By Shari Roan
Los Angeles Times Staff Writer

August 13, 2007

HER first baby wasn’t due for four days, but Misa Hayashi was advised by her obstetrician during a routine exam to check into the hospital that day.

“The doctor said the baby was too big for me to push out and we should go ahead and induce labor,” says the Alhambra woman, 24. “I didn’t really question it. Induction sounds so common. We went home and packed a bag and checked in at the hospital.”

Once there, however, Hayashi’s plans for an uncomplicated birth faltered. After receiving the drug Pitocin to trigger contractions, she labored for 20 hours. The pain was so intense she needed medication to ease it — something she had hoped to avoid — and eventually the baby became distressed, requiring constant monitoring of his heart rate.

Finally, almost a day after Hayashi entered the hospital, her son was born. Although he was healthy at 7 pounds, 10 ounces, Hayashi was left questioning the wisdom of labor induction.

Some hospitals and healthcare organizations across the nation share her concerns. Several have barred elective labor induction under certain circumstances, such as before 39 weeks of gestation (one week before the due date) or when there isn’t clear evidence that the mother’s cervix is primed for childbirth.

“There is renewed interest in these seemingly benign medical interventions,” says Dr. William Grobman, an assistant professor of maternal-fetal medicine at Northwestern University. “But the topic is somewhat hazy. We don’t have all the information we’d like to have about risks and benefits.”

The move appears to be a push back against the trend in recent decades to medically manage childbirth. Fewer than 10% of women underwent induction in 1990, but more than 21% did so in 2004, according to federal government statistics. No one knows how many of those inductions were prompted by legitimate medical concerns. But various studies have put the number of inductions for convenience at 15% to 55% of the total number.

At the same time, rates of caesarean sections increased to more than 29% in 2004, up from 23% in 1990, with many women requesting elective C-sections — surgical births without any medical justification. That trend too has generated debate about whether patients are undertaking unnecessary risks.

Labor induction is frequently, and legitimately, recommended when health problems complicate a pregnancy or when pregnancies are more than two weeks past the due date, obstetricians and gynecologists say. But sometimes the procedure is done solely for convenience. In a busy society, doctors and patients have grown increasingly comfortable with this practice.

“People want to schedule their birth like they schedule their nail appointments,” says Janie Wilson, director of nursing operations for women and newborns at Intermountain Healthcare, a Salt Lake City-based chain of hospitals that has tried to reduce the rate of labor inductions.

Until recently, few have questioned whether elective labor induction is appropriate. “There is not a unique description of elective labor induction that every single provider can agree on,” Grobman says. Indeed, the practice appears to vary widely among patients, doctors and hospitals. According to the national figures, for example, labor induction for both medical and nonmedical reasons occurs in 25% of white women but in only 18% of black women and 14% of Hispanic women. And a study published in 2003 in the journal Birth found that the percentage of inductions that were elective varied from 12% to 55% among hospitals and from 3% to 76% among individual doctors.

But some experts say the practice creates unnecessary risks and costs. It can lead to more interventions, such as caesarean sections, and increased use of forceps and vacuum devices to assist in delivery, research has shown. A 2005 study in the journal Obstetrics & Gynecology found that C-sections occurred 12% of the time among women having spontaneous labor compared with 23.4% for women having medically necessary labor induction and 23.8% for women having elective labor induction.

Other studies have found that, compared with spontaneous labor, elective induction leads to longer hospital stays and higher costs. Induced labor also may be more painful because some of the drugs administered to trigger labor can cause more intense contractions.

The risks of C-section or other complications appear highest when induction is performed before 39 weeks and in women who have not had a previous vaginal birth.

Charting a new course

NOW, some hospital administrators are saying, “Enough.” Intermountain Healthcare, which operates 21 hospitals in Utah and Idaho, implemented strict guidelines on elective labor induction eight years ago. Today, the company’s results are held up as a model for reining in birth practices that cannot be medically or financially justified.

The chain, which delivers 53% of all babies in Utah, told its doctors they must seek permission from a supervisor before inducing labor prior to 39 weeks. Doctors must also make sure the cervix is favorable for delivery.

When the cervix is optimal (it must be opened and thinned out enough to allow the baby’s head to pass through the vagina), labor averages about nine hours in a first-time pregnancy, according to Intermountain. If the cervix is not ready, however, an average labor is about 22 hours. The guidelines have reduced rates of elective labor inductions performed before 39 weeks gestation from 28% in 1999 to 3.4% in 2006. The percentage of first-time moms with an elective induction has fallen from 15% in 2003 to 4.7%.

Hospital administrators no longer see sudden spikes in deliveries before major holidays, three-day weekends and Jazz basketball playoff games.

The program has resulted in plunging C-section rates, fewer newborns in intensive care and fewer medical interventions in delivery. Length of labor has decreased by an average of two hours per patient. That’s important, Wilson says, because length of labor is linked to a higher risk of dehydration and infection.

“We feel pretty confident that it does make a difference,” she says.

There is little scientific evidence that labor induction causes any long-lasting harm to mother or baby. But even short-term medical problems are significant given the nation’s healthcare economics crisis, Wilson says. According to Intermountain’s data, healthy deliveries in the 39th week (and women whose cervixes were fully prepared) incur the lowest costs.

“It could be contributing to the double-digit premium increases you pay each year,” she says of elective labor induction’s effect on insurance rates. “Cost is the icing on the cake. But it’s not the main reason we should be doing this. We should do it because it’s safer.”

Trend starts to take hold

OTHER hospitals and provider organizations are also curbing elective labor induction.

Ascension Health Inc., the largest nonprofit healthcare system in the country with facilities in 20 states, last year requested its doctors follow criteria before proceeding with an elective labor induction. The criteria specified that the fetus must be at least 39 weeks in gestational age, in a specific size range and have established lung maturity, and that the mother isn’t already having contractions.

“We don’t discourage elective induction, but there have to be a number of things in place,” says Dr. Robert Welch, chairman and program director of obstetrics and gynecology at Providence Hospital in Southfield, Mich. The goal is not only to reduce C-sections, he says, but to “have zero preventable birth trauma.”

“Some doctors do many elective labor inductions at 38 weeks. But if you do them long enough, eventually you’re going to have a baby with respiratory distress and complications. And that can be very serious.”

Other healthcare organizations and hospitals have applauded the actions taken by Intermountain and Ascension. The Institute for Healthcare Improvement, a nonprofit group based in Cambridge, Mass., that advocates for improved quality in healthcare, and Premier Inc., in Charlotte, N.C., an alliance aimed at improving quality in 1,700 nonprofit hospitals, have also called for lower rates of elective labor induction as a way to reduce harm to infants during childbirth.

Not everyone thinks elective labor induction is harmful. A study published July 31 in the Annals of Family Medicine suggested that “preventive labor induction” may produce the best safety outcomes, including lower C-section rates.

Doctors practicing in a rural Connecticut hospital found that the approach, which includes the use of a mild-acting prostaglandin gel to ripen the cervix before inducing labor, significantly lowered C-section rates compared with women receiving traditional care. Specific criteria were used to determine the “optimal time” for the patient to undergo the preventive induction.

The idea is to perform an induction before the baby gets too big and the placenta can no longer fully support a healthy pregnancy.

If women are carefully selected — based on an accurate due date, fetal maturity and other risk factors — induction may produce the best results, says the study’s author, Dr. James M. Nicholson, assistant professor at the University of Pennsylvania Department of Family Medicine and Community Health.

“Over the last two or three years, there is evidence that if you induce when the cervix is favorable, then induction doesn’t cause adverse outcomes like C-sections,” he says.

The method needs more proof, Nicholson says. He is conducting a randomized, controlled trial at the University of Pennsylvania.

“If this is true, it really could change thoughts on how to manage labor in a big way,” he says. “It would lead to all sorts of different research questions: How to induce, when to induce, is race a factor? The questions are numerous.”

Calls for more study

MANY researchers believe elective labor induction — like elective C-sections — should be submitted to more rigorous research on safety outcomes.

Until then, however, interventions that are performed without an obvious medical need should be viewed skeptically, says Dr. Michael C. Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, who wrote an editorial in the same journal calling the study’s conclusions into question.

“Childbirth is complex,” says Klein, who has studied birth outcomes. “What they are doing is complex, but they are not acknowledging it.”

Klein says the lower C-section rates may be due to the especially attentive and intense care the laboring women in the study received — not because they were induced at an optimal time.

“This is another study saying to women, ‘You can’t survive without us making things better; nature is completely off-track,’ ” says Klein. “And there is a huge reservoir of practitioners out there who want to hear this message.”

Women of childbearing age today also seem to be receptive to the message that a medically managed birth is the best route, says Intermountain’s Wilson.

“We’ve been hammering on this guideline for a long time. It’s hard to get doctors to buy into it,” she says. “Their patients are really putting a lot of pressure on them.”

Despite the lack of research and sometimes conflicting data, women undergoing elective induction should discuss the potential risks and benefits with their doctors, says Wilson.

“I’m not sure consumers think about the risks. They think, ‘Gosh, I want elective induction at 38 weeks because I’m tired of being pregnant,’ ” she says. “Hopefully, educating them up front and setting expectations will make it easier.”

Doctors who want the convenience to schedule daytime deliveries may be the biggest force for elective labor induction, says Lisa Sherwood, a certified nurse midwife and women’s healthcare nurse-practitioner based in San Clemente. Women who “haven’t slept well in weeks, have swollen ankles and sore backs” are vulnerable to the suggestion of elective induction. “People look at the doctor as the expert and will do whatever he or she suggests.”

But, she says, “once you do an intervention, it begets more interventions, and many women feel they are led down a road they didn’t understand. Women tell me, ‘I didn’t know it was going to end up like this.’ Women need to be given all the information on what they are signing up for, not just told, ‘You’re going to have your baby today.’ “

Hayashi turned to Sherwood this year to deliver her second baby after she was informed — in the first trimester — that she would be induced again.

“I think these doctors kind of play bully. They give you the better of two horrible options and say your body can’t do it.”

Her second son was born two weeks after her due date following a spontaneous, four-hour labor.

Codeine linked to breastfeeding danger

Warnings and class action suit follow Toronto neonate’s poisoning death

By Owen Dyer

A class action suit over the death of an apparently healthy Toronto newborn, who died last year from opiate toxicity from breast milk, has renewed the debate over prescribing Tylenol 3 to breastfeeding mothers. After the baby’s death, doctors at Toronto’s Hospital for Sick Children issued a warning that codeine given for postnatal pain can produce deadly concentrations of morphine in breast milk.

Tariq Jamieson was delivered vaginally at full term and healthy weight — everything appeared normal. His mother Rani suffered some lingering pain from an episiotomy so she was prescribed two tablets of Tylenol 3 twice daily — a common pain treatment for mothers who have just given birth. Doctors halved that dose after two days due to constipation and somnolence.

Tariq developed increasing lethargy from the seven-day mark, and at 11 days was brought to a pediatrician due to concerns about his skin colour and poor feeding. He had, however, regained his birth weight. But two days later the family called an ambulance. Responders found the infant cyanotic and lacking vital signs. Attempts at resuscitation failed.

On post mortem, the child was found to have a blood concentration of acetaminophen at 5.9 µg/mL and morphine at 70 ng/mL. That morphine concentration is about six times higher than would normally be considered safe in a neonate.

Tylenol 3 contains 500mg of acetaminophen and 30mg of codeine. Codeine is metabolized to morphine in the body, but not all patients metabolize it at the same rate. Ms Jamieson was genotyped and found to carry three CYP 2D6 genes, which create the enzyme catalyzing the O-demethylation of codeine to morphine. This essentially made her an ultra-rapid metabolizer of codeine to morphine, leading to an unexpectedly fast build-up of the opiate in her breast milk.

EXCEPTIONAL WARNING
This is the first reported case ever of a child dying from opioid poisoning due to a breastfeeding mother’s use of codeine, and it was a fairly exceptional case. Not only did Ms Jamieson have three CYP 2D6 genes, but her husband and baby both had two, making all of them “extensive metabolizers.”

But it is not so exceptional as to be safely ignored. The ultrarapid metabolizer genotype occurs in about 1% of Caucasians, but runs as high as 30% in some African and Asian populations. For every baby whose life is threatened, many others may suffer morbidity, depressed breathing, lethargy or poor feeding. Even two CYP 2D6 genes can lead to unexpectedly high concentrations of morphine in breastmilk.

RISK REDUCTION
The child’s mother, not surprisingly, has said that codeine “should not be used by nursing mothers under any circumstance.” But the experts at the Hospital for Sick Children’s Motherisk program, who still have to deal with maternal pain somehow, are not quite ready to go that far. Instead they suggest sensible approaches to minimize the risk.

There are five strategies available, they suggest. One is simply to avoid using codeine in breastfeeding mothers. But this may leave the mother with uncontrolled pain. Another option is to give the codeine but avoid breastfeeding. No neonatologist, however, is going to recommend stopping breastfeeding at this crucial early stage if it can possibly be avoided.

A middle road is to give codeine, but limit concentrations by not giving a high dosage (240 mg/day codeine) for more than a few days. But the Motherisk team worries that this may not control pain adequately, and could still lead to toxic levels of morphine in the milk of ultrarapid metabolizers.

The ideal solution would be to genotype all mothers then limit codeine only in the cases of fast metabolizers — those with two or three 2D6 genes. Unfortunately this would be very expensive, and few centres currently have the facilities to do it.

That leaves old-fashioned clinical judgement. The mother should be informed of the potential for opioid toxicity, then she and the infant should be monitored closely for danger signs. If symptoms appear, administering naxolone, morphine’s antidote, will generally solve the problem and, in doing so, confirm it.

GUIDELINE REVISIONS
In the longer run, the question of codeine’s safety in breastfeeding mothers will have to be revisited. The American Academy of Pediatrics guidelines on the transfer of drugs into human milk, published in Pediatrics in September 2001, list codeine as a “maternal medication usually compatible with breastfeeding” and report no evidence of symptoms in infants or effect on lactation. It now appears as though that conclusion will have to be revisited, as the Motherisk researchers openly attack the guidelines for overlooking the risk of codeine in breastfeeding “despite lack of sufficient published data to support this recommendation.” Motherisk is now recruiting patients for its own study on the subject.

Science Daily — Researchers at the University at Buffalo and the University of Utah are beginning a clinical trial to test whether aspirin can improve a woman’s chances of becoming pregnant and of maintaining a pregnancy to term.

UB’s portion of the study is funded by a $2.8 million grant from the National Institute of Child Health and Development.

The trial is aimed at women who have miscarried a pregnancy in the past year.

“In women who have had their first miscarriage, the reasons for losing that pregnancy are in many instances unknown,” said Jean Wactawski-Wende, Ph.D., UB associate professor of social and preventive medicine and principal investigator of the UB clinical center.

“These women generally are advised to try to get pregnant again, but health-care providers can offer limited assistance on any specific actions to take to improve their next pregnancy outcome,” she noted. “If aspirin can help some women become pregnant or maintain a health pregnancy, it will be a critically important finding.

“Aspirin is available, inexpensive and has very few side effects,” she added. “We’re hopeful that this trial could produce an important finding.”

Statistics show that in the United States, 10-15 percent of couples trying to become pregnant are not able to conceive, 15-31 percent of pregnancies that do occur end in miscarriage, and 8-15 percent of pregnancies that continue beyond 20 weeks end in premature birth, putting these infants at risk for increased health problems.

Aspirin has been shown to have beneficial effects in humans, said Wactawski-Wende. “It is an anticoagulant and an anti-inflammatory agent. It may aid in implantation of the egg in the uterine wall, and has potential for producing a positive effect on blood flow to the placenta. It may aid in reducing preeclampsia. This clinical trial provides an opportunity to determine the impact of low-dose aspirin on many pregnancy outcomes.”

The Effects of Aspirin in Gestation & Reproduction trial, or EAGeR, will begin this spring and will continue for five years. The UB center will enroll 535 women. Another 1,070 will be recruited by investigators at the University of Utah, for a total enrollment of 1,600 women.

Participants must be between the ages of 18 and 40, have had one miscarriage in the year prior to entering the study, wish to become pregnant and are not already pregnant when they start the study. All will take 400 micrograms of folic acid (a B vitamin shown to reduce the chance of certain birth defects if started early) plus either an 80 milligram aspirin pill or a placebo pill daily.

The women will come to the UB study clinic twice a month for two months and will be followed for an additional four months in the clinic or by telephone. If they become pregnant they will be followed throughout the pregnancy. Participants will take their study pills daily, maintain daily records and provide both urine and blood samples.

Recruitment will begin shortly. “We are thrilled to be able to conduct this trial in Western New York and offer women in our community the opportunity to take part in this important study,” said Wactawski-Wende.

UB consultants include Richard Brown, Ph.D., Maurizio Trevisan, M.D., Moeen Abu-Sitta, M.D., John Yeh, M.D., Dennis Weppner, M.D., Lawrence Gugino, M.D., Ken Crickard, M.D., and Michael Sullivan, M.D.

The University at Buffalo is a premier research-intensive public university, the largest and most comprehensive campus in the State University of New York. The School of Public Health and Health Professions is one of five schools that constitute UB’s Academic Health Center.

Note: This story has been adapted from a news release issued by University at Buffalo.

At least two-thirds of drinking water in the US is Fluoridated, while the figure in Canada is around 38%. Fluoride is added to drinking water at a level of 0.8 – 1 mg/L to prevent cavities. Exposure to these levels of fluoride is not harmful for older children and adults, but in infants who
are in the early stages of dental development it can cause fluorosis. The major source of fluoride exposure for infants is drinking water used to dilute infant formula.

The government of Canada has for some time been aware of the danger of fluorosis to formula fed infants. According to the Ontario Ministry of Health and Long-Term Care, “In Canada, actual intakes [of fluoride] are larger than recommended intakes for formula-fed infants.”
http://www.health.gov.on.ca/english/public/pub/ministry_reports/fluoridation/fluoridation.html

The American Dental Association’s new guidelines support “the pediatricians’ recommendations on the benefits of breast feeding. If using a[n infant formula] product that needs to be reconstituted, parents and caregivers should consider using water that has no or low levels of fluoride.” http://www.ada.org/prof/resources/pubs/epubs/egram/egram_061109.pdf

At 5 to 10 parts per billion, breastmilk has extremely low levels of fluoride. Furthermore, it contains immulogical factors which protect against dental diseases. Risk of fluorosis appears to be yet another reason why formula is hazardous to infant health.

LONDON (AFP) – A British mother could get into the record books after she gave birth to twins and a single baby at the same time — from two wombs — in what is believed to be a world first.

Hannah Kersey, 23, gave birth to the rare triplets — identical twins Ruby and Tilly, and singleton Gracie — by Caesarean section seven weeks prematurely in September.

She was born with a condition called uterus didelphys, which means she developed two wombs, but doctors had warned her that she was unlikely to become pregnant in both.

After their early birth the triplets had to stay in hospital for nine weeks, but are now doing fine at home with Hanna and her partner Mick Faulkner, 23, in Devon in southwest England.

“We are just over the moon at how healthy and happy the girls are,” she said. “They are three lovely and incredible children, all with very different personalities.

“Gracie seems to be the ringleader — maybe because she grew up in her own womb. She is very determined and independent, always wanting her food before the others and to do things first,” she said.

Doctors say there are only 70 women in the world known to have become pregnant in two wombs, and this is the first reported case of triplets.

“This is so rare you cannot put odds on it,” said Ellis Downes, consultant obstetrician at Chase Farm Hospital in London. “I have never heard of this happening anywhere ever before – it is quite amazing.

“Women with two wombs have conceived a baby in each womb before but never twins in one and a singleton in the other. It is extremely unusual.”

Flowers are always nice, but perhaps the best gift you can give a brand-new mom is some quiet time alone with her baby.

Now that hospital visiting hours — not to mention staffing — are 24/7, maternity units are taking steps to minimize interruptions and lower the volume. They recognize that lack of privacy can get breast-feeding off to a rocky start, while lack of sleep might play a role in postpartum depression.

A study in the latest Journal of Obstetric, Gynecologic, and Neonatal Nursing found that women typically experienced dozens of interruptions during their first day after delivering a baby.

Researchers recorded the number and duration of visits and phone calls from 8 a.m. until 8 p.m. for 29 brand-new moms who intended to breast-feed. During that period, the mothers on average experienced 54 visits or phone calls, averaging 17 minutes in length. On the other hand, they were alone with their baby (or their baby and the baby’s father) only 24 times on average, and half of those episodes were nine minutes or less.

“I can remember when I first got into obstetrics, back in the late ’70s, early ’80s, fathers could stay on the floor all the time, and grandparents and siblings were the only ones who could come to visit,” says lead author Barbara Morrison, an assistant professor of nursing at the Case Western Reserve University Frances Payne Bolton School of Nursing. “I think we’ve kind of gone overboard in the other direction.”

Concern about how the hospital environment affects breast-feeding spurred her to do the study, Morrison says. “They need to breast-feed immediately after delivery and then very, very frequently in the first three or four days. They can’t do that if they don’t have private time.”

Mommy ‘nap time’

New moms often feel uncomfortable turning away visitors or hospital personnel so they can focus on breast-feeding, Morrison says.

At Covenant health care, a Saginaw, Mich., hospital that delivers about 3,500 babies a year, nurses are “the bad guys” when it comes to keeping the peace in the maternity unit, says Susan Garpiel, a perinatal and pediatric clinical nurse specialist.

A few years ago, the unit instituted a daily “nap time” from 2 to 4 p.m. For those two hours, the unit dims the lights and discourages — but doesn’t ban — visits by friends, family and staff.

“We wanted to be advocates on behalf of our mothers and babies,” Garpiel says. “Women who are having their first babies don’t realize how much their sleep is impacted with a new baby.”

Covenant patient Pamela Williams, who delivered Maegan, her first child, at 3:19 a.m. last Monday, says visitors began arriving around 8:30 a.m. Williams, 36, an elementary-school principal from Saginaw Township, says she welcomed the chance to nap undisturbed that afternoon. “I needed that time just to relax and refresh. They put a sign on the door: ‘Mom and baby resting,’ which I love. It takes some of the pressure off you.”

Since the establishment of a formal nap time, Garpiel says, “we saw a huge turnaround in terms of breast-feeding problems and moms who were melting down at night.”

By napping with their babies in the afternoon, she says, moms are more likely to keep the newborns with them at night — facilitating frequent breast-feeding — instead of shipping them off to the nursery so they can get some sleep.

New use for the Yacker Tracker

Covenant is one of 46 institutions working with the Institute for health care Improvement, a non-profit organization based in Cambridge, Mass., to improve the care of mothers and newborns during the perinatal period, or around the time of birth. The institute is encouraging all members of its perinatal network to institute “peace and quiet time,” says nurse Sue Gullo, who directs the program.

Gullo came to the institute from Elliot Hospital in Manchester, N.H., where 1:30-2:30 p.m. is nap time in the maternity unit. “You wouldn’t believe what it took to implement it,” she says. “Notifying every department in the hospital that they can’t do their work as usual for one hour just throws people over the edge.” But, says Gullo, “when people understood the reason for doing it, they were totally open to the idea.”

Oklahoma City’s Mercy Health Center, which delivers 3,000 babies a year, has taken a novel approach to keep noise to a minimum in its maternity unit: the Yacker Tracker. The portable device, developed by a teacher to reduce classroom noise levels, looks like a stoplight. Users can set their preferred decibel limits.

“Green means it’s quiet, yellow means you’re starting to get noisy,” explains Cindy Jennings, nurse manager of the Mercy BirthPlace, which also has “privacy please” lights above each patient door.

Some doctors saw red when the Yacker Tracker was first mounted near the BirthPlace nurses’ station earlier this year, Jennings says. But it has worked. Nurses duck behind closed doors if they need to talk. Doctors and visitors have lowered their voices.

“Now we notice it’s a lot quieter than it used to be.”

MONDAY, Dec. 4 (HealthDay News) — Women who are underweight before they become pregnant are 72 percent more likely to suffer a miscarriage in the first three months of pregnancy, according to a study from the London School of Hygiene & Tropical Medicine.

The study of more than 6,600 women, aged 18-55, also found that underweight women can significantly reduce their risk of miscarriage in the first trimester by about 50 percent by taking supplements with folate or iron and by eating fresh fruits and vegetables every day.

Chocolate was also associated with reduced risk of miscarriage in this group of women.

The study is published in the current online edition of BJOG: An International Journal of Obstetrics and Gynecology.

Among the study’s other findings:

• Women who weren’t married or living with a partner had an increased risk of miscarriage.
• Women who had changed partners (for example, after having been pregnant before by a previous partner) had a 60 percent increased risk.
• Previous pregnancy termination increased the risk of subsequent miscarriage by 60 percent.
• Fertility problems were associated with a 41 percent increased risk.
• All types of assisted reproduction were associated with increased risk, particularly intrauterine insemination or artificial insemination.
• Women who said their pregnancies were “planned” had a 40 percent reduced risk of miscarriage.
• Women who had nausea and sickness in the first 12 weeks of pregnancy had about a 70 percent reduced risk.

“Our study confirms the findings of previous studies which suggest that following a healthy diet, reducing stress and looking after your emotional well-being may all play a role in helping women in early pregnancy, or planning a pregnancy, to reduce their risk of miscarriage,” study author Noreen Maconochie, a senior lecturer in epidemiology and medical statistics, said in a prepared statement.

“The findings related to low pre-pregnancy weight, previous termination, stress and change of partner are noteworthy, and we suggest further work be initiated to confirm these findings in other study populations,” Maconochie said.

WASHINGTON – Pregnant women and those who plan to become pregnant should avoid taking the antidepressant Paxil if possible because of the risk of birth defects, a group of obstetricians said Thursday.

The opinion issued by the obstetric practice committee of the American College of Obstetricians and Gynecologists comes nearly a year after the Food and Drug Administration and manufacturer GlaxoSmithKline reclassified the drug to reflect studies in pregnant women that showed the drug poses a risk to the fetus.

Two studies of pregnant women who were taking Paxil during their first trimester have shown that their babies have heart defects at a rate that is as much as twice the norm, the FDA said at the time.

The American College of Obstetricians and Gynecologists also said the decision whether to treat pregnant women with SSRIs, a class of antidepressants that includes Prozac, Zoloft and Lexapro as well as Paxil, should be considered on an individual basis.

Exposure to SSRIs late in pregnancy has been associated with short-term complications in newborns, the doctors said.

However, reproductive-age women have the highest prevalence of major depressive disorders. The benefit to the mother of treatment with any of the drugs may outweigh the risk to the fetus.

The opinion appears in the December issue of the journal Obstetrics & Gynecology.

ANN ARBOR, Mich.—Doula work delivers love, not money.

In the first known national study of doulas, University of Michigan researchers found that while 96 percent of doulas find their work rewarding on a personal or emotional level, only one out of three find their work rewarding financially. The average gross annual income of a certified doula in 2002 was $3,645.

The word doula is from the ancient Greek term for woman servant or woman helping another woman. Today it’s used to describe an increasingly popular paraprofession as a supportive caregiver during childbirth.

The use of family members or friends helping women with childbirth declined in Western countries as women turned to hospital delivery rooms. But now, for a fee, certified doulas are part of maternity care teams. About 5 percent of women giving birth in the United States used a doula in 2002, and they are part of a movement that includes midwives, childbirth education and family birthing rooms—all aiming to humanize the birth experience, said Paula Lantz, lead author of a study appearing in the new issue of the journal Women’s Health Issues.

Lantz noted that more than a dozen studies have shown that providing continuous emotional support during childbirth can reduce the length of labor and need for interventions such as forceps and caesarean sections.

“Historically, it’s interesting that doulas are emerging as another way to push back against the medicalization of childbirth,” said Lantz, associate professor of health management at policy at the U-M School of Public Health.

With assistance from five professional doula associations that certify doulas, Lantz and her collaborators surveyed about 1,000 doulas nationwide, focusing on those who are certified through the associations or who have begun the certification process.

Among their findings about doulas:

• Most doulas are white—93.8 percent—with an average age of 40 years. Most are married women who have given birth before.

• About one-half said they had a college degree or more, and about 30 percent of them have a household income of $75,000 a year or more.

• About three quarters of doulas have paid jobs other than their doula practice, working an average of about 25 hours at those jobs.

• The vast majority are in solo practice, with an average number of 60 clients served during their time as doulas. They help an average of nine clients a year deliver babies.

About one quarter of respondents said they were planning to become a midwife in the future, indicating that being a doula might be a transitional career for them.

Lantz said several things point to challenges for the growth of doulas, including the prevalence of doulas planning to go on to be midwives and the low pay of the job, making it something women might choose as a second job or while they take care of their own children.

“It is likely that doula work will not become more financially lucrative or appealing unless more people are willing to pay for these services and/or third-party reimbursement becomes more common,” the authors wrote in their article.

Only 10 percent of doulas reported having been paid by third party, usually for having provided “labor support” or “prenatal education.”

In addition, many doulas report that they do not feel supported by physicians, and there are some debates regarding what doulas should and should not do with their clients, Lantz said.

Doulas are not supposed to provide medical care. They focus on continuous emotional support to clients, giving help with positions and breathing, words of encouragement, and massage during labor.

Lantz’s co-authors are Sanjani Varkey and Robyn Watson at the School of Public Health, and Lisa Kane Low, with joint appointments in the School of Nursing and the Women’s Studies Program.

The research was funded in part by a $25,000 grant from the Walter McNerney Fund at the University of Michigan.

For more on Lantz

Women’s Health Issues

U-M School of Public Health

Doula associations that participated in the study:

Association of Labor Assistants and Childbirth Educators

Birth Works

Childbirth and Postpartum Professional Association

DONA International

International Childbirth Educators Association