Wednesday, January 20, 2016

Before Worrying About The Latest "Epidemic", Consider the Following...

Ebola. Measles. SARS. H1N1. The media has no end to diseases that they want you to panic about. Add to that to freak out about the small possibility of something like post-earthquake radiation leakage from Japan and people's fears about an apocalyptic crisis (like government takeover, economic implosion, Armageddon...) and you have a population in a near constant state of anxiety over some crisis.

But after completing my first class in my Masters in Public Health, here are my thoughts...

Heart disease, cancer and accidents are more likely to kill you. More likely than what? More likely than just about everything. About 610,000 people die of heart disease in the United States every year. 589,430 estimated cancer deaths occurred in 2015. (Around 2,000 of these deaths were children.) 130,557 people died of accidents in 2013. OK, let's put a few things in perspective...

The number of people in the United States who died from ebola (as of March 2015) is two. Remember the SARS (severe acute respiratory syndrome) scare in 2002-2003? Eight cases in the United States were confirmed and none died. Hitting a little closer to home on a hot button topic, remember the panic about measles? Roughly one person has died each year of measles since 2000, most of which were immunocompromised individuals in their 30's. By comparison, before the measles vaccine was introduced, about 450 deaths annually were attributed to measles.  Now, H1N1 is a hornets' nest, but I'll wade in anyway for comparison's sake on both sides. According to the CDC, 12,469 American deaths were caused by H1N1 influenza during the global pandemic of 2009. (Which is interesting because initial numbers from the CDC claimed 36,000.) However, several people in the medical, public health and statistics fields have questioned these numbers because of liberal inclusion of deaths that were the result of secondary complications of the flu. (For example, a person who is in poor health from an underlying heart condition becomes sick with the flu, it exacerbates their condition and results in death. Or someone develops the flu, but the infection moves into the lungs developing into viral pneumonia.) Some estimates place the actual H1N1 flu death numbers at 500 for the flu season.

You and your loved ones are much, much, much more likely to die of heart disease, cancer or an accident than the latest media crisis disease.

It's a lot easier to panic about something that isn't happening to you at the moment and is unlikely to actually take place. It distracts from dealing from the actual threats in our lives. Whatever, exotic, rare, blast from the past disease or rare crisis you have heard about, remember that it's probably pretty unlikely to happen. Eat healthy, take preventative measures against cancer, and practice safety precautions. It's a lot better use of your time and effort than worrying about ebola.

Tuesday, January 5, 2016

What I Would Tell Another Parent Who Is Having A Baby With A Birth Defect

The other night we took CJ on his nightly adapted tricycle ride at the park and we met a man named Mark. Mark was born without arms. The cool thing he is that he was playing the electric guitar- with his feet. Mark drives, has had many great jobs, has had girlfriends, been married and was even a single dad to his three kids for several years on top of playing in a band. He drives a car with no adaptive equipment. We talked with him about growing up as a "disabled" kid and he confirmed what we have felt all along- it's about your attitude. If you or your parents think it's no big deal- it won't be to anyone else.

When we parted ways so Mark could charge his amp before another show, I was left with such a feeling of gratitude to God. Gratitude that my son is missing part of his spine. I had an epiphany and I realized what I was so grateful for- the chance to raise a kid who has challenges.

Seriously. It is a privilege and a gift. Yes, it's a challenge. Yes, there are days when I want to pull my hair out. But I believe there is a lesson that God has been trying to teach me through CJ the entire time. Actually, I think it's a lesson CJ was put here to teach the world. And here it is: It's not about the hand you are dealt, it's how you play it.

I know people who have big houses, the use of all their limbs and senses, plenty of food, clean water and clothing and the capability to pursue many good things. And they are miserable. And then I know people who were born with some kind of physical challenge who are happy and fulfilled. I'm ashamed to admit it, but there have been so many times in my life where I feel like I was dealt a raw deal and that I can't move on because of it. But this has been a big year for CJ. He took his first steps. Now, he can do a couple of yards unassisted- after we were told that he would never be able to walk unassisted and that even with assistance he would never do more than a very short distance. I have thought so many things were impossible in my life, but I believed in this one thing. And because we believed it, we were able to make it come to pass.

So after being the parent of a kid with a birth defect for over five years now, here is what I would tell someone who has just found that they are going to have a baby who will be a little different:

Accept it. One of my favorite Dr. Phil-isms is this: "You can't change what you don't acknowledge." This is absolutely the first thing you must do to be an effective parent. I saw parents in the NICU whose babies were in the NICU much longer than needed because they kept trying to avoid learning and demonstrating the skills needed to care for their babies at home. It can be devastating to find out that the things you planned and hoped for your baby won't happen in the way you wanted. (CJ isn't going to be hiking with us any time soon.) But until you acquiesce to the reality that your child is going to be a little different in some way you can't improve on the situation.

I really love the 1991 Disney movie Wild Hearts Can't Be Broken. It's based on the true story of Sonora Webster who was blinded in a horse diving accident and then taught herself to continue to riding and diving with horses. There is a scene in the movie that demonstrates this principle. Sonora tells her fiance Al that her blindness will go away; she just needs some rest or some time. And Al tells her that it is permanent. She can be angry, she can fight it, but none of that will change that it just is.Once she accepts that her blindness is a permanent condition, she's able to work with it and dive again, before that she's just waiting and staying stuck.

There are two books I recommend 110% to anyone who has found out that their baby has a birth defect: How To Stop Worrying and Start Living by Dale Carnegie and The Obstacle Is The Way by Ryan Holiday. (Actually I recommend these to anyone who is breathing and has troubles. And even if you're a ghost they might be helpful too.) If you've just been hit with a diagnosis on your  baby I'd specifically suggest chapters 2 and 9 in How To Stop Worrying and Start Living ("A Magic Formula for Solving Worry Situations" and "Co-operate With The Inevitable") and the chapter called "The Art of Acquiescence" in The Obstacle Is The Way.

Prognosis can be a fluid concept. I think that doctors often don't want to give parents a false sense of hope. So they hit them with the worst thinking they're preparing them to deal with the challenges ahead. In reality, this false despair is just as corrosive.

The reality is that every kid will have different challenges. When CJ was born we were told there was no chance he could walk unassisted or that he could relieve his own bladder or bowels. The specialists were wrong on all counts. If your baby has just had a diagnosis for something like spina bifida or Down Syndrome- especially a prenatal diagnosis- please take a page from Hitchhiker's Guide to the Galaxy  and DON'T PANIC. You will probably not know the full extent of your baby's function until he gets older. You also run the risk of assuming your child will have a problem or a severe form of a condition that he or she may not have and then creating that reality. I have seen kids with myelomeningocele who are running around like crazy but have multiple shunt revisions, adults with myelomeningocele who use mobility devices and have had their shunts removed because their bodies no longer use them, kids who need catheterization, kids who don't and on and on and on. It really depends on the individual.

I will forever be grateful that the first doctor I talked to after CJ was born was positive with us. I asked if my baby would have brain damage- I wanted to know so I could be prepared for that. He told me that CJ might have hydrocephalus and might need a device called a shunt to control fluid build-up in the brain, but if the hydrocephalus was under control there was absolutely no reason CJ couldn't be valedictorian of his graduating class. Nice! Honest answer, but focusing on ability- not disability.

Here is what I wish doctors and specialists would tell parents when giving them a diagnosis- especially a prenatal diagnosis: "Your baby has X Diagnosis. These are some of the conditions we often see with this diagnosis. Your baby could have several of these conditions or only a few. We need to watch and be aware of these things, but at this point we can't predict what particular abilities and limitations your baby will have in life. We need to focus on maximizing whatever abilities your child has." When you're looking at your baby, remember Will Smith's words in the movie Hitch: "You is a very fluid concept right now."

This is not a "parenting hall pass". You still have to parent your kid. All kids need discipline, you may have to adapt things a bit for your child's particular needs and capabilities, but they still need discipline. We still have to teach CJ to be polite, to be nice to his brother and that he can't everything he wants when he wants it. Another benefit is that people are charmed by a child in a walker with good manners. Do not get sucked into the trap of "Oh, she's been through so much, how can we say 'no' or punish her?" Otherwise, you may end up with this scenario dramatized in The Miracle Worker:

Oh, and you're not off the hook for talking to your kid about sex either. Depending on your child's intellectual level and physical condition you may need to make some adaptations, but they'll need to some things- especially about appropriate and inappropriate touches. (All kids need to know that for their protection.) With CJ, things are pretty basic right because he's only five. New babies provide a great opportunity to talk about some introductory aspects of human development. 

But we know that we'll have to have some discussions tailored to his needs as he gets a little older since fertility impairment and some other issues might be part of his condition. That's OK. We want CJ to have great friendships and later great dating relationships. We want him to find that special girl and get married and start a family. We think the best way to make that happen is for him to have frank, honest knowledge about human sexuality, relationships and his condition and understand the possibilities that are open to him.

Your kid still needs exercise, healthy food, hobbies/interests. One of the things I kept seeing in the information about myelomeningocele is how kids with it are at a higher risk for obesity. Based on my experience, I think this has a lot to do with parents and specialists who don't think the child can exercise. We are strong believers in the power of exercise to keep people healthy and wear children out. When CJ got his first walker, we made it a priority to take him out for exercise every day. As his endurance increased, we've had to make sure we get him out for longer or more intense walking or tricycling. We started taking him to the zoo and he has done some serious mileage there. Just like we need exercise every day, he does too. He's better behaved and goes to sleep more easily. And he needs healthy food just like any other kid. I think a good diet and plenty of exercise are part of the reason he is in such good health. He rarely gets sick and is at a normal weight for a kid his age.

As he gets older, we want him to try out some different activities. The really great thing is we live in an amazing time where there are more options available than ever before for adapted recreation. Wheelchair rugby, sledge hockey, adapted basketball, you name it. I once saw a YouTube video (unfortunately, I can't for the life of me find the link) which showed a man in a wheelchair who was doing martial arts and showed how he could disarm a standing opponent who had a knife. Some ballroom dance competitions even have wheelchair dance events. There are people hiking with prosthetic legs and paraplegics who go swimming. A new trend I've been seeing is dance studios that offer special needs dance classes for children with intellectual delays. 

Some of history's greatest people have had some kind of disability. Stephen Hawking's mind is sharp despite his physical limitations from ALS (Lou Gehrig's Disease). Franklin Roosevelt was paralyzed after developing Guillain-Barre Syndrome and went on to become the President of the United States for four terms.  Many historians say that he would not have been the leader he was if he hadn't had the challenges of losing the use of his legs. (I've always loved the irony that Hitler considered disabled people inferior and yet a paraplegic man was one of the instrumental figures in kicking Hitler's @$$.) James Earl Jones had a speech impediment and didn't talk for several years as a child. Even with limitations, we're all capable of a lot. I can't wait to see what CJ is going to do next. And other kids like him.

Tuesday, December 22, 2015

Investigation: Australian Mother Dies Giving Birth At Home

Note: This post is part of a series called "Birth Apologetics". "Apologetics" comes from the Greek and means "to speak in defense". (Often used in relation to defense of a particular idea or viewpoint, such as "Christian Apologetics".) In these posts, I will be taking blog posts and articles that are critical of home birth and natural birth and doing a critical analysis on the data and arguments. The idea is that if natural birth and home birth are safe for most women, arguments against them will have serious flaws.
Claims: Australian homebirth advocate Caroline Lovell suffered a cardiac arrest an hour after the birth of her second baby at home and subsequently died at a hospital. This is yet another proof of the dangers of homebirth and childbirth in general. A detailed news article is here, many of the facts cited in this post will come from this article.
Analysis: The first thing to understand in dealing with an individual case is what it can and can't tell us. The death of Caroline Lovell is one incident and can not be used alone as proof of the safety of homebirth in all cases. What it can tell us is what happened in her specific case and possibly whether a homebirth was a bad decision for her individually, or if in this specific case the midwives were some how lacking in the care they gave to her. It could possibly highlight problems within the homebirth and medical communities within Australia specifically. It can not tell us about homebirth as a whole, especially when we consider that other countries like the Netherlands and the United Kingdom which have a greater degree of cooperation between midwives and doctors than countries like Australia and the United States.
While this proved to be a very emotional topic in the media, we would all do well to remember that mothers also die in hospitals. For example, when a London mother died after an elective c-section at an upscale maternity clinic, there were no news reports about the dangers of elective c-sections or calls to outlaw elective c-sections, even though elective c-sections carry an increased risk of neonatal death and c-sections have an increased risk of maternal death as well. So I really feel that there is a double standard the media and the public have when it comes to maternity care.
However, examining the case of Caroline Lovell as an individual incident has definite merits. If something went wrong at the birth that could be prevented by better preparation on the part of the midwives or by giving birth in a hospital I think we need to know so that we can learn from it.
During 2015, most of the news reports have had little to say about the actual facts of the inquest or any new developments. Most have been speculation about whether the midwives called an ambulance soon enough or whether midwives were competent. Some of the more concrete data came from 2014. As of 2014, the inquest had narrowed the cause of death down to what the  experts think are the three most likely causes of death: postpartum hemorrhage, pulmonary embolism or amniotic fluid embolism. So let's take a look at each of these possibilities.
Postpartum hemorrhage: The news media has paid a great deal of attention to the possibility of postpartum hemorrhage and reports of Caroline Lovell having lost "litres of blood". However, when understood from a clinical standpoint, the possibility of postpartum hemorrhage becomes less likely. The inquest found that the midwives knew that Caroline had a uterine fibroid, but did not know that she had a history of postpartum hemorrhage from her previous birth at a hospital. It seems the records they received about the previous birth may not have been complete. Uterine fibroids do carry an increased risk of postpartum hemorrhage, though most women with uterine fibroids have uncomplicated pregnancies. Much of this depends on where the fibroid has grown. Fibroids in the pelvic area can be especially problematic, where as those in the upper part of the uterus tend to cause fewer problems. For a great discussion from several UK midwives on fibroids during pregnancy and labor, check out this link here.
In areas of the United States where midwives are allowed to attend homebirths, it is typical for the midwife to be required by law to carry pitocin with her to the birth to stop postpartum hemorrhage. (If you've seen The Business of Being Born, you might remember the New York midwife who talked about having pitocin ready before hemorrhage becomes a problem.) So while it's possible that Caroline Lovell was at an increased risk for postpartum hemorrhage, there are ways to handle it at home. Also problematic with this theory is the fact that the amount of blood she lost was 400 milliliters of blood and postpartum hemorrhage is generally defined as a loss of 500 milliliters or more. A minor postpartum hemorrhage is usually defined as between 500ml and 1000 ml, and a major hemorrhage is usually defined as a loss greater than 1000 ml of blood, so the amount of blood loss is not consistent with a severe hemorrhage.
Pulmonary embolism: A pulmonary embolism is when the pulmonary arteries of the lung become blocked, usually by a blood clot. A pulmonary embolism can cause cardiac arrest, which was the cause of death for Caroline Lovell.  Cardiac arrest from pulmonary embolism usually happens very fast and is typically fatal, and usually the cause of death is only discovered during autopsy. The symptoms of pulmonary embolism are consistent with the symptoms Caroline displayed after the birth such as fainting and loss of consciousness. In fact, pulmonary embolism is one of the leading causes of maternal death in the developed world. (As a side note, research has found that there has been a significant increase in pulmonary embolisms during pregnancy because of the increasing cesarean rate.) So there is a pretty strong case for death being due to a pulmonary embolism. If that is the case, a hospital may have been able to provide resuscitation if the staff figured out that a cardiac arrest was about to occur, however, this would be no guarantee. One study found that of patients who died suddenly and unexpectedly in hospitals, 80% had died from a massive pulmonary embolism. (Interesting trivia bit- If I am remembering right, the Ben Affleck/Liv Tyler movie Jersey Girl attributes Jennifer Lopez's character's death in childbirth to a blood clot.)
Amniotic fluid embolism: This is a rare, but very serious complication where amniotic fluid enters the mother's bloodstream. It is very hard to detect, even by doctors in hospitals and it kills the mother very quickly. In fact, there was a recent case of a mother dying in a hospital from an amniotic fluid embolism, even with a c-section. Amniotic fluid embolism presents with some of the symptoms that Caroline displayed, such as anxiety and circulatory failure. However, often the baby goes into distress as well and Caroline's baby did fine during and after the birth.

Conclusion: Of the three causes of death listed as most likely by the inquest, postpartum hemorrhage is treatable at home with the right skill and preparation. This is probably the least likely cause of death considering that Caroline Lovell's blood loss at autopsy was not within the range of a hemorrhage. A pulmonary embolism or amniotic fluid embolism is more likely, (with pulmonary embolism being the most likely based on the evidence given). However, even in hospitals, mothers die from these conditions. While this was a homebirth and the mother did die, there is strong evidence that even in a hospital she may still not have survived. This does not mean that the midwives were necessarily providing adequate care- this is a subject of much debate. But even with excellent midwife care or excellent hospital care, Caroline Lovell still may not have survived as maternal pulmonary embolisms remain frustratingly difficult to diagnose and predict, even with current technology.

Saturday, December 19, 2015

Birth Apologetics: Waterbirth- Friend or Foe?

Note: This post is part of a series called "Birth Apologetics". "Apologetics" comes from the Greek and means "to speak in defense". (Often used in relation to defense of a particular idea or viewpoint, such as "Christian Apologetics".) In these posts, I will be taking blog posts and articles that are critical of home birth and natural birth and doing a critical analysis on the data and arguments. The idea is that if natural birth and home birth are safe for most women, arguments against them will have serious flaws.
Case: The American College of Obstetrics and Gynecology released a bulletin in 2014 saying that waterbirth has no known benefits for babies and many potential dangers and should be limited only to controlled studies for research purposes. Full text of the ACOG's bulletin can be found here.
Analysis: The ACOG's position is based on individual case reports and case series of complications, which they acknowledge are not uniformly reported and there fore make it impossible to assess the actual incidence of these complications. The ACOG also bases their position on concerns about possible complications like "...higher risk of maternal and neonatal infections, particularly with ruptured membranes; difficulties in neonatal thermoregulation; umbilical cord avulsion and umbilical cord rupture while the newborn infant is lifted or maneuvered through and from the underwater pool at delivery, which leads to serious hemorrhage and shock; respiratory distress and hyponatremia that results from tub-water aspiration (drowning or near drowning); and seizures and perinatal asphyxia." They also state the they have believe that waterbirth could be potentially dangerous because of the possibility of the baby breathing in water: "Although it has been claimed that neonates delivered into the water do not breathe, gasp, or swallow water because of the protective “diving reflex,” studies in experimental animals and a vast body of literature from meconium aspiration syndrome demonstrate that, in compromised fetuses and neonates, the diving reflex is overridden, which leads potentially to gasping and aspiration of the surrounding fluid."
So let's take a look at these arguments in detail.
  1. Incidence of serious complications: The ACOG states that the information they have is not enough to actually find what the incidence of complications would be on a large scale. However, The United Kingdom provides a nice counterpoint to this. As stated in the ACOG's bulletin, approximately 1% of all birth in the UK have at least a period of water immersion. It should be noted that the United Kingdom has lower rates of neonatal mortality (3 deaths per 1,000 live births) than the United States does (4 deaths per 1,000 live births), so if waterbirth is as dangerous as the ACOG seems to be representing, then the UK would likely have higher rates of neonatal mortality than the United States, but this is not the case. Also, because the usage of waterbirth is not well regulated in the United States, the chance for problems to occur because of ill-informed and untrained attendants could be a significant (but very avoidable) risk factor for complications. Furthermore, the ACOG dismisses studies involving thousands of births which show that with a competent attendant water birth is very safe. One study from England showed that of 4,032 births in water that took place between 1994-1996, there was a mortality rate of 1.2 per 1,000 but none of those deaths were not attributed to waterbirth, but rather other causes. Out of the entire 4,032 births, two babies were admitted to the NICU for possible water aspiration, but recovered.
  2. Concerns over certain conditions: The ACOG very rightly brings up that there are risk factors for waterbirth. However, in the 2006 joint statement from the UK's Royal College of Obstetrics and Gynecology and the Royal College of Midwives, good practice of waterbirth requires taking measures to avoid these problems. For example, the Guidelines from the RCOG and RCM state that all birthing pools and equipment should be sterilized or disposed after use and that the water should be kept free from debris and fecal matter to prevent infection. They also state the need to watch for umbilical cord rupture and plan and prepare for it. Guidelines from Waterbirth International for waterbirth state that sterilization of all supplies and parts of the tub must take place and that no one should allowed in the tub if they have an infection. These guidelines also include recommendations for control of the baby's body temperature by monitoring the temperature of the pool or tub water and keeping the baby in the water with head out and close to the mother initially. The UK's policies for hospital waterbirth (similar to those of UK midwives) state that women who are at least 37 weeks along with an uncomplicated pregnancy and have well-established, spontaneous labor are candidates for water birth or water labor. This reduces many possible complications. One large study from Switzerland (which has a neonatal mortality rate lower than that of the United States at 3 per 1,000 live births) compared waterbirth to maia stool births and bed births for spontaneous, singleton babies in a head down position and found that there was no greater risk of infection with waterbirth. (In fact, out of the natural births, births in bed had a greater risk of infections, primarily in the eyes). They also found that waterbirths had far less complications with bleeding and hemorrhage than other birthing options.
  3. Concerns over drowning: Take note of the language in ACOG's comments on the possibility of drowning: " compromised fetuses and neonates, the diving reflex is overridden..." (emphasis mine). So the ACOG acknowledges that the diving reflex which keeps babies from gasping under water does work under normal circumstances. Their concern lies with babies who have been compromised, inhibiting the diving reflex. However, the RCOG and RCM's guidelines state that "If the woman raises herself out of the water and exposes the fetal head to air, once the presenting part is visible, she should be advised to remain out of the water to avoid the risk of premature gasping under water." Guidelines from Waterbirth International state: "The baby should be born completely underwater with no air contact until the head is brought to the surface, as air and temperature change may stimulate breathing and lead to water aspiration. If a change in position during delivery causes the baby to come in contact with air, the birth should be finished in the air." Both organizations advise the monitoring the baby's heart rate with a Doppler heart monitor to watch for problems. So those who are experienced, educated and competent in attending waterbirths acknowledge that the baby's protective diving reflex could be overridden and have guidelines in place to handle such a situation. Also, once the baby has been fully born a competent waterbirth attendant will quickly and gently get the baby's head out of the water and into the air while leaving the body in the warm water, held by the mother.
Conclusion: It is curious that American OB-GYN's have a habit of criticizing the birthing options of countries that have lower rates of neonatal death than that of the United States! Waterbirth is successfully used in many other countries to deliver babies and with competent and educated attendants has a great track record. For the most part, the ACOG's reasons against homebirth surround bad or incompetent usage of this tool. But we can't write something off as dangerous just because it has been used improperly.
Let's take for example, Cytotec (a.k.a. misoprostol). Cytotec is a drug for preventing stomach ulcers caused by non-steroidal anti-inflammatory drugs. However, doctors in America have been using it for about  20 years now to induce pregnant women because it works faster and causes stronger contractions than pitocin. This usage is in opposition to both the FDA and Cytotec's manufacturer Searle. Cytotec is contraindicated for use in pregnant women and not approved by the FDA for labor induction and has been associated with a large number of uterine ruptures and the deaths of many babies and mothers. Cytotec has proven so problematic that its manufacturer Searle issued a letter in August of 2000 warning obstetricians not to use it for labor induction.
Now, just because some doctors have chosen to use Cytotec in a way that it was never designed to work with resulting injuries and deaths does not mean that Cytotec itself is dangerous. Cytotec may be very helpful for someone with stomach ulcers from NSAID's. Cytotec is simply a tool. The results from its use depend upon the discretion of the practitioner. The same can be said of waterbirth. Waterbirth is a tool and while the improper use of it can result in injury or death, when used competently the evidence shows that it can have enormous benefits.

Wednesday, December 16, 2015

Investigation: Maternal Stroke

This is part of a series of posts aimed at attempting to uncover possible causes behind maternal and neonatal mortality. Often, these deaths are said to be "unpreventable" or have "unknown causes". The "Investigation" series of posts will delve into some of these cases and see what possible causes might be applicable so that greater awareness and education can hopefully lead to lower death rates for mothers and babies.
Case: 20 year old previously healthy pregnant mother admitted to the hospital for placenta tear at seven months gestation. All vitals appear normal, but the mother complains of a migraine. She is given a narcotic for the pain of the headache and over the next hour starts to go numb. She then turns blue and suffers a fatal stroke. The baby is delivered via emergency c-section and survives. Doctors say the cause of the stroke is unknown. News article here.
Analysis: Pregnant women are at a higher risk of stroke, and in fact it is the leading cause of death in pregnant women in the United States and Canada. Most of these strokes are caused by preeclampsia/eclampsia (a disorder of pregnancy characterized by high protein in the urine and high blood pressure). The migraine and the placenta tear are telling here, since migraine-like headaches are one of the telltale signs of preeclampsia and preeclampsia can lead to placenta abruption or a lack of blood flow to the placenta.
The doctors state that the mother's vital signs, including blood pressure were normal, but this may not have been the case. Typically, doctors won't consider preeclampsia unless the mother's blood pressure is greater than 140/90 on two separate readings more than six hours apart. The problem is that blood pressure rates can vary greatly from person to person (just like average basal body temperature). A woman whose blood pressure tends to be on the lower-than-average side may be technically within the guidelines of normal blood pressure numbers while her body is getting dangerously close to disaster.
A rise of 15 degrees or more in the lower number  (diastolic) or of 30 degrees or more in the higher number  (systolic) during pregnancy can also be a signal that preeclampsia is underway. But this sort of data requires multiple readings on separate occasions. A mother who shows up at the emergency room and gets a single reading may not get the help she needs because the number is taken out of context. For an account of a mother who experienced the nearly fatal situation of having a variation of preeclampsia called HELLP syndrome but was repeatedly told that her blood pressure was normal read here.
Preeclampsia is called the silent killer because often mothers don't feel poorly until the condition has progressed to a serious stage and it often goes undetected by doctors because of variations in blood pressure readings and dismissal of the symptoms as "normal pregnancy complaints". Preeclampsia can also progress to a dangerous point very quickly, another reason it sometimes escapes notice, even in women receiving full prenatal care. A urine test at the time of admission may have revealed dangerously high levels of protein in the urine and could have alerted doctors to possibility of preeclampsia, but it doesn't sound as if a urine test was performed. These tests are typically very quick and easy to do.
Conclusion: While it is impossible to know for sure what happened without a complete set of data from blood pressure readings or tests for protein in the urine, there are many indications pointing to advanced preeclampsia as the cause of the stroke. It is very possible that this mother had developed preeclampsia that quickly progressed to a dangerous stage.

Prevention: Because it is so easy for preeclampsia to be overlooked, it's important for mothers to know the signs and symptoms and also to know their blood pressure and even keep a log throughout their prenatal care visits. If you're feeling sicker than usual, yet being told that nothing is wrong, you may have to become very assertive in getting the care you need. If preeclampsia progresses to a point where the mother's and baby's lives are in danger, a c-section will probably be necessary, even if the baby has not reached full-term gestation. For information on signs of preeclampsia and it variations, go to the Preeclampsia Foundation's website here.

Monday, December 14, 2015

Birth Apologetics: Does The Netherlands Really Have The Highest Newborn Mortality Rate?

Note: This post is part of a series called "Birth Apologetics". "Apologetics" comes from the Greek and means "to speak in defense". (Often used in relation to defense of a particular idea or viewpoint, such as "Christian Apologetics".) In these posts, I will be taking blog posts and articles that are critical of home birth and natural birth and doing a critical analysis on the data and arguments. The idea is that if natural birth and home birth are safe for most women, arguments against them will have serious flaws.
The Claims: The blog post we will be looking at today is here. The claims are that The Netherlands has higher rates of newborn mortality while having some of the highest rates of planned home births of any developed nation and that this shows how dangerous home birth is.
Analysis: It is true that the Netherlands has higher rates of newborn mortality than other European countries. However, this blog post comes from an American OB-GYN, and the Netherlands still has lower rates of newborn mortality than the United States of America! (3 neonatal deaths per 1,000 live births in the Netherlands vs. 4 neonatal deaths per 1,000 live births in America.)
The Netherlands has acknowledged their high newborn death rates in comparison to other European countries, but have found that these rates are due to high rates of very premature births and not term babies born at home. The rate of prematurity in the Netherlands is 8 per 100 live births. This is higher than most European nations. (But by comparison, note that the United States has far worse rates of prematurity at 12 per 100 live births.) Prior to 2010, Dutch hospitals were not required to offer treatment to very premature babies, which could be another contributing factor to high death rates from prematurity in the past. Since instituting a policy that babies born at 24 weeks or beyond receive care, deaths from prematurity have dropped in the Netherlands. However, even babies born before 24 weeks can still be saved with treatment, so infants born before this time who would receive care in other countries like Great Britain and survive could still be a contributing factor to newborn mortality in the Netherlands.
Conclusion: Dutch newborn mortality rates reflect issues with premature birth rates and care of premature babies rather than flaws inherent in home birth and are still better than the newborn mortality and prematurity rates in the United States. Arguments that the Netherlands' high rates of newborn mortality in comparison to those of other European countries reflect supposed dangers of birthing options are based superficial analysis and inaccuracies.

Thursday, December 10, 2015


I've been drinking kombucha for about six years now and making my own for about nine months. Improved digestion, more energy, and less sickness are some of the benefits we have experienced since adding kombucha to our diet. So based on my experience and research, here is what I can tell you about kombucha:
What is kombucha? Most labels describe kombucha as a tea, but that's actually only true in the loosest sense. Kombucha is a fermented drink, very similar to raw apple cider vinegar.
How is kombucha made? Well, you make some black, green or oolong tea and add some sugar. When the tea is sufficiently cooled off, you dump in some starter kombucha and a SCOBY. (SCOBY stands for Symbiotic Colony of Bacteria and Yeast. Basically, a big blob of good bacteria and yeast. Sometimes called the "mother".) Over a period of approximately 2-4 weeks, the SCOBY eats the tea and sugar from the liquid and excretes out probiotics which soon permeate the liquid. The result is what we call kombucha.
Calling kombucha a tea is popular way of positioning it for businesses that sell it. Calling it a tea vinegar or bacteria and yeast juice does not sound appealing to most Americans.
How healthy is it? "Sugar, caffeine, and carbonation, how is it any different than a soda?!" So scorn the skeptics. This depends a lot on the particular brand of kombucha and how it's made. A traditionally brewed kombucha will have trace amounts of caffeine and alcohol. However, the alcohol and caffeine content can be controlled with the right fermentation conditions.
Kombucha that has been fermented between two and four weeks will have very low alcohol and caffeine content because at this point the SCOBY will have eaten up most of the tea and sugar, but won't start fermenting to the point of high alcohol content yet. This usually considered the ideal for kombucha. If you want to flavor kombucha, you put it in bottles with flavoring like juice or herbs and let it sit for a few days, a week at the most. After about a week, it will start developing higher alcohol content because the sugars from the additional flavoring (especially fruit juice) will quickly be converted to alcohol.
Federal law requires that all beverages that are marketed as non-alcoholic have 0.5% or less alcohol content, so the kombuchas that you find in the store have to meet this standard. In 2010, a public health official in Portland, Maine noticed some bottles of kombucha leaking and thought that the beverages might have high alcohol content. Four brands were taken from the store and tested at the University of Maine and found to have alcohol content ranging from slightly over 0.5% to 2.5%. In the United States, a drink with over 0.5% alchol content has to be regulated by the Alcohol and Tobacco Tax Trade Bureau. So many kombucha brands did a voluntary recall while they reformulated to strictly comply with the 0.5% standard.
Reformulation has meant different things for different brands, and herein lies the central issue with the kombucha vs. soda question. Most brands of commercial kombucha now use a short fermenation process, so the SCOBY doesn't eat up much of the sugar and tea. This makes the kombucha sweeter. It also makes it much easier for manufacturers to get under .5% because the kombucha isn't as active. Long brew kombucha can meet the 0.5% standard, but it requires more care. You have to make sure that your fermentation time and conditions are balanced to get to that happy medium.
Because short brewing doesn't give as much time for the fermentation process, this kind of kombucha ends up being on the flat side. Most short brew brands use forced carbon dioxide to make their kombucha effervescent, just like a soda. The downside to forced CO2 is that it can make the kombucha more acidic. So long story short, most commercial kombuchas are short brewed with forced CO2 making them more like a sweet tea soda with a little bit of probiotics. There are a few traditioanlly brewed brands that do a long brew and have very probiotic rich kombucha. Of course whether you do a long brew or short brew, the probiotic benefits will be neglible if your kombucha has been pasteurized.
What about alcohol and caffeine content (especially for pregnant women)? This is kind of a personal question you will have to answer for yoruself. An average kombucha is usually listed as having approximately 24 mg of caffeine per 8 oz. GT's brand kombucha says that theirs has about 8-14 mg of caffeine per 8 oz. serving. For a point of reference:
  • Starbucks 16 oz. coffee has 330 mg of caffeine
  • 2 Tbsp of Maxwell House ground coffee has about 100-160 mg of caffeine
  • 8 oz. of black tea brewed for 3 minutes has 30-80 mg of caffeine
  • 8 oz. of Lipton black or green decaf tea has 5 mg of caffeine
  • 16 oz. Starbucks decaf coffee has around 15-25 mg of caffeine
  • 2 Tbsp. of Maxwell House ground decaf coffee has 2-10 mg
  • 12 oz. diet Coke has 47 mg of caffeine
  • 12 oz. of Barq's reglular root beer has 23 mg of caffeine
  • A Rockstar Citrus Punched energy drink has 240 mg of caffeine
  • A 1 oz. package of Jelly Belly Extreme Sport Beans has 50 mg.
  • 16 oz. Starbuck's hot chocolate has 25 mg. of caffeine
  • 1 Tbsp. of Hershey's cocoa has 8 mg of caffeine
  • A 1.5 oz serving of Hershey's Special Dark chocolate has 20 mg of caffeine.
Alcohol has been a much publicized issue with kombucha. However, seeing as how any kombucha being sold as a non-alcoholic beverage has .5% or less alcohol the alcohol content is very low. A regular beer is 5% alcohol, so you would have to drink 10 kombuchas to even start approaching the alcohol content of one can of beer. Wines usually have 12% alcohol content in a 5 oz. serving and hard drinks like whiskey and gin are at around 40% alcohol content for a 1.5 oz serving. How does it compare to other non-alcoholic foods beverages?
The Washington State Toxicology Lab conducted a study on the alcohol content of foods and drinks thsat are considered non-alcoholic and found that many breads actually have alcohol content greater than 0.5%. The apples in a Great Harvest Apple Walnut Roll actually have an alcohol content of 1.066% and the roll itself has a total alcohol content 0.956%. Rosemary onion bread has an alcohol conent of 0.98%. Home Pride brand wheat bread has 0.48% alcohol content.
Fruit juices also have naturally occurring alcohol in them. In fact, the United Arab Emirates has pulled juices from stores for exceeding 0.03% alcohol content  (their legal limit for non-alcoholic beverages). In August 2013, Snapple's fruit punch drink and peach flavored tea were pulled from the UAE because they were found to have alcohol contents of .48% and .05% respectively. So a carefully long-brewed non-alcoholic kombucha has about the same alcohol content as a fruit juice drink.
GT's Kombucha still sells their original formula in certain states that have looser laws about how you can sell and label beverages, so if you are pregnant or concerned about alcohol you might consider passing on these in favor of their Enlightened line of kombucha which has <0.5% alcohol content.
I want to start drinking kombucha. What do you recommend? I do not recommend that you start off brewing your own. If you're not used to fermented foods and drinks, kombucha can be something of an acquired taste. I recommend starting with one bottle from the store every so often and work your way up as you see fit. As you start to get more familiar with kombucha and how it should taste, you can start thinking about making your own.
I think it's best to start with a fruit flavored kombucha like GT's Synergy. (Gingerberry, Trilogy and Mango are especially good to start with, in my opinion.) GT Dave is the Steve Jobs of kombucha: a pioneer with extra high standards that he refuses to compromise. High Country and Health Ade are other great store bought brands. High Country is pretty tart, but their Aloe and Wild Root (kind of like root beer) are really good in my opinion. Health Ade has a nice fruity taste and I was surprised at how much I really love their carrot juice and beet juice kombucha. Seriously, they were really good! The above brands are dedicated to brewing in glass, whereas most other brands brew in plastic tubs.
Most brands of kombucha that use forced CO2 don't list it on their label, so it is hard to tell from the label alone. Reed's Culture Club uses forced CO2 as does Kosmic Kombucha. Nationally distributed Kombucha Wonder Drink is pasteurized as well.
I love kombucha and I'm now ready to brew my own. How do I start? You can order a SCOBY from a reputable seller. (Kristen Michaelis of Food Renegade recommends Kombucha Kamp for getting a  ready-to-ferment SCOBY.) There are also sources for dried SCOBY's you can activate. Or... you can make your own SCOBY from a good quality bottle of unflavored kombucha. It takes a few weeks, but it's a really neat process. (This is what I did.)
We decided to try starting four SCOBY's in case one or two didn't work out. (They all did and are multiplying like rabbits to this day. Want one?) We used two bottles of Health Ade and two bottles of GT's Enlightened line of kombucha. (You may have seen the rumors online that you can't grow a SCOBY from GT's Enlightened line, in my experience this isn't true!) I suggest using organic tea and sugar. I opt for organic evaporated cane juice and it has worked great for me! (You may have seen the rumors online that you can only brew kombucha with refined sugar, in my experience this isn't true!)
I've heard of some folks who use rooibos tea in making kombucha, but they always have to put the SCOBY back into sugar-black/green/oolong tea solution to feed the SCOBY again and keep it alive. Green/black/oolong are the best food for the SCOBY. Rooibos doesn't actually feed the SCOBY.
Honey is generally considered a bad idea too because it comes with its own set of microorganisms that can compete with the microrganisms the kombucha is trying to create. If you want to control the amount of caffeine in your kombucha, make sure to get a lower caffeine content tea and don't let it steep very long. (3-5 minutes should be fine for a smaller batch, for a gallon, about 8-10 minutes.)
Glass is best for fermenting anything. Plastic can leach chemicals into the kombucha or harbor foreign bacteria. Metal can contaminate fermented foods or drinks of any kind and can make the batch go bad. Kombucha ferments faster or slower depending on the temperature. If you live in a very hot area, it might take only a week or a week and a half to get a batch ready in the summer. If it's winter and cold, it might take a good 4 weeks to really hit the tipping point. (You'll know your kombucha is nice and probiotc-y when it tastes tart like apple cider vinegar. Taste it periodically after a week or two to monitor it so it doesn't sit too long.) For more info on making your own kombucha, check out Cultures for Health. This is an awesome site for how to make your own fermented foods and beverages.

So is kombucha for you? You'll have to decide that for yourself. But if you're looking for a great way to add some probiotcs to your diet, a well-chosen, high quality kombucha will deliver every time.