Birth Story

Bring on the party hats!

I started my blog on Jan 3, full of trepidation about whether I would be able to keep up with posting three times a week about pregnancy, childbirth, medical history, maternal mortality, etc. After all, I have a job, a family, a dog, and on and on.

But I can do this! And I've learned a lot!

What's next?

My most popular post so far was "Birth in Haiti." You could've knocked me over with a feather.

My own favorites were the two posts I wrote after interviewing Robbie Goodrich, who lost his wife, Susan, last year to amniotic fluid embolism. Robbie was kind enough to talk with me while planning a big birthday celebration for his son, Charles Moses, and honoring Susan's memory on the anniversary of her death.

Career adviser Penelope Trunk tells bloggers not to succumb to the temptation to start that second blog. Penelope, you read my mind! I have been thinking how much fun it would be to lighten up a little, loosen up the voice, write about something else besides the point in childbirth at which bliss and safety concerns intersect.

But you know what? Penelope is right. "Birth Story" is my topic, because for 12 years, since I survived an amniotic fluid embolism during my younger daughter's birth, I have been fascinated with extreme childbirth. So I am going to stay with the difficult stories, the life-saving innovations and all those mixed emotions.

I enjoy the immediacy of blogging, and "meeting" other bloggers, many of whom are moms as well. I've settled into a Monday/Wednesday/Friday publishing schedule. And I'm still finding my voice.

So now we'll embark on the next leg of the journey. Maybe every couple of months I'll drop in a totally irrelevant picture like the one above and celebrate a little, just like today!

People talk about "evidence-based medicine" in obstetrics, and in the holistic birthing community as well, as if it's a sleek, shiny package tied up with a bow and ready for Christmas morning.

But evidence-based medicine is a shambling, messy thing, always on the move, only as reliable as the researchers who conduct it -- and as the research that has gone before and serves as its foundation.

The Lancet's retraction earlier this month of a 1998 study that appeared to establish a link between the development of autism in young children and the vaccine for measles, mumps and rubella is a good demonstration of the fallibility of evidence-based medicine.

One reason the original Lancet study collapsed was that other researchers could not duplicate lead author Andrew Wakefield MD et al.'s results. But even while 10 of the 13 original co-authors withdrew their support for the study, the public absorbed the idea that a cause-effect relationship exists between vaccination and autism.  That idea has not been eradicated by the Lancet's retraction.

And while such a retraction is unusual, it is unfortunately not unheard of.

Last July, anesthesiology researcher Scott S. Reuben MD of Baystate Medical Center in Springfield, Mass., was revealed to have falsified results in at least 21 studies that appeared in several peer-reviewed journals. Anesthesia and Analgesia alone retracted 10 of Dr. Reuben's articles.

Dr. Reuben specialized in multimodal analgesia, a drug-delivery system designed to control the pain of surgery.

In January, Dr. Reuben pleaded guilty to fraud for such audacious creations as a 2005 trial of Pfizer's drug Celebrex as an agent in a multimodal analgesia model. Dr. Reuben accepted $74,000 from Pfizer to conduct the study, simply did not do the work, and then published fabricated results in Anesthesia and Analgesia.

Unfortunately, other researchers based their own work on those phony results.

The collapse of Reuben's data has left multimodal analgesia “in shambles....The big chunk of what people have based their protocol on is gone,” said Jacques Chelly,  an anesthesiologist at the University of Pittsburgh Medical Center, in Anesthesiology News last March.

Should pregnant women participate in trials to discover the effectiveness and potential side effects of new drugs?

This is a controversial topic, because participating in drug tests exposes pregnant women and their babies to possible harm.

Ruth Macklin, an ethicist writing in The Lancet, makes a compelling case for enrolling pregnant women in drug research and retaining women in studies if they become pregnant.

After all, once approved, drugs go on the market, where doctors will prescribe them to many people across the board, including pregnant women in potentially large numbers, Macklin notes. If researchers haven't had a chance to see the effects of a particular drug on pregnant women and their fetuses, then drugs that cause damage might injure large numbers of people before an alarm is sounded.

We don't have to imagine such an event. Thalidomide, a multi-purpose drug introduced in Europe in 1957, was prescribed for morning sickness for pregnant women. It took four years for researchers to realize and then prove that the drug was causing devastating birth defects. More than 10,000 babies in 46 countries whose mothers had taken thalidomide were born with deformed, often truncated limbs.

"Had the drug been tested in very few women in a ... clinical trial, the mutagenic effect would more likely have been discovered and the number of babies born with deformities would have been much smaller," Macklin writes.

Various governmental bodies, including the U.S. Food and Drug Administration, have gone back and forth on whether to test drugs on pregnant women since it became known that drugs can cross the placenta and affect babies.

HIV-AIDS has forced the issue because not only will pregnant women likely take the drugs that are being developed to combat the fatal disease, but clinical trials also present an opportunity for infected women to obtain potentially life-saving treatment that has not been approved for general use. It is "essential" to include infected pregnant women in these trials, Macklin writes.

The Microbicide Trials Network, based at the University of Pittsburgh and Magee-Womens Research Institute in Pittsburgh, which is working to develop new treatments for HIV-AIDS, is doing just that. In a drug study now under way, MTN is retaining women who become pregnant, and is enrolling pregnant women as well, including healthy, HIV-negative pregnant women, Macklin writes.

However, researchers who enroll pregnant women in studies must "ensure that the informed consent process meets the highest standards," so the women who choose to participate in trials understand the risks to them and their fetuses, Macklin writes.

Image from "Pregnant Graffiti" by Petteri Sulonen

At the beginning of the 20th century, pregnant women put their affairs in order and kissed their families with fervor before they went into labor, knowing they might not survive their "travail."

A decade into the 21st century, birth has become so safe in industrialized countries that we tend to take that safety for granted. The vast majority of women sail through birth without a hitch.

In addition, women who 100 years ago could not have hopefully embarked on a pregnancy -- women with diabetes, for example -- now are able to bear children with careful monitoring.

Some women do still encounter problems that can be life-threatening, however, and it's not always possible to predict which women those will be.

The World Health Organization estimates that the "natural" maternal mortality rate, which women with no access to health care could be expected to suffer, is between 1,000 and 1,500 per 100,000 births.

In Ireland, which has the world's lowest rate of maternal mortality, one woman dies per 100,000 births, so attention to laboring mothers makes a difference. In 2005, the worldwide maternal mortality rate was 402 deaths per 100,000 births.

The highest rates occur in politically unstable parts of Africa and Asia, notably Sierra Leone (2,000 deaths) and Afghanistan (1,900). The rate in the United States is 13, up from 12 the previous year. (All figures are from 2005.)

WHO defines maternal mortality as the death of a woman while pregnant or within 42 days of termination of pregnancy, regardless of the duration or site of the pregnancy, as long as the cause of death is related to or aggravated by the pregnancy or its management, and not from accidental or incidental causes.

Canada's full-bore pursuit of gold at the Olympics the country is hosting in Vancouver, B.C., has attracted much comment, mostly about how out-of-character overt ambition supposedly is for Canadians.

Writing in the New York Times last week, Charles McGrath quoted the Canadian writer George Woodcock on the subject: “Canadians do not like heroes, and so they do not have them. They do not even have great men in the accepted sense of the word.”

Here's one for the books, then -- William Osler, the so-called "father of modern medicine," a great man if ever there was one, born in Bond Head, Ont., in 1849.

Dr. William Osler

Osler received his medical degree from McGill University in Montreal in 1872 but, critically, then went abroad to study in London, Berlin and Vienna before returning to join the McGill faculty. By 1883, he was one of two Canadian fellows of the British Royal College of Physicians. The next year, he accepted a post as professor of clinical medicine at the University of Pennsylvania in Philadelphia.

It was as a founding faculty member of Johns Hopkins School of Medicine in Baltimore, where he went in 1888, that Osler had the opportunity to put the innovations he had seen in Europe to work.

Osler insisted that the patient could teach medical students nearly everything they needed to know -- that the study of medicine was properly conducted at the bedside -- and that hands-on laboratory research must also be part of medical training.  He also introduced the German model of post-graduate training, a one-year internship followed by several years of full-time residency.

These innovations began a profound change in American medical education, which up to this point had been largely a matter of learning from lectures.

Osler was able to implement his ideas because he was an excellent doctor. In 1905 he moved to England to take up a prestigious post as professor of medicine at the University of Oxford. His book, The Principles and Practice of Medicine, was a major work in medicine for nearly half a century.

Osler died in England in 1919, of the Spanish flu.

Canadians might say that Osler's absconding to the United States and England rules him out as a national hero, but it says something when a boy from Bond Head can hit the heights of world medicine.

Who doesn't love them? Aren't curiosity and a desire to improve the human condition two of the most interesting traits a person can display?

Paul de Kruif's 1926 book, Microbe Hunters, is an  early, influential collection of some great medical detective stories, 12 important successes in the field of microbiology, which were achieved by extraordinary medical detective work.

Microbe Hunters dramatizes the journeys, among others, of  Anton van Leeuwenhoek, the first microbiologist; Sir David Bruce, who traced African sleeping sickness to the tsetse; and Walter Reed, who led the team that discovered that yellow fever is caused by mosquitoes.

Medical historian William Summers was one of many dazzled as a teen-ager by the book, which he says "inspired a generation or more of budding young microbiologists."

Microbe Hunters has sold millions of copies and is still in print, but from a modern perspective, the book is flawed -- De Kruif presents detailed conversations between historical figures, for example.

Even when it was written, the book had its detractors, Summers writes. Ronald Ross, a researcher who won the Nobel Prize in 1902 for identifying the parasite that causes malaria, describing its life cycle and explaining how it comes to infect human beings, successfully sued to prevent publication in the United Kingdom of the chapter about his work.

But De Kruif was one of the most successful medical science writers of his time, and when readers take up a book like Richard Preston's The Hot Zone, about the Ebola virus, they are reading an account profoundly influenced by Microbe Hunters.

The conquest of infectious disease is important to obstetrics.  Infection was the leading cause of maternal mortality until well into the 20th century -- and it still is in many parts of the world.

One of the studies presented at the annual meeting of the Society of Maternal Fetal Medicine last week was an intriguing medical detective story.

Researchers at the University of Washington in Seattle noticed that their state had a high incidence of a devastating birth defect called gastroschisis, in which organs, especially the intestines, develop outside the abdomen. The defect has a 90 percent survival rate but requires extensive interventions at and after birth.

The incidence of gastroschisis has doubled and in some places quadrupled in the past 30 years, according to the study. The researchers -- Sarah Waller, Kathleen Paul, Suzanne Peterson, and Jane Hitti, all MDs -- wondered if it might have an environmental cause.

Rural areas in Washington were the hardest hit

Using the state's birth-certificate data base, they determined that the highest incidence of gastroschisis was in the agricultural eastern part of the state.  They matched cases of the defect with a history of agricultural spraying provided by the U. S. Geological Survey. Three possible culprits emerged -- atrazine, nitrates, and 2,4-dichlorophenoxyacetic acid, chemicals commonly used in agriculture.

The researchers looked at all 805 babies born with gastroschisis in Washington between 1987 and 2006 (with a control group of 3,616), and then they calculated how close the babies' mothers lived to water sources with high levels of the three chemicals.

An association between gastroschisis and atrazine, a common herbicide, emerged in the study. The closer mothers lived to a water source with high levels of atrazine, the more likely they were to have a baby with gastroschisis.

The researchers also found that the incidence of gastroschisis increased with babies conceived in the spring, when spraying is especially prevalent. No association was found with the two other chemicals.

This elegant study will be the basis of more study, no doubt, the first steps down the road toward protecting babies from a possible environmental hazard.

The Society for Maternal Fetal Medicine held its annual conference in Chicago last week, and I went to a few sessions. The physicians, who specialize in the health of mothers and their babies, spent up to six days in meetings, so I got a canape-size serving compared to theirs.

Research teams from all over the country, and from other countries as well, reported on their investigations into conditions that jeopardize mothers' and babies' health in pregnancy.  Several important findings came out of the meeting. Here are just a few:

* A simple new urine test with a cool name, the "Congo Red Dot Test," appears to be able to predict and diagnose preeclampsia, a condition that can kill mothers and babies, cause birth defects, and is a major contributor to pre-term birth. A research team from the Yale University School of Medicine found that the test accurately predicted preeclampsia in 347 women in their study. Preeclampsia symptoms include hypertension and protein in the urine. The condition affects 5 to 10 percent of pregnancies. It is commonly treated by delivering the baby.

* One of every three pre-term births is caused by a "silent" infection inside the uterus. Now it appears some women and babies are genetically more susceptible to inflammatory infections, according to a study led by Roberto Romero MD, Chief of the Perinatology Research Branch at the National Institute of Child Health and Human Development. The study won an award from the March of Dimes, a nonprofit group that works to prevent birth defects, premature birth and infant mortality.

At the SMFM meeting, the Yale U. School of Medicine also presented the results of a couple of other investigations that might lead to a decrease in preterm births as well.

Health consumer, meet your first best friend, Johannes Gutenberg.

Johannes Gutenberg

Of all the instruments and processes medical researchers have invented, none has been more important to the advancement of medicine than the printing press, which Gutenberg developed in the mid-15th century, publishing 180 copies of his celebrated Bible around 1455.

A former goldsmith, Gutenberg developed moveable type that could be made of wood or metal, and adapted a wine press to imprint the image on the paper.

Soon, scholars and scientists all over Europe were exchanging ideas. Relatively few people could read at the time, and books were expensive, but that ability to convey information to more than a small group at a time resulted in an explosion of understanding of how the world works.

For the record, the Chinese invented moveable type hundreds of years before Gutenberg did.