian TE, Aynsley-Green A, Bloom SR. Iatrogenic hyperinsulinism at birth. Lancet. 1980 Jan 19;1(8160):144-5.
3 - Kenepp NB, Kumar S, Shelley WC, Stanley CA, Gabbe SG, Gutsche BB. Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. 1982 May 22;1(8282):1150-2.
4 - Carmen S. Neonatal hypoglycemia in response to maternal glucose infusion before delivery. J Obstet Gynecol Neonatal Nurs. 1986 Jul-Aug;15(4):319-23
5 - Grylack LJ, Chu SS, Scanlon JW. Use of intravenous fluids before cesarean section: effects on perinatal glucose, insulin, and sodium homeostasis. Obstet Gynecol. 1984 May;63(5):654-8.
6 - Kenepp NB, Shelley WC, Kumar S, Gutsche BB, Gabbe S, Delivoria-Papadopoulos M. Effects of newborn of hydration with glucose in patients undergoing caesarean section with regional anaesthesia. Lancet. 1980 Mar 22;1(8169):645.
7 - Singhi S, Sharma S. Neonatal hypoglycemia following maternal glucose infusion prior to delivery. Indian J Pediatr. 1991 Jan-Feb;58(1):43-9.
8 - Odent M. Laboring women are not marathon runners. Midwiferytoday
9 - Malek A, Blann E, Mattison DR. Human placental transport of oxytocin. J Matern Fetal Med. 1996 Sep-Oct;5(5):245-55.
10 - Saunders NR, Habgood MD, Dziegielewska KM. Barrier mechanisms in the brain, II. immature brain. Clin. Exp. Pharmacol. Physiol. 1999;26(2):85–91
11 - Noseworthy M, Bray T. Effect of oxidative stress on brain damage detected by MRI and in vivo 31P-NMR. Free Rad. Biol. Med. 1998;24:942–951
12 - Agnagnostakis D, Messaritakis J, Damianos D, Mandyla H. Blood-brain barrier permeability in healthy infected and stressed neonates. J. Pediatr. 1992;121:291–294.
13 - Noseworthy M, Bray T. Zinc deficiency execerbates loss in blood–brain barrier integrity induced by hyperoxia measured by dynamic MRI. PSEBM. 2000;231:175–182.
14 - Schneid-Kofman N, Silberstein T, Saphier O, Shai I, Tavor D, Burg A. Labor augmentation with oxytocin decreases glutathione level. Obstet Gynecol Int. 2009;2009:807659. Epub 2009 Apr 16.
15 - Robinson C, Schumann R, Zhang P, Young R. Oxytocin-induced desensitization of the oxytocin receptor. Am. J. Obstet. Gynaecol. 2003;188:497–502.
16- Gimpl G, Fahrenholz F. The oxytocin receptor system: structure, function and regulation. Physiol. Rev. 2001;81:642–643.
17 - Phaneuf S, Rodríguez Liñares B, TambyRaja RL, MacKenzie IZ, López Bernal A. Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labour. J Reprod Fertil. 2000 Sep;120(1):91-7.
18 - Phaneuf S, Asboth G, Carrasco M, Lineares B, Kimura T, Harris A, et al. Desensitization of oxytocin receptors in human myometrium. Hum. Reprod. Update. 1998;4:625–633.
19 - Odent M. The Scientification of Love. Free Association Books. London 1999.
20 - Modahl C, Green L, et al. Plasma oxytocin levels in autistic children. Biol Psychiatry 1998; 43 (4): 270-7.
21- Green L, Fein D, et al. Oxytocin and autistic disorder: alterations in peptides forms. Biol Psychiatry 2001; 50 (8): 609-13.
22 - Demitrack MA, Lesem MD, Listwak SJ, et al. CSF oxytocin in anorexia.nervosa and bulimia nervosa: clinical and pathophysiologic considerations. Am J Psychiatry 1990 Jul;147(7):882-86
23 – Odent. Autism and anorexia nervosa: two facets of the same disease? Med Hypotheses 2010. doi:10.1016/j.mehy.2010.01.039
24 - Baker RW. Diethylhexyl phthalate as a factor in blood transfusion and haemodialysis. Toxicology.1978 Apr;9(4):319-29.
25 - Cho SC, Bhang SY, Hong YC, et al.. Relationship Between Environmental Phthalate Exposure and the Intelligence of School-Aged Children. Environ Health Perspect. 2010 Mar 1. [Epub ahead of print]
26 - Saillenfait AM, Payan JP, Fabry JP, et al. Assessment of the developmental toxicity, metabolism, and placental transfer of Di-n-butyl phthalate administered to pregnant rats. Toxicol Sci. 1998 Oct;45(2):212-24.
27- Kihlström I, Placental transfer of diethylhexyl phthalate in the guinea-pig placenta perfused in situ. Acta Pharmacol Toxicol (Copenh) 1983 Jul;53(1):23-7.
28 - Mose T, Knudsen LE, Hedegaard M, et al. Transplacental Transfer of Monomethyl Phthalate and Mono(2-ethylhexyl) Phthalate in a Human Placenta Perfusion System.0. International Journal of Toxicology 2007; 26(3): 221-229.

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BETWEEN THE MID-ATLANTIC AND THE MID-PACIFIC CONFERENCES
The Mid-Atlantic Conference on Birth and Primal Health Research – which attracted 1250 participants from 39 countries – has been a successful rehearsal before the Mid-Pacific Conference.
The Mid-Pacific Conference will occur on October 26-28, 2012, in Honolulu. The venue will be the prestigious Hawaii Convention Center, as the meeting point between Western and Eastern cultures.
Once more, the main objective of the conference will be to phrase new questions after presenting an overview of technical and scientific advances that will influence the history of childbirth. As in Las Palmas, the participation of Pr. Michael Stark, the “father” of the new simplified technique of cesarean, will symbolize technical advances, while the participation of Pr Kerstin Uvnas-Moberg, as an expert in behavioural effects of oxytocin, will symbolize scientific advances. The need to think globally will be emphasized by the participation of Dr Mario Merialdi, coordinator for maternal and perinatal health at WHO.
The Mid-Pacific conference will be characterized by the emergence of new important themes, such as the transgenerational effects of early experiences (during the “primal period”), the expected importance of economical factors in the evolution of medicine in general and obstetrics in particular, and also by the great diversity of renewed practical topics presented during the thirty concurrent sessions and through posters.
During these three days, inspired by our logo and surrounded by the foams of the oceanic waves, we’ll be in an ideal place to dream of and to work for the Rebirth of the Goddess of Love.
Aloha means Love!
Michel Odent and Heloisa Lessa

Friday, September 10, 2010

Bertha finds a midwife

"If you can type you can make movies"

.
That challenge was too much for me, so I have made this little 2-minute animation movie, in response to the one I posted below thismorning. Enjoy! JJ




NEW 17 Sept 2010 Bertha's first birth







BERTHA'S VBAC

midwife 'humor'



If you are able to think critically about midwifery, natural birth, women's choice in health care, advocacy, pain relief, ..., this quirky video clip is worth watching.

Yes, it's American, and we're different, aren't we?

Here's a thumbnail sketch of the clip:

The midwife talks with the anaesthetist and says the labouring woman needs an epidural.
The anaesthetist asks the usual medical questions.
The midwife says the woman feels fine - but no objective measurements of the woman's condition have been made.  The epidural is being ordered so that the cervix can be checked.  But the woman wants a natural birth, so she doesn't want all that medical stuff done, and the midwife is advocating for the woman's choice.
[Thanks to Caroline Hastie for this video clip]

Sunday, September 05, 2010

Fathers

Happy Father's Day, from Poppy

Fathers are an integral part of a midwife's life, yet they don't often find themselves being the focus of my writings.

Today we have celebrated father's day, with a nice breakfast of pancakes, bacon and eggs, and a few little gifts including the standard 'sox-n-jocks'. Poppy has given me permission to use her drawing of herself, her daddy, and grandpa and granny.


Our society has changed in the past couple of generations, from excluding fathers from any involvement in birth to an expectation that they will be present and accounted for throughout the labour and birth.

Today the father's ritual of cutting the cord is almost comic relief after a highly medicalised birth. Occasionally a father says "no, thank you" when the scissors are being thrust in his direction, and someone else has to step up to the task.

What is a father's chief role in birth and early parenting?

Many aspects of a role come to mind, including encouragement, support, caring, looking after household chores, preparing meals, making cups of tea, ... These are like pieces of a puzzle - each one incomplete in itself. They only make sense when they fit together perfectly.

Looking beyond the individual pieces of the puzzle, the role of the father can be summarised as "to love the mother".

There are enormous adjustments that have to be made when a new baby is brought into a family. The father who loves the mother, in a gentle and unconditional way, is providing the strong cement that will hold that family together through sleep deprivation, and feeding challenges, and the many other unexpected journeys that come up in ordinary life.

Father's Day is to a great extent a product of materialism, and a great marketing opportunity. Today I encourage each father to truly love the mother of your children, and in that way you will be establishing strong bonds within your family, and protecting your children as well as their mother.

Unfortunately there is no plan that will guarantee that you will live 'happily ever after'. I simply encourage parents to commit yourselves to the work of parenting, to the best of your ability, and you will not regret the investment you make.