Thursday, July 24, 2014

Induction or Waiting in Obese First-Time Mothers?


This is a follow-up post about a study reported on briefly here earlier this year.

It is about the question of whether "obese" women should have their labors induced proactively at term or be expectantly managed, and whether elective induction increases their risk for cesarean and other poor outcomes (like fetal distress, more Neonatal Intensive Care Unit utilization, etc.).

Induction of Labor: Help or Harm?

Induction of labor is an increasingly common intervention in women of all sizes. The question is whether it does more harm than good.

Much research shows it is associated with an increased risk for cesarean, but other research does not always show this. A definitive answer still eludes us on whether/when induction is appropriate.

Complicating this question is the whether or not the mother's cervix is ripe. Inducing on a very ripe cervix is much less likely to lead to a cesarean than inducing on an unripe cervix (Bishop Score less than 5-7, or cervical dilation more than 3 or 4).  And this is especially true in first-time mothers (nulliparous women).

An increased maternal BMI complicates this debate because of a perceived heightening of risk. One of the biggest dilemmas facing maternity care providers who are caring for "obese" women is how to manage them at term. Should they electively induce labor at 39 or 40 weeks, or should they wait for labor to start on its own if no complications occur?

Many care providers these days seem to be electively inducing obese women at 39 or 40 weeks, sometimes regardless of cervical ripeness (when they are not trying to talk them into a planned cesarean).

Many have the best intentions with this; they think inducing a smaller baby will lessen the risk for cesarean or shoulder dystocia, or they think that baby will have better outcomes if they induce before complications might develop. But do these assumptions hold up under scrutiny?

The problem is that little research has actually examined the question of whether it is beneficial to routinely induce obese mothers without specific medical indications for induction.

Care providers usually go ahead and do so, assuming that inducing obese women at term is beneficial, but there has been little direct evidence one way or the other in a study specifically designed to look at the benefits and risks of routine elective induction in high-BMI women.

Sadly, there is still no large study that rigorously examines this question.

However, we now have a small study that begins to address it. The study looks at the outcomes of elective induction or expectant management of obese first-time mothers with an unripe cervix.

The Study

This retrospective study was conducted by doctors at a hospital in Washington D.C. They studied obese (BMI 30 or more) first-time mothers with no chronic medical co-morbidities (like chronic hypertension, pre-existing diabetes, etc.). Women were admitted to the study between 39 and 41 weeks, and only if they had an unripe cervix (Bishop score less than 5) that was documented during week 38.

The researchers compared the results of electively inducing obese first-time mothers with an unripe cervix (n=60) at 39-41 weeks with expectant management (waiting for spontaneous labor or inducing only if medical indications arose, n=410). Age, BMI at delivery, and prenatal weight gain were similar between groups.

It's important to note that the authors did not compare elective induction to only spontaneous labor. They compared elective induction to expectant management, many of whom eventually were induced if medical indications for induction of labor arose.

The results of this study would probably be even more striking if they compared elective induction only to spontaneous labor, but the authors felt that this was not an appropriate comparison, stating,
"Because spontaneous labor is not something a provider can choose for a patient, it is not realistic to use this as a comparison control group; it is more appropriate to compare the induction of labor to expectant management."

Even so, the bottom line was that the researchers found that electively inducing labor in high-BMI first-time mothers with an unripe cervix raised the risk for cesarean. By quite a bit.

The cesarean rate was 25.9% in the obese women in the expectant management group, and the cesarean rate was 40% in the elective induction group.

That's a significant increase in risk for cesarean.

Only 10.7% of women in the expectant management group were still pregnant by 41 weeks; all the others had either gone into labor spontaneously (36.8%) or had been induced for commonly-accepted medical indications (rupture of membranes, gestational hypertension, non-reassuring fetal heart rate tracings, etc.). So quite a few of the expectant management group were eventually induced, yet the difference in the cesarean rate was still quite marked.

Another important finding was that the elective induction group had three times the rate of admission to the Neonatal Intensive Care Unit (NICU) after the birth (18.3% vs. 6.3%).

This suggests that instead of reducing harm to the baby (as many care providers believe), elective induction in this population may actually increase the risks of poor outcomes.

Now, of course the study had a relatively small sample size, especially in the electively induced group. It was also a retrospective study. So the authors point out that further research on this topic is needed, preferably with a large prospective study.

Still, even with the study's weaknesses, it suggests strong caution towards elective induction in obese women with an unripe cervix. As the authors note:
In a joint summary from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists, physicians are urged to perform labor induction primarily for a medical indication and if done for nonmedical indications...to ensure that the 'cervix should be favorable, especially in the nulliparous patient.' Our findings support this assertion.
Other studies 

This study echoes a number of studies which have found higher c-section rates and complications in obese women who were induced (especially first-time obese mothers).

Of course, these studies did not specifically examine the question of whether routine induction in obese women improved overall outcomes. Still, their findings seem to also suggest caution around the idea of routine induction in obese women.

Although a higher rate of complications like pre-eclampsia means that some obese women will be induced for true medical indications, many others are induced for more dubious indications, based on questionable beliefs. These must be examined carefully.

For example, many providers believe that inducing early when the baby is smaller will lessen the risk for cesarean. Yet a number of studies have shown that it actually increases the risk for cesarean.

The combination of a suspected big baby and a high-BMI mother is a particularly potent combination that leads to many cesareans. A 2006 Massachusetts study found that the combination of induction, a suspected big baby, and first-time mother doubled the cesarean rate in the high-BMI women studied.

Many women of size are induced labor at term ostensibly to prevent a shoulder dystocia. Yet a recent New York study found that induction of labor actually increased the risk for shoulder dystocia (2.85x the risk), and especially so in obese women (5.64x the risk). By inducing women of size, providers may often be creating the very situation they are trying to avoid.

Other care providers induce because they believe it will improve outcomes in high-BMI women. A 2005 Welsh study on obese women with no complications found that the cesarean rate was 19% in the group with spontaneous labor and 41% in the induced group. Like in the present study, the Welsh study noted that the induction of labor was the start of many problems for the obese women in the group, including more blood loss, more UTIs, more babies in the NICU, more feeding difficulties, more neonatal trauma, etc.

So while many care providers think they are doing obese women a favor by inducing them proactively at term, there is strong reason to suspect that they may actually be doing more harm than good.

So much so that a 2013 Irish study (which found higher rates of emergency cesarean in induced obese first-time mothers) concluded:
Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
Conclusion

Research is clear that induction of labor is an extremely common intervention in obese women.

These and other studies suggest that perhaps a little more time and patience is needed at the end of pregnancy in obese women, and that induction should only be undertaken for strict medical indications.

Furthermore, it is time that larger studies directly address the question of whether routine induction at term improves or harms outcomes in obese women and their babies.

These potential studies should particularly look at outcomes among subsets of high-BMI populations, including obese women with complications and those without, those with differing levels of obesity, obese first-time mothers with an unripe cervix, obese multips with a prior vaginal birth, obese women where a big baby is suspected, etc.

Only then will care providers receive clearer guidance on the best management of women of size at term in many of the scenarios they are likely to encounter. It's FAR past time for such targeted research to occur.

We need care based on real evidence, not simply on assumptions about what's best for obese women.


References

Am J Obstet Gynecol. 2014 Jul;211(1):53.e1-5. doi: 10.1016/j.ajog.2014.01.034. Epub 2014 Jan 31. Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Wolfe H1, Timofeev J2, Tefera E3, Desale S3, Driggers RW2. PMID: 24486226
OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m(2) or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks...RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.
Acta Obstet Gynecol Scand. 2013 Dec;92(12):1414-8. doi: 10.1111/aogs.12263. Maternal obesity and induction of labor. O'Dwyer V1, O'Kelly S, Monaghan B, Rowan A, Farah N, Turner MJ. PMID: 24116732
...Of 2000 women enrolled, 50.4% (n = 1008) were primigravidas and 17.3% (n = 346) were obese. The induction rate was 25.6% and the overall cesarean section rate 22.0%. Primigravidas were more likely to have labor induced than multigravidas (38.1% vs. 23.4%, p < 0.001). Compared with women with a normal BMI, obese primigravidas but not obese multigravidas were more likely to have labor induced. In primigravidas who had labor induced, the cesarean section rate was 20.6% (91/442) compared with 8.3% (17/206) in multigravidas who had labor induced (p < 0.001). In obese primigravidas, induction of labor was also more likely to be associated with other interventions such as epidural analgesia, fetal blood sampling and emergency cesarean section. In contrast, induction of labor in obese multigravidas was not only less common but also not associated with an increase in other interventions compared with multigravidas with a normal BMI. CONCLUSIONS: Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
BJOG. 2005 Jun;112(6):768-72. Outcome of pregnancy in a woman with an increased body mass index. Usha Kiran TS1, Hemmadi S, Bethel J, Evans J. PMID: 15924535
...The study sample was drawn from the Cardiff Births Survey, a population-based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999. POPULATION: Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation... METHODS: Comparisons were made between women with a body mass index of 20-30 and those with more than 30...RESULTS: We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2-1.7); induction of labour, 1.6 (1.3-1.9); caesarean section, 1.6 (1.4-2); macrosomia, 2.1 (1.6-2.6); shoulder dystocia, 2.9 (1.4-5.8); failed instrumental delivery, 1.75 (1.1-2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2-1.8); urinary tract infections, 1.9 (1.1-3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement. CONCLUSION: Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events....
J Midwifery Womens Health. 2006 Jul-Aug;51(4):254-9. Maternal body mass index, delivery route, and induction of labor in a midwifery caseload. Graves BW1, DeJoy SA, Heath A, Pekow P. PMID: 16814219
...This retrospective cohort study examined the outcomes of 1500 consecutively delivered women who were cared for by two midwifery practices and delivered between January 1, 1998, and December 31, 2000. Cesarean delivery was significantly associated with the obese BMI (P < .001), nulliparity (P < .02), and newborn birth weight (P =.006). Prenatal weight gain did not have a significant correlation with cesarean birth (P = .24). In multivariable modeling, obese BMI, high newborn birth weight, nulliparity, and induction of labor increased the risk of cesarean birth. There was also a significant association between higher BMI and risk of induction of labor (P < .001). In a secondary analysis, obese BMI was associated with increased risk of induction in cases with ruptured membranes (OR 2.2; 95% CI 1.4-3.4) and postdates pregnancy (OR 2.0; 95% CI 1.1-3.4).
Obstet Gynecol. 2014 May;123 Suppl 1:172S. doi: 10.1097/01.AOG.0000447182.21511.09. Shoulder dystocia and labor induction stratified by maternal weight: to induce or not to induce? Sirota I1, Francis A, Chevalier M, Ashmead G. PMID: 24770084
...Retrospective study of all shoulder dystocia patients who delivered from 1998 to 2010, women in a control group without shoulder dystocia were matched two to one by maternal BMI, age, parity, and diabetic status...RESULTS: Included in the study was 57,259 deliveries; 144 shoulder dystocia cases and 288 women in the control group met study criteria. One hundred seven (74%) shoulder dystocia cases were induced or augmented; 37 (26%) labored spontaneously. One hundred thirty-six (47%) women in the control group were induced or augmented; 152 (53%) labored spontaneously... Across all BMIs, induced patients were 2.85 times more likely to have shoulder dystocia than noninduced patients (95% confidence interval 1.57-6.14; P<.001). After stratifying by BMI, induced normal-weight patients were 2.11 times more likely to have shoulder dystocia than spontaneously laboring normal-weight patients; induced or augmented overweight patients were 4.74 times more likely to have shoulder dystocia than their spontaneously laboring counterparts; and induced or augmented obese patients were 5.64 times more likely to have shoulder dystocia than their noninduced cohorts...CONCLUSION: Induction or augmentation appears to be associated with an increased shoulder dystocia risk with increasing maternal BMI.
Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A114-5. doi: 10.1136/archdischild-2014-306576.330. PLD.30 A 5-year review of maternal obesity and induction of labour on mode of delivery and risk of labour, anaesthetic and neonatal complications. Joannides C, Hon M, McGlone P, Parasuraman R, Al-Rawi S. PMID: 25020968
...Retrospective analysis of women with a booking BMI >45 between January 2009 and October 2013...RESULTS: 158 patients were analysed (mean BMI 49). 68% of all patients were either induced or required labour augmentation (background rate of 39%). 64% of these women achieved a vaginal delivery, increasing to 70% if no induction or augmentation. 71% of multiparous women who spontaneously laboured and had previously achieved a vaginal delivery, delivered vaginally again. Half of primiparous women requiring induction or labour augmentation had an emergency caesarean. 49% had intrapartum regional anaesthetic. 42% required multiple attempts, 19% needed an epidural re-site or spinal for theatre. CONCLUSION: These results mirror the UKOSS study findings. Higher maternal BMI is associated with an increased incidence of induction and augmentation of labour. Despite this the vaginal delivery rate is high. Primiparous women requiring induction or augmentation of labour were most susceptible to obstetric intervention....

Monday, July 14, 2014

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider

Many women want to choose their pregnancy care provider carefully, but aren't sure what questions to ask when interviewing doctors or midwives. 

Here are some general questions that some care providers* have suggested asking any provider you are considering during your pregnancy and birth.
  1. How do you define “normal birth”?
  2. Can you give me an example how you typically manage a normal birth?
  3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
  4. How long will you “allow me” to wait if I go overdue?
  5. What position(s) will you allow me to use when giving birth?
  6. How do you feel about IVs and continuous fetal monitoring?
  7. How do you feel about a woman eating and drinking in labor?
  8. What are your thoughts on pain relief in labor?
  9. How do you feel about cesareans?
Some childbirth educators would substitute different questions here and there from this list but it's a reasonable basic list to start with. Adapt as necessary for your own personal situation and concerns.

Also pay close attention to the provider's response to your questions. Of course, care providers have limited amounts of time to answer questions at most visits so it's important to be considerate and concise when you ask questions, but if they are impatient with your questions or dismissive of your concerns, that's a sign you might want to look elsewhere.

There are other additional questions you might want to ask if you are a woman of size, but more on that in future posts. If anything, women of size need to be even more vigilant in asking questions of potential care providers because size bias is so prevalent in maternity care. But for now, the above questions are a reasonable start to the process.

Sample Answers to These Questions

So what are reasonable answers to the above questions? It really depends on the type of birth you are looking for and how interventive you want your care provider to be.

Some people want a totally natural birth, and some want all the interventions and machines that go PING that technology can give them. Neither approach is right or wrong; it's more a matter of what you prefer and the unique needs of your pregnancy.

However, it's far more difficult to find a provider truly supportive of natural birth than a provider that routinely uses lots of technology and interventions. So the slant of this post is going to lean more in the direction of finding someone supportive of natural birth, but readers should not infer any judgment of their own personal preferences. Again, adapt the questions to your own personal needs and preferences.

1. How do you define "normal birth"? 

To some care providers, "normal" birth means just about anything (including significant amounts of interventions), whereas to others it means an undisturbed, spontaneous labor resulting in a vaginal birth without any interventions. You can get some idea of a care provider's attitude towards birth and interventions by what they think of as "normal" in birth.

2. Can you give me an example how you typically manage a normal birth?

To some care providers, typical management includes inducing labor at 39 or 40 weeks, mandatory IV, epidural by 4 cm dilation, and active management of care (breaking the waters early in labor, aggressive management of contractions with oxytocin, etc.). To other care providers, induction is used only when medically indicated (concern over blood pressure, baby not growing well, etc.), IVs are not mandatory, epidurals are completely up to the mother's choice, and routine interventions in labor are not utilized unless medically indicated.

Again, neither is inherently right or wrong, just different ways of looking at and managing labor. By asking the question of how the care provider typically manages normal birth, they can begin to understand where the caregiver falls on the continuum of intervention.

3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?

This is an important question because it speaks to the caregiver's respect for patient autonomy and how they prefer to interact with patients. Some care providers never want their dictates questioned. Others give education on the pros and cons of procedures and make strong recommendations based on their training and knowledge, but respect the mother's right to choose for herself.

It's important to also point out that women vary greatly in their desire for informed decision-making. Some prefer to leave all the decision-making up to the care provider and don't want to be "burdened" with having to make those choices. Others want to be very involved in the decision-making. The question is designed to help you figure out which style of care you prefer, and whether that aligns with the care style of the provider you are interviewing.

4. How long will you "allow me" to wait if I go overdue?

There is a great deal of controversy about the safest time for women to go into labor. There is a small but significant risk for stillbirth as gestational age increases, but this risk has to be weighed against the significant risks of inducing labor earlier, which may increase the risk for harm from strong drugs or may increase the risk for cesarean. Current research varies quite a bit on whether a pregnancy should be induced to lower the risk for stillbirth or other poor outcomes. There is no "right" answer here, only an answer that reveals to you what your care provider routinely does.

Many care providers induce labor right at 39 or 40 weeks, some wait till 41 weeks, some wait till 42 weeks, some wait even longer as long as the baby's status is reassuring. Some prefer inducing earlier but will respect the mother's decision to wait if baby looks okay. The point is to know your care provider's preferences on this very important point and to explore how flexible they are about it.

5. What position(s) will you allow me to use when giving birth?

Most hospital births occur with the mother either flat on her back, propped up with her legs in stirrups, or with the mother pulling back on her knees ("supine" or "lithotomy" positions). This is our cultural expectation of birth, and nearly all media images of birth show this position.

In other cultures, however, many other birth positions are used, including kneeling, squatting, side-lying, hands-and-knees, and asymmetrical positions, and these labor positions have distinct advantages. Some providers are very comfortable allowing the mother to labor in positions like these, while other providers restrict the mother to only the typical hospital positions. The question is designed to help you find out how your provider feels about birth positions.

Be careful how you word the question, though. Many care providers tell you that they will "let" you labor in whatever position you want, but fail to reveal that when it comes time to actually push out the baby they want you in the usual positions. Many providers are extremely uncomfortable attending a birth in a position other than supine or lithotomy and will pressure you to change positions, even though there is quite a bit of evidence for the benefit of upright and other positions in birth.

Some women don't care about what position they give birth in or are uncomfortable experimenting with different positions. Others are adamant about having the freedom to move as their bodies dictate, especially as the baby emerges. The important thing is to find a provider that is comfortable with your preferences, so be sure to ask ahead of time about not only labor positions, but also what position they want you in for when the baby is actually coming out.

6. How do you feel about IVs and continuous fetal monitoring?

It is important to establish your provider's preferences about routine interventions like IVs and continuous fetal monitoring.

Some providers are fine with women laboring without an IV. Others mandate an IV for all their patients, while still others strike a middle course and only request that a heplock be placed so that emergency access would be faster if an IV became needed.

Although continuous fetal monitoring has not been shown to improve outcomes in low-risk women, it is still extremely common in nearly all hospitals. However, some providers are more flexible than others about when it starts, whether intermittent monitoring can be used instead, and whether mobile monitoring is allowed.

7. How do you feel about a woman eating and drinking in labor?

Some care providers and hospitals have strict rules about whether a woman is "allowed" to eat food or drink during labor, despite a lack of evidence showing harm from this practice. Many allow only ice chips to be used during labor. It is important to understand your caregiver's policies before labor.

8. What are your thoughts on pain relief in labor?

Women vary greatly in their wishes towards pain relief during labor. Some prefer to go natural, some want an epidural "in the parking lot," some would rather take a wait-and-see-if-it's-needed approach.

Some care providers are very respectful of a woman's wishes about pain management in labor. However, some practically mandate that all their patients receive an epidural, while others can be judgmental about any use of pain medications. Still others know many "tricks" to help women lower their need for pain relief in labor but are supportive of whatever the woman chooses at the time.

Respect for one's wishes regarding pain management during labor plays a strong role in women's satisfaction with their birth experience. It is vitally important to find a care provider who is aligned with your preferences and who will be supportive of your choices.

9. How do you feel about cesareans?

Some providers truly believe that vaginal birth is dangerous and that cesarean birth is to be preferred. Others believe that cesareans are to be avoided at virtually any cost. Most providers fall somewhere in between, but most tend to "lean" one way or the other. Obviously, every caregiver is supportive of cesareans when they are truly life-saving but their attitudes towards other cesareans (and the current cesarean rate in first-world countries) can be revealing about their underlying philosophies of birth and likelihood to use a cesarean.

Beware: Nice Is Not Enough

Don't let a care provider's bedside charm and personality supercede your own commonsense about interventions. A care provider can be really charming, caring, and nice and still have a 50+% c-section rate and a 40+% episiotomy rate, which will do far more harm than good in the long run.

Just because they are "nice" doesn't mean you are going to get care from them that doesn't put you at risk for more complications. 

One midwife told the story of the following doctor on her blog:
What is the definition of a “good doctor”? I once knew a physician whom everyone believed was a “good doctor”. Let’s call him Dr. Wonderful. He had a very high cesarean rate, a high episiotomy rate, a high forceps/vacuum rate, and yet his patients adored him. Why?
He made each woman who came to him feel special. He was handsome and charming, and would treat each woman as if she were the only patient in the world that mattered to him. This is not necessarily a bad thing–I believe each patient should feel special and important to her provider. However, when this perception of being special clouds a woman’s judgment, it is time to have a reality check.
Dr. Wonderful would visit his patient after whatever unnecessary procedure he did, sit by the bedside, take her hand, and very regretfully tell her how sorry he was that she needed ___________ (insert the procedure of your choice), but if he had not done it, ___________ would have happened (insert catastrophe of your choice). So he very reluctantly had heroically intervened to save her life, or the life of her baby. The woman would be trembling with gratitude toward this marvelous physician by the time he left the room. None of his patients could ever believe that any of these procedures were unnecessary.
This bait-and-switch tactic is very common among some care providers. They know how to manipulate patients into going along with what they think is best and/or what is most convenient, even when the actual research doesn't support these interventions as best practice. 

Most women think that if their doctor recommends a procedure to them, it must be necessary, and who are they to question the doctor's judgment? But most don't realize how much interventions vary from caregiver to caregiver. Nor are most given adequate information about the pros and cons of most procedures.

The point is not that all interventions are "bad" or must be avoided, but that the benefits and risks of proposed interventions should be discussed thoroughly and true patient autonomy respected, not manipulated. 

If you are sure you want a hospital birth but you'd like to try and find a provider who is more friendly to natural childbirth and patient autonomy than most, the midwife above summarized one strategy for scoping out the possibilities:
I suggest that women who are planning hospital birth call their local [Labor and Delivery] unit, and ask to speak to a nurse who enjoys helping women who want unmedicated birth. Then ask that nurse for names of doctors [or midwives] that she thinks are most likely to support you in your goals.
Last, and perhaps most important, don’t be fooled by a charming bedside manner. Make sure there is substance behind it.
Amen to that. "Nice" is wonderful, but some care providers use it as a way to convince women into all kinds of risky interventions as a way to lower the risk for being sued or because it's more convenient for him/her. 

In particular, many women of size are just so grateful just to find a doctor who doesn't yell at them about their weight that they fail to ask further questions about the provider's rates of interventions that increase the risk for cesarean (a high induction rate, inducing for suspected big baby, etc.). 

I've been there done that myself and gotten burned, so learn from my mistakes.

Don't fall for "nice" over substance. Nice is a good start, but you still have to ask further questions.

Ask for Specific Intervention Rates

It's really important to ask a provider's intervention rates, especially his/her intervention rates for first-time moms.

What's his/her induction rate, cesarean rate, episiotomy rate? 

Also observe how the provider responds to questions about these things. That's as telling as the actual intervention rate.

For example, "I only do them when necessary" is not a helpful answer; for some docs, interventions like these are seen as "necessary" 60% of the time, and that rate presents far more risk than benefit. 

For example, episiotomy rates should be quite low; if it's not, the provider is not practicing evidence-based medicine, which has clearly shown routine episiotomy to be more harmful than helpful

Many doctors say they "only do episiotomies when necessary" --- but if they find it "necessary" 40% of the time, there is something wrong with their definition of "necessary."

Moral of the story: Actual numbers are important for evaluating a provider.

Primary cesarean rates (cesareans in first-time moms or mothers who have never had a cesarean before) is another benchmark by which you can judge providers. Women who have not had cesareans before should not have a very high rate of cesareans during labor; if they do, it suggests that the doctor has a low threshold for surgery or encourages a lot of interventions that lead to more cesareans.

(Of course, if a provider regularly provides care to many high-risk women, the cesarean rate is going to be higher than a provider who mostly sees only low-risk women.....but generally speaking a high cesarean rate is a red flag.) 

It's also helpful to ask how the care provider feels about cesareans. 

If they have a high cesarean rate but are defensive about that, they'll likely say something that minimizes the impact of cesareans and ridicules the mother for caring. 

Watch out for comments like, "The real priority is a healthy baby" or "A healthy baby is more important than the delivery method".....as if that justifies any intervention the doctor uses, as if the mother's outcome is of no importance, and as if the mother questioning things means she doesn't really care about her baby over herself.

Of course the priority is a healthy baby, but a healthy mother is also a priority, and one recovering from unnecessary surgery is not a healthy mother. Nor should a woman be ridiculed for caring about avoiding a cesarean or an episiotomy whenever possible. 

A provider that avoids the question of intervention rates by blaming the mother, brushing off her concern, or making her feel selfish for caring is a giant red flag.

Beware care providers that "don't know" their cesarean rate, or who subtly deride anyone who asks questions about cesarean or episiotomy rates. All providers should have a general idea of their cesarean and episiotomy rates. If they don't, that suggests that they don't think these rates are important or aren't concerned about their use.

Also ask when/why the provider would want to induce labor. If they routinely induce labor if the baby is thought to be  "big," that's another tremendous red flag.  Research shows that inducing early for a "big baby" actually increases the cesarean rate, but despite the evidence, many providers still induce early for a big baby anyway.  [This is one major factor driving the high rate of cesareans in women of size.]

If you interview a provider and they would induce early for a big baby, this is a huge red flag.

Many providers also routinely induce labor at 39, 40 or 41 weeks, and research is mixed on the pros and cons of this practice

Particularly for women of size (whose pregnancies tend to last longer), inducing labor early or right around term "just in case" probably leads to more cesarean risk and a whole host of other potential complications. You may want to find a provider who is more willing to wait and not rush things as long as mother and baby are doing well.

Conclusion

You can have the "nicest" doctor or midwife in the world, and he or she can still coax you straight down the path to a cesarean or episiotomy you don't need by engaging in unnecessarily high rates of interventions with dubious benefits.

Being nice is just not enough. You have to ask careful questions when interviewing a care provider, you have to ask for specific intervention rates, and it's very important to watch for the classic red "alarm" flags.

What questions were most helpful to you when you were interviewing providers? What questions do you wish you had asked? What advice do you have for other pregnant women looking for maternity care providers?


*July 2014 Update: These questions were originally shared in a much longer article ("In Search of Dr. Right: 11 Questions to Ask" by The Midwife Next Door) on another website, and I gave credit and linked to that article in my original post in 2010. Sadly, the original link has since been compromised and now goes to an extremely undesirable site, so I have stripped out all those links and am re-posting this article without them. The questions are helpful so I am keeping the post; but it's important to note that it originally arose from another's work.

Saturday, July 5, 2014

Looking for PCOS Stories

Happy holiday weekend everyone!

Just wanted to let you know that I'm working on continuing my series on PCOS (Polycystic Ovarian Syndrome) later this summer.

While, as always, I'll have lots of research and facts, I'd also like to add some stories from real women with PCOS. One of the difficult things about PCOS is that it's a syndrome, and that means it can present really differently in different people. Not everyone's experience is going to be the same, and not every treatment regimen is right for every person.

Thus it's important to represent a wide variety of experiences and treatment regimens, and it's really important to bring that personal voice of experience to the discussion, especially as we start to delve into some of the more personal aspects of PCOS.

In the past we've worked on discussing treatment choices for various aspects of PCOS, and I'd like to continue that. We've been focusing on treatment for menstrual irregularity and insulin resistance/blood sugar issues; now I'd like to focus on treatment for other common aspects of PCOS.

I'll be looking particularly for stories dealing with treatment choices for androgen excess, for hirsutism, for hair loss, and for infertility. Not all at once, of course...each one separately.

So, for example, if you are a person who has used The Pill to deal with androgen excess or menstrual irregularity, share which one was recommended to you and your experience in using it. Did it help? Did it make things worse in some ways but better in others? Did you have any complications with it? How did treatment recommendations for it change as you aged? What types are best for women with PCOS in your experience?

Or if you are a person who has dealt with hirsutism (excess hair on the face and body) or alopecia (hair loss on the head), summarize how you have dealt with it. Did you choose to do anti-androgen medications, cosmetic methods, or a combo of both? How successful were the treatments? Or did you opt out of treatment eventually? What information would you like to have read about treatment choices when you were first dealing with PCOS? What encouragement can you give to other women dealing with these challenges to their self-esteem?

Or if you are one of the many women with PCOS who have dealt with infertility, share your infertility journey and what has helped you. Did you use Clomid or other medications, did you use IVF, did you use alternative treatment like herbs or acupuncture, or something else? How long did you try? What was most effective for you? What was a waste of time and money? What would you like to have known about treatment choices ahead of time? If you were not able to have children, did you choose to remain childless or did you choose to adopt or go with surrogacy? If you were able to have children, what was most helpful in that process?

Obviously, some of these issues are very personal. Rest assured that your story will be shared anonymously or under a pseudonym (pen name). If you do have a story to share, please email a brief summary of your experiences to kmom AT plus-size-pregnancy DOT  org. Don't forget to give me specific permission to share your story, and please tell me what pseudonym you'd like to use (if you have a preference).

Because I may be sharing multiple stories, it's important that you keep your story brief. Focus on one or two aspects of your treatment or experience rather than trying to cover the whole thing. Ask yourself, what would you most like to get across to another woman with PCOS who is starting to deal with the same issues?

Keep in mind that I may not be able to use all entries, or I may choose to quote only part of your story. I may also edit for practical stuff like grammar, spelling, etc. Again, I will not be publishing under anyone's real name, so choose a pseudonym you are comfortable with.

Try not to give medical advice in your piece; none of us are healthcare providers, and we don't know the details of anyone else's case. It's okay to share what has worked for you or to advocate awareness of a particular treatment approach, but avoid telling people what they should do or getting preachy. We are all adults, we all make our own choices, and what's right for one person may not be right for another. Raise awareness, educate people about their options, but respect their right to make their own choices.

I'd also love for people to share their favorite PCOS resources....books, websites, blogs, and links. I'm aware of many of them but I'm sure there are many more out there I'm not familiar with. Tell me the resource, give its link, describe what it deals with, and tell me why you think it's helpful for women with PCOS.

Rest assured, this will be a continuing periodic series. In the future, we will be dealing with PCOS pregnancy, birth, breastfeeding, menopause issues, and many other things. But for now, it's time to continue posting about treatment options for some of the more common PCOS symptoms and health concerns, and it's time to add some personal voices to these discussions.

I look forward to reading your stories!

Friday, June 27, 2014

Canning Books for Beginners

Image by Carter Housh

It's that time of year, when all the bounty of summer fruits are starting to roll in. Strawberries are in, rhubarb is in, the raspberries have just sprung to fruition, and cherries are hitting full force. Blueberries are just around the corner, and then it's time for plums. Yummm!

For me, that means it's time to start canning in order to preserve all these delicious fruits so I can enjoy them next winter too.

This is not something I grew up doing or learned from my mother; I had to learn it on my own. I came to it only in middle age, but it's a skill I'm determined to teach all my children because I think it's something everyone should know how to do.

If for no other reason, people should know how to preserve food so they have some emergency food on hand that doesn't depend on a refrigerator or freezer to keep it safe. And of course it's great to have these summer foods available to eat out of season, and they make great homemade gifts. But the best reason is because these foods just taste delicious!

So let's talk about the very easiest foods to can, jams and preserves, and the best books for learning how to prepare these.

Canning Books for Jams

When I was first learning how to can, I looked for a book that was quick and easy to understand, had great diagrams and instructions, and which had a lot of interesting recipes.

I found quite a number of good canning books and resources out there. Each one had something different to recommend it. Here are the best ones for beginners.

Put 'Em Up by Sherri Brooks Vinton is my favorite canning book and the one I recommend to beginners. I find the explanations very clear and concise, with some of the most clear illustrations of the process I've seen. When I was a beginner, this was the book that was most helpful to me.

I also liked that she organized the book by types of produce, so if cherries are in season and you are looking for something new to do with your overload of fresh cherries, you just turn to the "cherry" section of the book (which is clearly labeled and easy to find). That is really helpful. Many canning books are not organized like this.

The author has a great sequel too, just for fruits, with further recipes and hints on how to use them. And she now has a Preserving Answer Book, to answer common questions about canning, drying, freezing, etc. for those fairly new to food preservation.

One of the most common canning books, of course, is the Ball Blue Book Guide to Preserving and the Ball Complete Book of Home Preserving. Its companion website is www.freshpreserving.com, and it has a great guide to getting started with canning if you want to learn about canning without having to spend the money to buy a book.

This book is the classic canning book, and all its recipes have been extensively tested for safety. It's been around forever so it's got lots of time-tested recipes that have been favorites for generations. It goes far beyond the basic jam recipes included in most books and has recipes for many other types of foods besides jams.

A newer canning book that many people seem to like is Food In Jars by Marisa McClellan. The author has an excellent blog from which the book sprang. It has lots of interesting hints for canning and links to unusual products like special canning jars.

One interesting thing about Food In Jars recipes is that they often have unusual flavor combinations that go beyond the usual basic recipes found in most books. She typically does not use pectin in her recipes, but teaches the old-fashioned cook-em-till-they-set method. She has a great Canning 101 section on her blog where she answers a lot of questions about canning technique and safety.

The author has also written Preserving By The Pint, which specializes in canning recipes for very small batches, which can seem more do-able to the beginning canner since no special equipment and no huge pots of water are needed. You don't need to buy big batches of fruit and you end up with only a few jars to store, which is important if you have only limited storage. Most canning recipes were written for women with large families to feed; this is the scaled-down version for folks with very small families, not much time, or limited storage.

Another bonus is that the author does a lot of touring and offers classes all over the country teaching many of the recipes used in her book. That's good marketing and it helps a lot of people who feel insecure with canning to get past the fear and start doing it.

Another book which might be really handy for some is Preserving with Pomona's Pectin by Allison Carroll Duffy. This book specializes in recipes using Pomona's Pectin, which is a somewhat harder-to-find pectin but which offers the distinct advantage of being able to adjust the sugar content in a recipe.

With most other pectins, you have very little flexibility about how much sugar to use in a recipe. The full-sugar pectins use insane amounts of sugar in their recipes; usually far more sugar than fruit. Even the "reduced sugar" pectins (like Sure-Jell in the pink box) still use quite a bit of sugar.

But Pomona's Pectin works differently than other pectins. It doesn't need sugar to help "gel" the jam; it uses calcium water instead to get the gel. This means that the sugar content of these jams can be adjusted to your heart's content. You can use as much or as little as you prefer, and you can use honey, agave syrup, fruit juice, or artificial sweeteners to sweeten your jam instead of sugar. If you are one of the many people trying to reduce the sugar content in your diet for health reasons, this is a great option to have.

Pomona's Pectin offers a lot more flexibility than other pectins, but it has a little steeper learning curve than the full-sugar pectins. Having a book that discusses the process of using this pectin in minute detail can be useful for those new to canning with Pomona's Pectin.

Summary

There are many, many great canning books available out there, but these are some of the best canning books for beginners. Youtube also has many video tutorials available on canning, and you can find many canning instructional DVDs as well.

Once you get good at the basics, then you can start adding wet and dry "zing" (spices and liqueurs) to your fruit ingredients and creating your own custom recipes. Or you can learn how to make pectin-free jams. But first, it's helpful to get comfortable with the fundamentals.

There are so many great resources on learning to can out there; get started on learning this important skill this summer! Or take your basic knowledge of canning to a whole new level of experimentation instead by playing around with the more advanced recipes in these books and blogs.

Remember, it's perfectly okay not to be a Canning Diva; you're not a canning failure if you don't spend all your time in the kitchen or put up great quantities of food. Do as much or as little canning as you have time for, but do learn to can so we keep this important skill alive and so that you have shelf-stable food put aside for emergencies. 

Wednesday, June 18, 2014

Breastfeeding And Gestational Diabetes, Part One: Vital Benefits to Mother and Baby



More and more research is showing how important breastfeeding is after a Gestational Diabetes (GD) pregnancy, both for mother and baby.

Yet research consistently also shows lower rates of breastfeeding after Gestational Diabetes.

Promoting and improving breastfeeding rates in GD mothers is one easy way to improve the long-term health of mothers and babies exposed to GD, yet there are still far too many barriers to it.

Let's start with the many benefits of breastfeeding after GD, both for mother and baby.

How Breastfeeding Helps After Gestational Diabetes

Image credit: Much 2014
Breastfeeding improves the mother's blood sugar and insulin levels very quickly post-partum, and improves glucose utilization. It may also improve pancreatic beta cell mass, proliferation, and function, which should improve the mother's capacity to produce insulin adequate to compensate for any insulin resistance.

GD women who breastfeed have lower rates of abnormal blood sugar at their 6-week follow-up glucose tolerance test postpartum.

Breastfeeding also lowers insulin levels and improves insulin sensitivity more long-term.

As a result, breastfeeding lowers a mother's risk for developing diabetes later in life.

Even only a short period of breastfeeding offers some protection. However, the more you breastfeed and the longer the duration, the more your risk for diabetes may be diminished. That's HUGE.

Image credit: Much 2014, adapted from Ziegler 2012
Look at the graph above. Although many women were lost to follow-up, there was a clear and strong trend towards less diabetes in the women who breastfed their babies for more than three months. 72.6% of those who did not breastfeed or who breastfed for three or fewer months developed diabetes by 15 years post-partum, vs. 42% of those who breastfed for more than three months.

And really, three months of breastfeeding isn't that long in the scheme of things. Studies that looked at moderately longer periods found much lower insulin levels and better insulin sensitivity in those that nursed more than 10 months.

And 10 months does not even meet the American Academy of Pediatric's recommendation to nurse at least a year, or the World Health Organization's recommendation to nurse at least two years. How much more protection might there be for longer periods of breastfeeding?

One very large 2005 study found that the risk for diabetes declined about 15% for each additional cumulative year of breastfeeding, and another 2008 study found that the relative risk for diabetes was 0.68 in those with 4 or more years of lifetime lactation duration.

Breastfeeding may also offer some degree of protection against certain types of cancer which GD mothers may be more at risk for, including breast, endometrial, ovarian and possibly pancreatic cancers.

Even more imporantly, long-term breastfeeding may also offer some protection against heart disease and mortality

Some studies have found lower rates of cardiovascular risk factors in women with long-term breastfeeding. Most importantly, research has shown that breastfeeding translates into fewer heart attacks and lower mortality rates too. That's also HUGE.

One theory to explain all this is that pregnancy induces temporary changes in glucose and lipid metabolism that are beneficial for baby but not for the mother, and that these changes are even more marked in women with Gestational Diabetes. In this theory, breastfeeding is nature's way of "re-setting" the mother's metabolism back to normal afterwards. If breastfeeding does not occur (or is brief), the mother's metabolism doesn't really return to normal and she is much more likely to develop diabetes, hypertension, and heart disease with time.

Although this is still just a theory at this point, it is a logical one, and one with some data to support its premise. Obviously, the human body is complex and many different factors play a role in the development of disease, but long-term breastfeeding may be an effective, low-cost, and extremely practical way to lower the risk for later disease.

Clearly, breastfeeding (and especially long-term breastfeeding) has important potential benefits for GD mothers.

Extra Benefits for GD Babies

Breastfeeding has so many benefits for all babies. We've known this for quite a while, yet it's surprising how often this does not get communicated well to pregnant women or the general public.

The general benefits of breastfeeding include lower risk for infections, asthma, diarrhea, ear infections, celiac disease, Sudden Infant Death Syndrome (SIDS)necrotizing enterocolitis in pre-term infants, and many other things. That's all pretty important right there.

But breastfeeding has extremely important immunological functions that are under-appreciated even among care providers. When in utero, the baby depends on the mother's placenta for immunological protection. After the baby is born, its own immunological system is quite immature. Nature designed breastfeeding to help bridge the gap between in utero protection and when the baby's own immunological system matures.

The first milk, colostrum, plays a vital role in "coating" the surface of the baby's intestines to help them be less vulnerable to pathogens. Later, human milk encourages the growth of the villi in the intestine and develops antibody responses specific to the pathogens the mother encounters. It also helps the baby strengthen and develop its own immuno-responses to pathogens, which may provide enhanced immuno-protection even after breastfeeding ends. Thus, breastfeeding is crucial in protecting the baby's immune system both short- and long-term. Its benefits do not end with weaning.

These are all important reasons to raise breastfeeding rates in the general population. However, there are additional potential benefits for babies of GD pregnancies.

The biggest benefit of breastfeeding after a GD pregnancy is that it lowers the risk of the baby developing diabetes as he/she grows to adulthood.

This is another HUGE advantage. Babies exposed to higher blood sugar rates in utero tend to have poorer glucose metabolisms, more insulin resistance, and more metabolic syndrome later in life.

If breastfeeding can prevent or delay many cases of metabolic syndrome and diabetes in a GD mother's offspring, it has tremendous public health implications for babies as well as mothers.

And this may be a particularly important finding for people of color, because of their increased risk for diabetes. One early study in a particularly vulnerable population (Pima Indians) found about half the risk for diabetes in adults who were breastfed for at least two months compared to those who were not. Imagine what the difference might be with longer periods of breastfeeding!

One study projected that if 90% of families in the U.S. breastfed exclusively for 6 months, about 911 deaths would be prevented each year. Of course, data projections like this are merely speculative, but even so, a clear trend in the statistical model implies that increasing breastfeeding rates would be a low-cost, effective strategy for improving public health in babies as well as in mothers.

And this may especially be true for babies of GD pregnancies.

Conclusion

Breastfeeding is a vital part of the so-called "fourth trimester" of pregnancy...and well beyond.

In other words, the mother's biological role in protecting her baby does not end with the baby's birth. It extends into breastfeeding and even beyond weaning.

Nature intended babies to be breastfed for significant periods of time in order to protect them while they are immunologically immature and to produce optimal and healthy growth and development. Nature also intended breastfeeding to benefit the mother by re-setting her metabolism and lowering her risk for heart disease and some cancers. Breastfeeding's benefits to both baby and mother do not end with weaning but appear to last for years afterwards.

Obviously, there are times when breastfeeding isn't possible, doesn't work out, or isn't wanted for various reasons, and it's good that we have substitutes available for these situations. Formula isn't "bad" or "evil," and it's a reasonably good substitute when human breastmilk is not available. Although uncommon, there are women who are truly unable to breastfeed and it's important that we have respect for that experience and support for those women even as we promote breastfeeding.

However, we must remember that Nature's design results in the most optimal outcomes and we subvert that design at the risk of significant harm on a population-wide basis. 

How much of our public health woes today are due to the widespread and very strong discouragement of breastfeeding by physicians in the last century? We may never know, but I would bet that at least some of the increase in diabetes and other problems we see today is at least partly due to the tremendous pressure on women from the mid-20th century not to breastfeed.

Even today, when most care providers at least pay lip service to the benefits of breastfeeding, many women are subtly discouraged from nursing or are told that there is little benefit to continuing to breastfeed past a few months. (Yep, I heard this one).

Even more alarming, despite evidence of EXTRA benefits to breastfeeding after a GD pregnancy, women with Gestational Diabetes have lower rates of breastfeeding than other women. 

Although some of this may have some basis in biological differences like PCOS (Polycystic Ovarian Syndrome), much of it is rooted in routine practices and interventions common during and after births in women with Gestational Diabetes. Yet care providers often fail to recognize that breastfeeding "failure" often begins with the interventions that occur during and after birth. 

There is much that can be done to raise breastfeeding rates in women with GD, if only caregivers and hospitals would recognize the role that common interventions plays in interfering with establishment of breastfeeding.

That's not to say that interventions should never take place. Sometimes interventions are truly necessary, especially in complicated cases of GD, but the reality is that they are often overused, and reducing them is a good first step in increasing breastfeeding rates. And even when interventions are truly necessary, there is much that can be done to protect and promote breastfeeding under less than ideal conditions, yet full implementation of these measures is lacking in many hospitals.

In our next post, we will discuss specifics on how to remove barriers and raise breastfeeding rates in women with GD. For the long-term health of babies and mothers, it is critical that we do this.


References

Breastfeeding and Short-Term Maternal Glucose Tolerance

Ir Med J. 2012 May;105(5 Suppl):31-6. Breast-feeding is associated with reduced postpartum maternal glucose intolerance after gestational diabetes. O'Reilly M, Avalos G, Dennedy MC, O'Sullivan EP, Dunne FP. PMID: 22838108
...We prospectively examined the prevalence of postpartum dysglycaemia after GDM and examined the effect of lactation on postpartum glucose tolerance. We compared postpartum 75g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT). Breast-feeding data was collected at time of OGTT...The prevalence of persistent hyperglycaemia was significantly lower in women who breast-fed versus bottle-fed postpartum (8.2% v 18.4%, p < 0.001). Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.
Diabetes Care. 2012 Jan;35(1):50-6. doi: 10.2337/dc11-1409. Epub 2011 Oct 19. Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. Gunderson EP, Hedderson MM, Chiang V, Crites Y, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Quesenberry CP, Lo JC, Sternfeld B,Ferrara A, Selby JV. PMID: 22011407
OBJECTIVE: To examine the association between breastfeeding intensity in relation to maternal blood glucose and insulin and glucose intolerance based on the postpartum 2-h 75-g oral glucose tolerance test (OGTT) results at 6-9 weeks after a pregnancy with gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: We selected 522 participants enrolled into the Study of Women, Infant Feeding, and Type 2 Diabetes (SWIFT), a prospective observational cohort study of Kaiser Permanente Northern California members...RESULTS:...Exclusive or mostly breastfeeding groups had lower prevalence of diabetes or prediabetes (P = 0.02). CONCLUSIONS: Higher intensity of lactation was associated with improved fasting glucose and lower insulin levels at 6-9 weeks' postpartum. Lactation may have favorable effects on glucose metabolism and insulin sensitivity that may reduce diabetes risk after GDM pregnancy.
Obstet Gynecol. 2012 Jul;120(1):136-43. doi: 10.1097/AOG.0b013e31825b993d. Influence of breastfeeding during the postpartum oral glucose tolerance test on plasma glucose and insulin.
Gunderson EP, Crites Y, Chiang V, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Hedderson MM, Quesenberry CP, Lo JC, Ferrara A,Sternfeld B. PMID: 22914402
...Participants were enrolled in the Study of Women, Infant Feeding, and Type 2 Diabetes, a prospective observational cohort study of 1,035 Kaiser Permanente Northern California members who had been diagnosed with GDM...RESULTS: Of 835 lactating women, 205 (25%) breastfed their infants during the 2-hour 75-g OGTT at 6-9 weeks postpartum....CONCLUSION: Among postpartum women with recent gestational diabetes mellitus, breastfeeding an infant during the 2-hour 75-g OGTT may modestly lower plasma 2-hour glucose (5% lower on average) as well as insulin concentrations in response to ingestion of glucose.
Breastfeeding and Subsequent Maternal Diabetes

Diabetes Care. 2010 Jun;33(6):1239-41. doi: 10.2337/dc10-0347. Epub 2010 Mar 23. Parity, breastfeeding, and the subsequent risk of maternal type 2 diabetes. Liu B, Jorm L, Banks E. PMID: 20332359
...Using information on parity, breastfeeding, and diabetes collected from 52,731 women recruited into a cohort study, we estimated the risk of type 2 diabetes using multivariate logistic regression. RESULTS A total of 3,160 (6.0%) women were classified as having type 2 diabetes. Overall, nulliparous and parous women had a similar risk of diabetes. Among parous women, there was a 14% (95% CI 10-18%, P < 0.001) reduced likelihood of diabetes per year of breastfeeding. Compared to nulliparous women, parous women who did not breastfeed had a greater risk of diabetes (odds ratio 1.48, 95% CI 1.26-1.73, P < 0.001), whereas for women breastfeeding, the risk was not significantly increased. CONCLUSIONS: Compared with nulliparous women, childbearing women who do not breastfeed have about a 50% increased risk of type 2 diabetes in later life. Breastfeeding substantially reduces this excess risk.
Diabetes. 2012 Dec;61(12):3167-71. doi: 10.2337/db12-0393. Epub 2012 Oct 15. Long-term protective effect of lactation on the development of type 2 diabetes in women with recent gestational diabetes mellitus. Ziegler AG, Wallner M, Kaiser I, Rossbauer M, Harsunen MH, Lachmann L, Maier J, Winkler C, Hummel S. PMID: 23069624
...To investigate whether breastfeeding influences short- and long-term postpartum diabetes outcomes, women with GDM (n = 304) participating in the prospective German GDM study were followed from delivery for up to 19 years postpartum for diabetes development. All participants were recruited between 1989 and 1999. Postpartum diabetes developed in 147 women and was dependent on the treatment received during pregnancy (insulin vs. diet), BMI, and presence/absence of islet autoantibodies. Among islet autoantibody-negative women,breastfeeding was associated with median time to diabetes of 12.3 years compared with 2.3 years in women who did not breastfeed. The lowest postpartum diabetes risk was observed in women who breastfed for >3 months. On the basis of these results, we recommend that breastfeeding should be encouraged among these women because it offers a safe and feasible low-cost intervention to reduce the risk of subsequent diabetes in this high-risk population. 
Lactation Duration and Subsequent Maternal Diabetes

Eur J Endocrinol. 2013 Mar 15;168(4):515-23. doi: 10.1530/EJE-12-0939. Print 2013 Apr. Relationship between lactation duration and insulin and glucose response among women with prior gestational diabetes. Chouinard-Castonguay S, Weisnagel SJ, Tchernof A, Robitaille J. PMID: 23302255
...The study group comprised 144 women with a history of GDM between 2003 and 2010. Plasma insulin and glucose concentrations were obtained from a 75 g oral glucose tolerance test (OGTT). Total lactation duration (exclusive breastfeeding and breast and bottle-feeding) for all infants was self-reported in months. RESULTS: Mean age was 36.5±5.0 years. Time between delivery and metabolic testing was 4.0±1.9 years. Women breastfed for an average of 13.9±16.8 months. Most women (80.6%) reported a history of lactation...Compared with women who lactated for <10 months, women who lactated for ≥10 months had improved insulin sensitivity-secretion index, higher HOMA-IS and Matsuda indices, lower fasting and 2-h post-OGTT insulin concentrations as well as AUC for insulin, and lower incidence of impaired glucose intolerance (P≤0.05 for all). In multiple linear regression analyses, lactation duration emerged as an independent predictor of fasting insulin concentrations (β=-0.02) and insulin sensitivity indices (β=0.02) (P≤0.05 for all). CONCLUSIONS: These results suggest that longer duration of lactation is associated with improved insulin and glucose response among women with prior GDM.
JAMA. 2005 Nov 23;294(20):2601-10. Duration of lactation and incidence of type 2 diabetes. Stuebe AM1, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. PMID: 16304074
...Prospective observational cohort study of 83,585 parous women in the Nurses' Health Study (NHS) and retrospective observational cohort study of 73,418 parous women in the Nurses' Health Study II (NHS II)...RESULTS: ...Among parous women, increasing duration of lactation was associated with a reduced risk of type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% (95% confidence interval, 1%-27%) among NHS participants and of 14% (95% confidence interval, 7%-21%) among NHS II participants, controlling for current body mass index and other relevant risk factors for type 2 diabetes. CONCLUSIONS: Longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women. Lactation may reduce risk of type 2 diabetes in young and middle-aged women by improving glucose homeostasis. 
Diabetologia. 2008 Feb;51(2):258-66. Epub 2007 Nov 27. Duration of breast-feeding and the incidence of type 2 diabetes mellitus in the Shanghai Women's Health Study. Villegas R1, Gao YT, Yang G, Li HL, Elasy T, Zheng W, Shu XO. PMID: 18040660
...This was a prospective study of 62,095 middle-aged parous women in Shanghai, China, who had no prior history of type 2 diabetes mellitus, cancer or cardiovascular disease at study recruitment... RESULTS: Women who had breastfed their children tended to have a lower risk of diabetes mellitus than those who had never breastfed [relative risk (RR)=0.88; 95% CI, 0.76-1.02; p=0.08]. Increasing duration of breast-feeding was associated with a reduced risk of type 2 diabetes mellitus. The fully adjusted RRs for lifetime breast-feeding duration were 1.00, 0.88, 0.89, 0.88, 0.75 and 0.68 (p trend=0.01) for 0, >0 to 0.99, >0.99 to 1.99, >1.99 to 2.99, >2.99 to 3.99 and >or=4 years in analyses adjusted for age, daily energy intake, BMI, WHR, smoking, alcohol intake, physical activity, occupation, income level, education level, number of live births and presence of hypertension at baselines....
Breastfeeding and Cardiovascular Implications

BMC Public Health. 2013 Nov 13;13:1070. doi: 10.1186/1471-2458-13-1070. A prospective population-based cohort study of lactation and cardiovascular disease mortality: the HUNT study. Natland Fagerhaug T1, Forsmo S, Jacobsen GW, Midthjell K, Andersen LF, Ivar Lund Nilsen T. PMID: 24219620
...In a Norwegian population-based prospective cohort study, we studied the association of lifetime duration of lactation with cardiovascular mortality in 21,889 women aged 30 to 85 years who attended the second Nord-Trøndelag Health Survey (HUNT2) in 1995-1997. The cohort was followed for mortality through 2010 by a linkage with the Cause of Death Registry...RESULTS:...Parous women younger than 65 years who had never lactated had a higher cardiovascular mortality than the reference group of women who had lactated 24 months or more (HR 2.77, 95% confidence interval [CI]: 1.28, 5.99)...CONCLUSIONS: Excess cardiovascular mortality rates were observed among parous women younger than 65 years who had never lactated. These findings support the hypothesis that lactation may have long-term influences on maternal cardiovascular health.
Breastfeeding and Maternal Cancer

Am J Clin Nutr. 2013 Oct;98(4):1020-31. doi: 10.3945/ajcn.113.062794. Epub 2013 Aug 21. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Luan NN1, Wu QJ, Gong TT, Vogtmann E, Wang YL, Lin B. PMID: 23966430
...We performed a meta-analysis to summarize available evidence of the association between breastfeeding and breastfeeding duration and EOC [ovarian cancer] risk from published cohort and case-control studies...RESULTS: Five prospective and 30 case-control studies were included in this analysis. The pooled RR for ever compared with never breastfeeding was 0.76 (95% CI: 0.69, 0.83), with moderate heterogeneity (Q = 69.4, P < 0.001, I(2) = 55.3%). Risk of EOC decreased by 8% for every 5-mo increase in the duration of breastfeeding (RR: 0.92; 95% CI: 0.90, 0.95). The risk reduction was similar for borderline and invasive EOC and was consistent within case-control and cohort studies. CONCLUSIONS: Results of this meta-analysis support the hypothesis that ever breastfeeding and a longer duration of breastfeeding are associated with lower risks of EOC....
Breastfeeding and Diabetes in Children

Am J Clin Nutr. 2006 Nov;84(5):1043-54. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. PMID: 17093156
...DESIGN: A systematic review of published studies identified 1010 reports; 23 examined the relation between infant feeding and type 2 diabetes in later life or risk factors for diabetes...RESULTS: Subjects who were breastfed had a lower risk of type 2 diabetes in later life than did those who were formula fed (7 studies; 76 744 subjects; odds ratio: 0.61; 95% CI: 0.44, 0.85; P = 0.003). Children and adults without diabetes who had been breastfed had marginally lower fasting insulin concentrations than did those who were formula fed (6 studies; 4800 subjects; percentage difference: -3%; 95% CI: -8%, 1%; P = 0.13); no significant difference in fasting glucose concentrations was observed...CONCLUSION: Breastfeeding in infancy is associated with a reduced risk of type 2 diabetes, with marginally lower insulin concentrations in later life, and with lower blood glucose and serum insulin concentrations in infancy.
Lower Rates of Breastfeeding in Women with Diabetes

Diabet Med. 2013 Sep;30(9):1094-101. doi: 10.1111/dme.12238. Epub 2013 Jun 21. Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study. Finkelstein SA, Keely E, Feig DS, Tu X, Yasseen AS 3rd, Walker M. PMID: 23692476
...METHODS: A retrospective cohort analysis was conducted using data from four Ontario hospitals. Women who delivered a viable infant between 1 April 2008 and 31 March 2010 were included in the study...CONCLUSIONS: Women with insulin-treated diabetes had the poorest outcomes with respect to breastfeeding rates. Gestational and non-insulin-treated diabetes were associated with lower rates of breastfeeding in hospital, while gestational diabetes was additionally associated with lower breastfeeding rates on discharge.
Dtsch Med Wochenschr. 2008 Feb;133(5):180-4. doi: 10.1055/s-2008-1017493. [Breastfeeding in women with gestational diabetes]. Hummel S, Hummel M, Knopff A, Bonifacio E, Ziegler AG. PMID: 18213549
...METHODS: Breastfeeding habits (breastfeeding of any duration) were recorded of 257 mothers with gestational diabetes...who participated in a prospective post-partum study between 1989 and 1999 and compared to breastfeeding habits of 527 healthy mothers... all enrolled in the prospective BABYDIAB study between the years 1989 and 2000...RESULTS: Compared to children of healthy mothers, fewer children of mothers with gestational diabetes were breastfed (75% vs 86%; P<0.0001). Among breastfed children the duration of full or any breastfeeding was shorter in children of mothers with gestational diabetes (median for full breastfeeding 9 weeks. [mothers with gestational diabetes] vs. 17 weeks. [healthy mothers]; p<0.0001; median duration of any breastfeeding 16 weeks. vs. 26 weeks.; p<0.0001)...Full and any breastfeeding was shorter in women with insulin-dependent gestational diabetes than in those with diet-controlled gestational diabetes (full breast-feeding 4 weeks. vs. 12 weeks.; p<0.01 and any breastfeeding 10 weeks. vs. 20 weeks,; p<0.0001)....