Alcohol, caffeine, soft boiled eggs, liver, raw meats and blue cheese: all foods pregnant women are advised to avoid because of potential risks to their unborn children. But what of foods women consume, or chemicals they come into contact with, that have a less immediate impact, where the damage might not become obvious until many years down the line? 300,000 women from across Europe are to take part in a project involving the Leeds Institute of Genetics, Health and Therapeutics (LIGHT), to look at the ‘unseen’ effects of food and chemicals on the unborn child.

The €15m NewGeneris study will look for changes to DNA and proteins, which are signs of an increased risk of cancer or immune disorders such as eczema or asthma in later life. Women and their newborn children from Denmark, Norway, Greece and Spain as well as 10,000 women from Bradford will be taking part. The aim of the five-year project is to come up with more effective food regulations and clear public health messages about what constitutes safe levels of chemical exposure for women during pregnancy.

Heading the research at Leeds is LIGHT acting director, Professor Chris Wild: “We know very little about how sensitive the child is to the environment when it’s in the womb and shortly after birth. A review of existing research, recently highlighted in the Guardian, confirmed that there is some evidence that the young are more sensitive than adults, so what might be a safe level of exposure for an adult might not be for a child. However, no conclusive link has yet been made and we hope that this study will finally do that.”

The women will have blood and urine samples taken and fill in questionnaires on their diet, lifestyle and habits and the environment in which they live. Following the birth, a blood sample will also be taken from the placenta to determine which chemicals have crossed from the mother to the child.

The target toxic chemicals include those found in processed or contaminated food, air pollution, tobacco smoke and alcohol: polycyclic aromatic hydrocarbons, heterocyclic amines, nitrosamines, acrylamide, mycotoxins, dioxin, polychlorinated biphenyls (PCBs) and ethanol.

Professor of Biochemistry, John Findlay said: “What we’re looking for are things called ‘biomarkers’ to show where chemical exposure has occurred: changes to DNA and proteins that are indications of damage, and damage can mean an increased risk of disease.”

An expert in proteomics – the analysis of how proteins function in our bodies – Professor Findlay will be working with blood samples from across Europe. From each sample, the proteins will be isolated and analysed using new software originally developed by astrophysicists to look at the patterns of stars. This software highlights changes in the distribution and density of the proteins and then the individual ‘damaged’ protein can be identified. “It’s a long process which will need to be carried out with a huge number of samples,” said Professor Findlay.

There’s a lot of variance across different individuals but we’ve got to look beyond this to identify minute changes that are outside what’s ‘normal’. The sheer numbers involved in this study and the fact that the samples come from many different countries will increase this variability and make it bigger than anything we’ve tackled before.”

But this complex molecular analysis is only one part of the project. The results from the samples from both mother and child will be linked by epidemiologists, including Professors Patricia McKinney and Janet Cade, to the information gathered from the volunteers about their environment and lifestyles, to see where exposure is translated into biological changes which predict disease.

Professor Wild and his team will be looking particularly for which environmental chemicals in the mother are able to cross the placenta, and whether or not the foetus transforms these chemicals into a more toxic form that results in damage to DNA.

With 10,000 volunteers to be recruited in the Born in Bradford part of the project over the next few years, the researchers also hope to follow those children through, to see how their growth and development can be linked back to the early stage ‘biomarkers’ found in the lab. The Leeds end of the project is worth ВЈ1.6m.

“It’s rare to see one research project go from molecular analysis through to a practical clinical or public health application in this way, but this is exactly the kind of thing LIGHT was set up to achieve”, says Professor Wild.

“The institute brings together researchers from medicine, biological sciences, epidemiology and biostatistics. Our work combines basic science with population-based and clinical research to enable a fast transfer of knowledge from the laboratory both to intervention strategies in populations and improved treatment in the clinic. It’s this multidisciplinary approach as well as the state-of-the-art facilities in the LIGHT laboratories that enable us to take a leading role in this important European project.”

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For more information, see the following:
env-health/a/2038
euractiv/Article?tcmuri=tcm:29-152907-16&type=News

Contact: Hannah Love
h.e.b.loveleeds.ac
University of Leeds

A single nutrient found in soy products elicits changes in gene behavior that permanently reduce an embryo’s risk of becoming obese later in life, according to an animal study at Duke University Medical Center.

The findings, yet to be confirmed in humans, could explain why Asians have lower rates of obesity and cancer, said the Duke researchers. Asians consume large amounts of soy, which has been linked to lower rates of breast, endometrial and prostate cancer, among other health benefits.

In the Duke study, pregnant Agouti mice that ate a diet rich in genistein, an active ingredient in soy, gave birth to pups that stayed slimmer as adults. Mice that did not receive genistein in utero were much heavier as adults – double the weight of their genistein-fed counterparts. Prenatal genistein also shifted the offspring’s coat color from yellow to brown, demonstrating that a single nutrient can have a widespread systemic impact, said the researchers.

Genistein’s effect occurred early in pregnancy, the equivalent of eight gestational days in humans. The Duke scientists said their results lend support to the “developmental origins of adult disease” hypothesis, in which an individual’s long-term health is influenced by prenatal factors.

Results of the study, funded by the National Institute of Environmental Health Sciences and the National Cancer Institute, are published in the April 1, 2006, issue of the journal Environmental Health Perspectives.

“We are increasingly finding that our parent’s and even our grandparent’s nutritional status and environmental exposures can regulate our future risk of disease,” said Randy Jirtle, Ph.D., professor of radiation oncology and senior author of the study. “In other words, it may not only be the hamburgers and fries we are eating, but also what our parents consumed or encountered in the environment that predisposes us to various conditions.”

Jirtle said a mechanism called DNA “methylation” is increasingly identified as the trigger for environmentally-caused gene alterations. During this process, a person’s exposure to chemicals, nutrients, or even a behavioral experience such as nurturing can elicit a change in how a specific gene behaves – but without altering the genetic sequence in any way.

Rather, the exposure or event prompts a quartet of atoms or “methyl group” to attach to the regulatory region of a gene, where it acts as a switch to activate or silence the gene. Such an effect is called “epigenetic” because it occurs over and above the gene sequence without altering any of the letters of the gene’s four-unit code, said Jirtle. Micronutrients can change the extent of DNA methylation by directly donating methyl groups or by altering the efficiency by which DNA methylation is modified, said Jirtle.

In the current study, maternal dietary genistein caused a single mouse gene called “agouti” to become methylated at six specific sites near its regulatory region, thereby reducing the gene’s expression. The agouti methylation consistently occurred throughout several germ layers of embryonic tissue, indicating that genistein acted during early embryonic development. Moreover, the methylation changes persisted into adulthood, providing the first evidence that in utero dietary genistein alters epigenetic gene regulation, coat color, and susceptibility to adult obesity in animals.

The agouti gene is not epigentically regulated in humans as it is in the Agouti mouse, said Jirtle. But soy’s potential benefits could exert themselves through other human genes whose expression is altered by DNA methylation, he said.

“Methylation is a common event in the human genome, and it is a highly malleable effect that occurs during rapid periods of development, but it can also occur in childhood and even in adulthood,” he said.

Because many infants receive soy milk, the impact of genistein in humans should be carefully assessed, he said. Pregnant women are exposed to hundreds of compounds in foods, prenatal vitamins and the environment that could potentially methylate susceptible genes, he said. The effects of each compound could be beneficial or detrimental, depending upon the timing of exposure, the dose and the tissue exposed, said Jirtle.

“Our study demonstrates there are highly sensitive windows early in development when environmental exposures can permanently alter the offspring’s adult susceptibility to disease,” said Jirtle. “Therefore, we need to examine the effect of environmental exposures during pregnancy, not just in adulthood, if we want to accurately assess their risk or benefit to humans.”

His earlier research demonstrated that four common nutritional supplements fed to pregnant mice, including folic acid and vitamin B12, lowered their offspring’s susceptibility to obesity, diabetes and cancer by methylating the same agouti gene. Yet how nutrients interact in combination or in extremely high doses remains unclear, he said.

“There could be additive or synergistic effects between folic acid and genistein, or any such compounds, that hypermethylate certain genes,” said Dana Dolinoy, MPH, lead author of the study. “What is good in small amounts could be harmful in large amounts. We simply don’t know the effects of literally hundreds of compounds that we intentionally or inadvertently ingest or encounter each day.”

Of related concern, soy is a staple of almost all laboratory mouse diets. Soy could inadvertently methylate select genes and thus mask the deleterious effects of various chemicals being tested for their risk in humans, she said.

“In the future, we may be able to potentially select compounds to protect a person from being predisposed to developing a variety of conditions,” said Jirtle. “There is a vast, unknown potential for studying how our environment interacts with our epigenome to determine how we developed and who we will become.”

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Contact: Becky Levine
levin005mc.duke.edu
Duke University Medical Center

An independent panel convened by the National Institutes of Health announced today that the available information comparing the risks and benefits of Caesarean delivery on maternal request (CDMR) versus planned vaginal birth do not provide the basis for a recommendation in either direction.

The panel defined CDMR as a Caesarean delivery for a pregnancy with a single baby at the mother’s request when she has no established medical indication for the procedure. CDMR is a subset of elective Caesarean delivery, and distinct from both emergency Caesarean delivery and Caesarean performed following attempted vaginal delivery.

Potential benefits of CDMR as compared with planned vaginal delivery include a decreased risk of hemorrhaging for the mother, and a reduced risk of certain birth injuries for the baby. Potential risks of CDMR include an increased risk of respiratory problems for the baby and a longer maternal hospital stay.

The panel added that each woman requesting CDMR deserves individualized counseling regarding the potential risks and benefits of both vaginal and Caesarean delivery. When counseling patients, providers should also consider such factors as societal and cultural conventions, ethical issues, available resources, and other factors pertaining to the individual patient.

Panel members did find evidence to suggest caution in certain situations. They concluded that CDMR should be avoided for women desiring large families. This is because the risk of serious complications for subsequent pregnancies increases with each additional Caesarean delivery.

The panel further stressed that CDMR should not be performed before the 39th week of pregnancy or without verification that the fetus’ lungs have matured sufficiently to avoid newborn respiratory complications.

In its report, the panel also expressed concern that a woman might choose a Caesarean delivery because effective pain management would not be available at the facility in which she would give birth.

“CDMR should not be motivated by unavailability of effective pain management,” the panel wrote. “Efforts must be made to assure availability of pain management services for all women.”

To address the weaknesses they identified in the available scientific literature, the panel made a variety of recommendations for future research, including:

* Surveys of women (before and after birth), providers, insurers, and health care facilities regarding CDMR,
* Development of strategies to predict and influence the likelihood of successful vaginal birth,
* Establishment of uniform documentation of CDMR, to accurately reflect prevalence of the procedure,
* Examination of existing large databases to assess incidence of various complications, including rare but critical outcomes, and
* A thorough assessment of the costs of CDMR.

The panel released its findings this morning, following two days of expert presentations and panel deliberations. Full text of the panel’s draft state-of-the-science statement will be available late today at consensus.nih/. The final version will be available at the same Web address in three to four weeks. Statements from past conferences and additional information about the NIH Consensus Development Program are also available at the Web site, or by calling 1-888-644-2667.

The 18 members of this State-of-the-Science panel were nominated for selection by peers who were confident that these individuals’ areas of expertise would significantly contribute to the process of critically examining scientific evidence on Caesarean section on maternal request. The panel included educators, researchers, statisticians, and practitioners in obstetrics and gynecology, preventive medicine and biometrics, family planning and reproductive physiology, nurse midwifery, anesthesiology, patient safety, epidemiology, pediatrics, perinatal medicine, urology, urogynecology, general nursing, inner city public health sciences, law, psychiatry, and health services research. The panel was chaired by Mary D’Alton, M.D., chair of the Department of Obstetrics and Gynecology at Columbia University Medical Center and Chief of Obstetrics and Gynecology at the New York-Presbyterian Hospital.

In addition to the material presented at the conference by speakers and the comments and concerns of conference participants presented during discussion periods, the panel considered pertinent research from the published literature and the results of a systematic review of the literature commissioned by the NIH Office of Medical Applications of Research (OMAR). The systematic review was prepared through the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program, at the RTI International-University of North Carolina Evidence-based Practice Center. The EPCs develop evidence reports and technology assessments based on rigorous, comprehensive syntheses and analyses of the scientific literature, emphasizing explicit and detailed documentation of methods, rationale, and assumptions.

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The panel’s statement is an independent report and is not a policy statement of the NIH or the federal government. The NIH Consensus Development Program, of which this conference is a part, was established in 1977 as a mechanism to judge controversial topics in medicine and public health in an unbiased, impartial manner. NIH has conducted 118 consensus development conferences, and 26 state-of-the-science (formerly “technology assessment”) conferences, addressing a wide range of issues. A backgrounder on the NIH Consensus Development Program process is available at consensus.nih/forthemedia.htm.

The conference was sponsored by the Office of Medical Applications of Research (OMAR) and the National Institute of Child Health and Human Development (NICHD). Cosponsors included the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the Office of Research on Women’s Health (ORWH), and the National Institute of Nursing Research (NINR).

Note to Radio Editors: An audio report of the conference results will be available after 5:00 p.m. today from the NIH Radio News Service by calling 1-800-MED-DIAL (1-800-633-3425) or visiting nih/news/radio/index.htm.

The National Institutes of Health (NIH)–The Nation’s Medical Research Agency–is comprised of 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary Federal agency for conducting and supporting basic, clinical, and translational medical research, and investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit nih/.

Contact: Kelli Marciel
marcielkod.nih
NIH/National Institutes of Health, Office of Disease Prevention

More than one-fourth of all first-time mothers in the United States deliver their babies by cesarean section, and the recent rise in the nation’s C-section rate can’t be attributed to rising risk factors among mothers.

Using national birth certificate data from 1991 through 2002, researchers analyzed both the overall C-section rate as well as the primary rate for first-time mothers. While the primary C-section rate actually dropped between 1991 and 1996, it shot up in the remaining study years, accounting for about 53 percent of all C-sections. As concerns about the safety of vaginal births after C-section rose, overall C-section rates rose as well. The increasing rate was not attributed to higher risk factors among mothers.

The study’s author said growing restrictions on VBACs, coupled with the current rise in primary C-sections, will result in “a large cohort of women in which repeat cesareans will become the norm.

“More research is needed into the causes of these trends since the growth in primary cesareans combined with increasing restrictions on vaginal birth after cesareans will lead to a continuation and likely acceleration of the current growth in the overall cesarean rate in the U.S.”

[From: "The Rise in Primary Cesarean Births in the U.S., 1991- 2002: Changing Risk Profiles or Changing Practice?" Contact: Eugene R. Declercq, Boston University School of Public Health]

The American Journal of Public Health is the monthly journal of the American Public Health Association, the oldest organization of public health professionals in the world. APHA is a leading publisher of public health-related books and periodicals promoting high scientific standards, action programs and policy for good health.

More information is available at apha.

Inaccurate or misleading headlines and reporting about the recent NIH panel on cesarean delivery for maternal request will exacerbate the harm unnecessary surgery causes women, said the American College of Nurse-Midwives (ACNM) today. Coverage of the event by several major media organizations — including The Washington Post, NBC’s Today and Nightly News programs, and others — presented women with a distorted view of the National Institute of Health’s State of the Science findings, released yesterday. Such reporting precludes a thorough understanding of the complexity of this decision. In addition, the story is incomplete if it ignores recommendations regarding appropriate ethical behavior for health care professionals. Members of the panel stated repeatedly that because the evidence on the risks and benefits is so weak, doctors should not be asking women if they want this surgery.

The NIH conference report covers twenty-four outcomes for mothers and babies. In the case of twenty-one of those outcomes, the available evidence is labeled as weak-quality or absent. In the case of three of the outcomes, the evidence is labeled as moderate-quality. In the quality rating used by the panel, no evidence was deemed to be strong. The panel did make two important clinical recommendations: one is that cesarean delivery on maternal request is not recommended for women desiring several children, and the other is that the surgery should not be performed before 39 weeks, or without verification of lung maturity.

While ACNM believes it is appropriate for the panel to recognize that difficult surgical decisions must be individualized, new Listening to Mothers national survey data just released by Childbirth Connection reported that nearly 10 percent of survey respondents reported feeling pressure from health professionals to have a cesarean delivery. In the same survey, the majority indicated that it is necessary to know every possible complication before consenting to a cesarean section, yet the data also revealed that respondents were poorly informed about specific complications of cesarean section. The Listening to Mothers survey conducted by Harris Interactive is the only national survey to report mother’s views and experiences with cesarean section. These results raise serious concerns about the adequacy of current informed consent processes for this major surgical procedure.

Health care professionals report that it is not unusual to find women who believe that cesarean delivery offers protection from problems with incontinence. The NIH report found only weak-quality evidence to support cesarean section as an appropriate approach to avoid urinary incontinence or other complications related to sexual function or bowel/bladder control.

“As long as we do not know if cesarean delivery on maternal request is the safest option, and we do know that a scarred uterus increases the risk of serious complications with subsequent pregnancies, it is not sound medical practice to do anything that encourages this option,” said Deanne R. Williams, CNM, MS, ACNM executive director. “As health care professionals, who might be asked to help women consider these options, we must remember that women often change their minds about their plans for future pregnancies.”

Better coverage – balanced reporting that offers a clear view of the NIH’s findings – can be found in newspaper articles in USA Today, wire service reports such as from the Associated Press, and broadcast reports such as on National Public Radio. Health care professionals are likely to be deluged with calls from women who are reading or viewing misleading news reports, and ACNM encourages those professionals to direct women to more appropriate and informative sources of information.

Based on the NIH’s findings yesterday, women need to seek out clear and understandable resources that can help them make an informed decision. Resources are available from organizations such as Childbirth Connection and Lamaze International, and ACNM encourages women, as well as media outlets working on this issue, to consider that information seriously.

With roots dating to 1929, the American College of Nurse-Midwives is the oldest women’s health care association in the U.S. ACNM’s mission is to promote the health and well-being of women and newborns within their families and communities through the development and support of the profession of midwifery as practiced by certified nurse-midwives and certified midwives. Midwives believe every individual has the right to safe, satisfying health care with respect for human dignity and cultural variations. More information about ACNM can be found at midwife.

American College of Nurse-Midwives
8403 Colesville Road, Suite 1550
Silver Spring, MD 20910-6374

ACNM 51st Annual Meeting & Exhibit
May 26 – June 1, 2006 – Salt Lake City, Utah

midwife

U.S.-born Asian-Indian women are more likely than their Mexican-American peers to deliver low birth weight infants, despite having fewer risk factors, say researchers at Lucile Packard Children’s Hospital and Stanford’s School of Medicine. The finding confirms previous research that showed a similar pattern in more recent immigrants, and suggests that physicians should consider their patients’ ethnic backgrounds when planning their care.

“Now we see that the daughters of foreign-born women have similar issues,” said Packard Children’s neonatologist Ashima Madan, MD, “and that the indicators we have traditionally used to predict pregnancy outcomes – maternal educational level and age, and access to early prenatal care, for example – aren’t reliable for every population.” Madan is the lead author of the research, published in the March issue of the Journal of Pediatrics.

Researchers call the previously identified differences in pregnancy outcomes between Indian and Mexican immigrants the “dual paradox.” That’s because Mexican women giving birth in the United States are more likely than women from India to have healthy-sized newborns, even though they are less likely to have completed high school or to have initiated prenatal care during the first trimester of their pregnancy. In contrast, newborns of Indian immigrants, most of whom have completed college and begun prenatal care early, are more likely to deliver a low birth weight infant.

Madan, associate professor of pediatrics at the medical school, and her colleagues set out to determine for the first time whether this pattern persisted in the U.S.-born daughters of these immigrants. They surveyed more than 6 million births that occurred in 11 states between 1995 and 2000 to white, foreign and U.S.-born Asian-Indian and Mexican women. In addition to collecting data about the mother’s birthplace and ethnic group, the birth records documented maternal age, history of prenatal care, maternal use of alcohol or tobacco, maternal educational level, and common complications of pregnancy and labor.

They found that Asian-Indian women were more than twice as likely to have low birth weight infants as were white women. These infants weigh 2,500 grams (about 5.5 pounds) or less at birth, either because they grew poorly in the womb or were born prematurely. They were also more than twice as likely to have babies that were small for their gestational age, regardless of whether they were premature. In other words, a generation in America didn’t significantly improve or worsen the outcome for the Asian-Indian infants.

In contrast, although infants of foreign-born Mexican-American women closely mirror white infants in weight, the infants of U.S.-born Mexican-American women didn’t fare as well, despite the fact that their mothers were more likely to have completed high school and tended to initiate prenatal care earlier. But even though they were more likely to be premature or smaller than infants of foreign-born Mexican-American mothers, they still weighed more, on average, than the infants of Asian Indians.

“You might ask, ‘What’s so bad about being small?’” said Madan, who points out that the growth curves used for this and other similar studies are based on white infants. “Is this just normal for Asian Indians? But we’re concerned because we know that abnormally small babies run a higher risk of fetal distress and often require more intensive medical care and longer hospital stays after birth.”

In addition, unusually small babies are known to be at higher risk for a variety of medical problems in adulthood, including diabetes, hypertension and an increased risk of heart disease – conditions that some studies have reported to be higher in Asian Indians.

Madan and her colleagues speculate that, among other things, maternal birth weight, stress, attitudes toward pregnancy and family support or other biological risk factors may play a role in fetal growth. In addition, Indian mothers were more likely than either Mexican Americans or whites to have diabetes, which in severe cases can restrict fetal growth.

“Our findings point out how much more we have to learn about fetal growth and well-being,” said Madan. “Hopefully by continuing to study these populations we may identify new interventions that improve perinatal outcomes for women of all ethnic backgrounds.”

The paper’s senior author is Jeff Gould, MD, professor of pediatrics. Other researchers from the Stanford Prevention Research Center include instructor Latha Palaniappan, MD; research associate Guido Urizar, PhD; Yan Wang; and Stephen Fortmann, MD, professor of medicine.

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PRINT MEDIA CONTACT: Krista Conger at (650) 725-5371 (kristacstanford.edu)
BROADCAST MEDIA CONTACT: Robert Dicks at (650) 497-8364 (rdickslpch)

Stanford University Medical Center integrates research, medical education and patient care at its three institutions – Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children’s Hospital at Stanford. For more information, please visit the Web site of the medical center’s Office of Communication & Public Affairs at mednews.stanford.edu/

Ranked as one of the nation’s top 10 pediatric hospitals by U.S. News & World Report, Lucile Packard Children’s Hospital at Stanford is a 264-bed hospital devoted to the care of children and expectant mothers. Providing pediatric and obstetric medical and surgical services and associated with Stanford School of Medicine, Packard Children’s offers patients locally, regionally and nationally the full range of health-care programs and services – from preventive and routine care to the diagnosis and treatment of serious illness and injury. For more information, visit lpch/

Contact: Krista Conger
kristacstanford.edu
Stanford University Medical Center

Panelists at the National Institutes of Health (NIH) State-of-the-Science Conference on elective cesarean surgery (March 27-29 in Bethesda, Md.) determined that the quality of the existing research about long-term effects of elective cesarean is “weak.” Lamaze International agrees that the research NIH examined is weak; however, their research also did not consider many recognized long-term adverse outcomes associated with cesarean surgery and they did not take into account the impact that avoidable obstetric practices can cause during vaginal birth. Failure to include these factors in the review of existing research renders their guidance to women and clinicians incomplete and inadequate.

According to the NIH panel’s review of the existing research, long-term effects of elective cesarean surgery include subsequent infertility, as well as placenta previa (placenta attaches near or over the opening to her cervix), uterine rupture and/or stillbirth in future pregnancies. The NIH panel did not address future fetal or neonatal risks other than stillbirth.

A recent independent review of the research by Lamaze International found that cesarean surgery, including elective surgery, also is associated with a higher risk of hysterectomy, cesarean-scar ectopic pregnancy (pregnancies that develop outside the uterus or within the scar), surgical adhesions that may contribute to serious future surgical injuries or cause bowel obstruction and chronic pain, wound pain beyond six months, and birth of a preterm or “small for gestational age” baby in a future pregnancy.

Furthermore, conventional obstetric management may contribute to poor outcomes of vaginal birth including hemorrhage, pelvic floor disorders, sexual dysfunction and unplanned cesarean surgery in labor. For instance, continuous electronic fetal monitoring (EFM) has not been found to improve outcomes for low-risk mothers or babies, but routine use is associated with a higher rate of cesarean surgery in labor. Despite this body of research, continuous EFM is used in 89 percent of labors in the United States.

Pelvic floor disorders, such as incontinence and sexual dysfunction, are most often attributable to obstetric interventions during vaginal birth, rather than vaginal birth itself. In fact, routine episiotomy has not been found to improve maternal or newborn outcomes, but is linked to pain, pelvic floor injury and sexual dysfunction. According to a 2002 survey conducted by Childbirth Connection (formerly Maternity Center Association), 35 percent of women who gave birth vaginally had episiotomies. Unnecessary, forceful staff-directed pushing also contributes to a higher incidence of pelvic floor disorders.

“Any researcher who wishes to evaluate the safety of elective cesarean surgery must use a study design that includes long-term outcomes, including effects on subsequent pregnancies,” said Lamaze International President Raymond De Vries, PhD. Future studies must also compare elective cesarean surgery to normal vaginal birth, or, at a minimum, control for the effects of harmful obstetric practices used routinely in hospitals. When elective cesarean surgery is compared to a style of obstetric management that has been shown to be harmful – including unnecessary episiotomies, forceps and vacuum deliveries – it gives the false appearance of equivalent risk between surgical and vaginal birth.

Lamaze International has developed evidence-based documents about the Six Care Practices that Support Normal Birth : 1) labor begins on its own (avoidance of unnecessary induction of labor), 2) freedom of movement throughout labor , 3) continuous labor support , 4) no routine interventions , 5) non-supine (upright or side-lying) positions for birth , and 6) no separation of mother and baby with unlimited opportunity for breastfeeding. Available research suggests that these care practices contribute to optimal outcomes for both mother and baby and are associated with high satisfaction among childbearing women. However, all six care practices are used in very few maternity care settings.

“Ideally, when making personal decisions about medical care, including routine interventions, women clarify their desires and expectations, discuss alternatives, access and understand best evidence as well as gaps in the research, continue discussions with their caregiver, and then make a personal decision,” says Judith A. Lothian, RN, PhD, LCCE, FACCE, author of The Official Lamaze Guide: Giving Birth with Confidence .

Lamaze International, based in Washington, DC, envisions a world of confident women choosing normal birth. For more information about Lamaze and the Institute for Normal Birth, visit www.lamaze.

Current available evidence comparing the risks and benefits of elective caesarean sections with vaginal deliveries is not sufficient to recommend one procedure over the other, according to an NIH draft report released on Wednesday, the Washington Post reports (Stein, Washington Post, 3/30). NIH on Monday opened a three-day meeting that aimed to determine what is known about the dangers and advantages of pre-planned c-sections and how to ensure that pregnant women receive appropriate information about the procedure (Kaiser Daily Women’s Health Policy Report, 3/28). A panel of 18 independent experts defined an elective c-section as “a [c]aesarean delivery for a pregnancy with a single baby at the mother’s request when she has no established medical indication for the procedure,” according to an NIH release (NIH release, 3/29). “Limited evidence suggests that [elective c-section] is increasing, but it is unclear why,” the panel wrote in the report, estimating that elective c-sections account for 4% to 18% of all c-sections performed in the U.S. (Rubin, USA Today, 3/30).

Risks, Benefits of C-Section, Vaginal Delivery
According to the report, elective c-sections substantially increase the risk of a life-threatening placenta complication in a later pregnancy and thus should be avoided by women planning to have multiple children, the AP/Forbes reports. C-sections also can increase an infant’s risk of respiratory problems and doctors should perform an elective c-section only if the fetus’ lungs are fully developed, the report says (Neergaard, AP/Forbes, 3/29). The benefits of c-section compared with vaginal delivery include reduced risk of hemorrhaging and certain birth injuries. The panel wrote that women “should not be motivated by unavailability of effective pain management” when deciding to have an elective c-section, adding, “Efforts must be made to assure availability of pain management services for all women” (NIH release, 3/29). If a pregnant woman requests a c-section, the health provider should counsel her on both risks and benefits, the panel said (CQ HealthBeat, 3/29).

Recommendations
The panel included several recommendations for further research to address the lack of information on elective c-sections, including:
Conducting surveys of women, providers, insurers and health care facilities before and after delivery regarding the procedure;

Creating plans to foresee the chances of a vaginal delivery without complications;

Developing accurate records of the procedure;

Evaluating existing databases to calculate previous incidences of complications and unsuccessful outcomes;

Assessing costs of the procedure (NIH release, 3/29); and

Establishing a Web site to offer information on all types of deliveries (Talan, Long Island Newsday, 3/30).

Reaction
“We don’t believe [c-sections] should be discouraged or encouraged,” Mary D’Alton, obstetrics chief at Columbia University Medical Center, who chaired the panel, said (AP/Forbes, 3/29). Some health advocates hailed the report for providing women with choices in how they deliver their infants, while opponents who say c-sections are risky and overused refuted the report (Washington Post, 3/30).

Newsweek Examines Increased Number of Elective C-Sections, Risks Associated With Procedure
Newsweek in its April 3 edition examines how c-sections, in spite of the associated risks, have “increasingly become a matter of choice, not necessity.” Even though fewer than one in 10 c-sections is elective, the trend of scheduling c-sections because of convenience for the pregnant woman or fears associated with vaginal birth has “alarmed many” health professionals, Newsweek reports. Although the procedure, similar to any abdominal surgery, has risks — including infections and bleeding — there is controversy over how much risk is involved, according to Newsweek. Duane Alexander, a presenter at this week’s NIH conference, said, “There are a lot of myths out there we hope to replace with strong scientific evidence” (Barrett, Newsweek, 4/3)

Several broadcast programs reported on the increasing number of elective c-sections:
ABCNews’ “World News Tonight”: The segment includes comments from Rebecca Brightman, OB/GYN at Mount Sinai School of Medicine, and a woman who had an elective c-section (McKenzie, “World News Tonight,” ABCNews, 3/29). A related ABCNews story is available online. The complete segment is available online. Video of an expanded interview with Brightman is available online. In addition, video of an interview with Stephen Emery, OB/GYN at the Cleveland Clinic, is available online.

NBC’s “Nightly News”: The segment includes comments from D’Alton and a woman who had an elective c-section (Bazell, “Nightly News,” NBC, 3/29). The complete segment is available online in Windows Media.

NPR’s “Morning Edition”: The segment includes comments from Michael Klein, family physician at the University of British Columbia; James Nicholson, a physician who attended the conference; and women who have planned or have had elective c-sections (Aubrey, “Morning Edition,” NPR, 3/30). The complete segment is available online in RealPlayer.

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

The circumstances around their dying – and not the location – are what matter most to terminally ill Canadians, says Queen’s University Professor of Medicine Daren Heyland.

A national study on end-of-life care led by Dr. Heyland, research director in the Department of Medicine at Kingston General Hospital, shows that patients rated dying at home as less important than having confidence and trust in the doctors looking after them. The results may cast doubt on current efforts to support more patients dying at home, says Dr. Heyland. At present, seven out of every 10 Canadians die in hospital.

Results of the study are published in the current edition of the Canadian Medical Association Journal (CMAJ).

Also on the research team from Queen’s are Sam Shortt (Centre for Health Services and Policy Research), Joan Tranmer (School of Nursing) and Miu Lam (Community Health and Epidemiology).

Conducted between 2001 and 2003 in hospitals in Kingston, Vancouver, Halifax, Toronto and Edmonton, the survey involved 434 seriously ill elderly patients and 160 family members. Out of 28 factors describing quality care, patients and family members rated “to have trust and confidence in the doctors looking after you” and “not to be kept alive on life supports when there is little hope for a meaningful recovery” as most important.

“To be able to die in the location of your choice, e.g. home or hospital” rated 24th of 28 from the patient’s perspective and 14th of 26 from the family member’s perspective.

Dr. Heyland heads a national research group on palliative and end-of-life care initiatives located at Queen’s and McMaster, with affiliates at other Canadian universities and hospitals. Funded by the Canadian Institutes of Health Research (CIHR), the five-year project began in 2004 and focuses on care in hospitals, intensive care units and home settings.

This is one of five studies to be undertaken by the team. They will also examine how satisfied patients are with their care; how they make decisions about the kinds of treatments they receive at the end of life; the importance of where they die; and how aware patients are of the course of their disease and the odds of recovery.

“Our research focus is to describe, understand, evaluate, and ultimately, improve communication and decision-making at the end of life,” says Dr. Heyland. “We believe the knowledge and tools generated by our research efforts will inform strategies to improve the quality of and satisfaction with end of life care.”

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Composed of 13 institutes, CIHR provides leadership and support to more than 8,000 researchers and research teams in every province of Canada.

Contacts:
Nancy Dorrance, Queen’s News & Media Services, 613.533.2869
Lorinda Peterson, Queen’s News & Media Services, 613.533.3234

Attention broadcasters: Queen’s has facilities to provide broadcast quality audio and video feeds. For television interviews, we can provide a live, real-time double ender from Kingston fibre optic cable. Please call for details.

Contact: Nancy Dorrance
dorrancepost.queensu
Queen’s University

80% of vasectomy patients didn’t complete all-clear semen tests says latest research A quarter of the men who had vasectomies at a US clinic didn’t return for any follow up tests to make sure that the procedure had worked, according to research published in the April issue of the British-based urology journal BJU International.

And only a fifth of the 436 men turned up for both of the tests needed to finally put them in the clear, according to a study carried out by researchers at the Cleveland Clinic Glickman Urological Institute in Ohio, USA.

Of the 75 per cent that did attend their first, eight-week test, a quarter provided samples that still contained sperm. 80 of the 83 men were producing nonmotile (present but inactive) sperm, but three were producing motile (present and active) sperm, including one who was eventually diagnosed with a vasectomy failure.

65 of the 80 men producing nonmotile sperm were clear at their 12-week checks, but six months after their procedure eight men were still producing positive sperm samples. By ten months, all but the vasectomy failure were finally in the clear.

“Our results show that only three-quarters of the men in the study turned up for their eight-week sperm test, which means that a quarter of them had no idea whether the procedure had worked and whether their partner could still fall pregnant” says lead author Dr Nivedita Dhar, Chief Resident in Urology at the Clinic.

“It is impossible to assess the true vasectomy failure rate in the full study sample as many failed to turn up for follow-up tests, despite careful counselling.

“But what concerns us most is that a quarter of the men who had vasectomies did not return for any tests, despite us stressing the important of these followups” adds Dr Dhar.

According to the researchers up to 90 per cent of urologists require two semen samples to confirm sterility and up to 95 per cent request further samples if nonmotile sperm are present. Doctors recommend that couples use additional contraception until vasectomy patients receive the all clear.

“The result of the study are consistent with other research which has estimated that non-compliance among vasectomy patients is between 25 and 40 per cent” says Dr J Stephen Jones, vice chairman of the Glickman Urological Institute, who directed the study.

“It may, however, be possible to improve full compliance among those who return for at least one test by simplifying the follow-up tests in line with current medical evidence and making sure that this is backed up by adequate counselling.

“For example, our study found that 65 of the men tested at eight weeks needed re-testing, but this fell to 15 when it came to the 12-week test. This suggests that a single test at 12 weeks may be adequate in the majority of cases.

“However, it is very important to stress that couples need to use additional contraception until the vasectomy patient has been given the all clear.”

– Determining the success of vasectomy. Nivedita Bhatta Dhar, Amit Bjatt and J Stephen Jones. Glickman Urological Institute, Cleveland Clinic, Ohio, USA. BJU International. Volume 97. Pages 773-776. (April 2006).

– Cleveland Clinic Glickman Urological Institute is a not-for-profit multispeciality academic medical center in Ohio that integrates clinical and hospital care with research and education. Together with Cleveland Clinic Florida it employs full-time 1,5000 physicians representing more than 100 medical specialties and sub-specialties.

– Established in 1929, BJU International is published 12 times a year by Blackwell Publishing and edited by Professor John Fitzpatrick from University College Dublin, Ireland. It provides its international readership with invaluable practical information on all aspects of urology, including original and investigative articles and illustrated surgery.

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