Thoughts on the CDC statement

In the land of instant information and where everyone has a blog (like me – ha!) it can be hard to know where to turn for reliable, trustworthy information. This fact is especially true for any hot-button or emotional topic, like circumcision. If you google the word, you get hundreds of thousands of hits, with tones varying across the whole spectrum from dry academic research to heated parental debate to the frankly weird. From my perspective, even the results that seem to be trustworthy can be tricky, because, as with everything involving statistics and medical research, numbers can be read many different ways, and research can be spun. The two key lines of distinction that need to be drawn in reading research and making decisions are first, the difference between relative and absolute risk, and second, the difference between causation and correlation. I’ll come back to this point below. I am rather reinventing the wheel here – all the links I posted last time contain this information. The absolute best thing to read is by an Oxford University ethicist named Brian Earp.

One response to my previous post on circumcision raised the current stance of the American Academy of Pediatrics (AAP), which reads as follows:
‘Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmision of some sexually transmitted diseases, including HIV.’ You can read the short statement here and the full technical report here. This week the CDC has come out with a very similar statement, claiming the same ‘benefits’.

As a dear friend once asked me, ‘What mother wouldn’t want to protect her son from UTIs and especially cancer and HIV?!’ The question to ask is, DOES male infant circumcision protect against these things, and if so, how much?

Let’s start with UTIs. Certainly some studies have shown that circumcision reduces the risk of UTIs (although other, more recent studies have not) – but let’s look at the numbers. According to one study from 1985, of every 1000 boys who remain intact, 7 will be admitted to hospital for a UTI before the age of 1 year old. Of every 1000 boys who are circumcised, 2 will be admitted to hospital for a UTI before the age of 1 year old. We could look at those numbers in various ways: circumcision reduces the risk of UTIs by more than two-thirds! Or we could look at the absolute risk: 7/1000 is 0.7%. Circumcising reduces the chance of a hospital-bound UTI from one very tiny number to another very tiny number. We can flip that number around and look at it from the other side: of every 1000 boys circumcised, 993 would never have needed hospitalisation for a UTI in any case. Or you could look at it another way, and say that for every hospital-bound UTI prevented by this choice, about 141 circumcisions were performed needlessly (this is the ‘number needed to treat’ to achieve the goal). This point also highlights what we mean when we say that the health benefits of circumcision are potential rather than actual – they prevent (possibly) things that might happen. Before moving on we can also note that girls under the age of 1 have approximately as many UTIs as boys. We treat them with antibiotics.

The second health benefit listed by the AAP is the prevention of penile cancer. Let’s look at the numbers. Of every hundred thousand men who are intact, 3 will develop penile cancer. Of every hundred thousand circumcised men, 1 will develop penile cancer. So, we could indeed say that circumcising a baby boy reduces his risk of penile cancer by two-thirds. Or we could flip the numbers and see that 99,997 circumcisions were performed needlessly. Penile cancer is so incredibly rare that, in fact, more men die of breast cancer in the United States every year than of penile cancer. About 1 in EIGHT women will get breast cancer at some point in their lives. We do not remove the breast buds at birth.  This argument for performing circumcision is so ridiculous that decades ago the American Cancer Society actually asked the AAP to stop using it  and today the American Cancer Society recommends good hygiene and not smoking as far more effective methods of risk reduction.

Finally, the AAP suggests that circumcision can reduce the transmission of STDs including HIV. The link with HIV came out of three main studies performed in Sub-Saharan Africa about ten years ago. Adult men who chose (please note it was a choice) circumcision were found to have about 60% protection against contracting HIV. However, many scholars have found problems with these studies, mostly around the difference between correlation and cause. The men who chose to be circumcised had more clinic visits and thus access to lectures on safe sex and condoms than the men who did remained intact, for example. The studies were stopped early. The ‘protective effect’, even if considered ‘real’, is still only 60% (and the absolute reduction was just 1.3%), meaning that even the circumcised men should wear condoms to avoid infection or infecting others. We can also draw two national comparisons. Most HIV transmission in Africa is by male-female sex. Most HIV transmission in the USA is by male-male sex and contaminated blood (like sharing drug needles) – circumcision does not protect against these means of transmission and the risk of female to male HIV transmission in the USA is incredibly low anyway. Finally, if this link is causal, we would expect the USA, with its relatively high levels of circumcision, to have low rates of HIV, and countries with low rates of circumcision to have higher rates of HIV. That is simply not the case: Norway, for example, has almost zero male circumcision and much lower rates of HIV than the US – 0.47 per 1000 in the adult population compared to 3.7 per 1000 in the US. Once again ask what is the number of men circumcised for this reason who never would have contracted HIV in the first place – what is the number needed to treat? Some studies have shown that males are less likely to contract other STDs like genital warts if circumcised, while others have shown that they are more likely to infect women if infected themselves. You can read an overview (from an admittedly anti-circumcision site) here. One fundamental point to consider is this: is your baby boy going to be sexually active? Is he going to be engaging in activity likely to land him an STD? Could you teach him how to have sex safely, that is, by using a condom or avoiding promiscuity? Could you let him choose circumcision as a preventative measure if he so desires, in the knowledge that he would STILL need to wear a condom to have sex safely?

To sum up, the health benefits of circumcision are not at all clear. They are disputed. They are potential rather than actual.They are all either treatable by other means or avoidable by methods far less drastic. If any scientist or government committee suggested introducing any new surgical procedure (rather than one entrenched in this country’s culture) on the basis of these kinds of number, they would be laughed at.

One final note: all of these perceived and potential benefits are predicated on the notion that the foreskin is pointless – that there is no advantage to having one and that it serves no function. This is certainly the stance of the committee that prepared the AAP and CDC statements referenced above. That stance could not be further from the truth, but you will have to wait for another blog post to read about the wonders of the male foreskin.

A hard decision, but the right one for me

I’ve been thinking about a question, sparked by a new doula friend. A huge part of my job is helping mamas to protect their bodily autonomy – that they make the decisions about what happens to their bodies with genuinely informed consent – and genital integrity – specifically, avoiding episiotomy unless medically indicated and minimising the chance of tearing during birth by following physical cues for positioning and pushing, ‘breathing the baby down’, or perineal support, for example. I hear things like ‘I don’t want to be cut unless it’s an emergency’ or ‘I want my vagina or vulva to be the same afterwards’ or ‘I’m afraid that I will tear and it will hurt’ or ‘I tore last time and it was very painful and took time to heal: how can I avoid that this time?’ Imagine helping a VBAC (vaginal birth after cesarean) mama birth a nearly ten pound baby over an intact perineum. Think of seeing a mama who had had a huge episiotomy (to which she had not consented) that extended to a fourth degree tear with complications, birth her second sweet baby with no tearing at all. It’s incredible. I say, ‘Trust your body. Your body is not broken. Your body was perfectly designed to birth this baby. You will open and stretch. Trust your body. Your body is perfect.’ These are some of the mantras of doula-assisted birth. Again: women want me to help them guard their own bodily autonomy and genital integrity. And I am very, very happy to do so.

How do I hold this role in my mind with some parents’ decision to circumcise baby boys, breaching their bodily autonomy and genital integrity? Recently I have come to the conclusion that I can’t hold both things in my mind at the same time. I hear in my head the same requests and questions above, this time in the voice of a baby boy: ‘Please don’t cut me unless it’s an emergency…Please let me decide…Please let my penis be the same as it is now…Please don’t hurt me.’ In a whisper, so that parents cannot hear, I have told brand new baby boys ‘You are perfect, and whole, and your body is not broken.’ And I have said ‘I’m so so sorry, I tried my best.’ Someone might tell me to mind my own business, that’s it’s not my decision or my place to apologise. To this I can only say: it is this one baby boy’s penis. He has the right to bodily autonomy and genital integrity. Just as his mama does.

Consequently I’ve decided not to offer doula services to mamas who are carrying boys and choose to circumcise. I understand that (male) infant circumcision is seen as a legal right* and a cultural norm in much of the United States. I know that there are a number of spurious health claims about circumcision, myths about cleanliness and frankly offensive ideas about the aesthetics of the intact penis. I believe, most of the time, that parents who choose to circumcise make their decisions out of love and with the best information they have at that time. I recognise that for at least two religions it is an important rite.** But for myself, for my own mental and spiritual well-being, I can no longer reconcile working so hard to help mamas have a gentle birth, a ‘gentle welcome’ into motherhood, and leave knowing that I have failed to secure a ‘gentle welcome’ for a baby into life just because he is a boy, born in a country where routine infant male circumcision is normal and often unquestioned. It is true that this decision may cost me clients: in fact, it already has. But I think that is an easier cost to live with.

If you want to learn more about circumcision, why it’s done and why it’s important to leave all babies, boy or girl, intact, these are some great resources:

http://www.psychologytoday.com/blog/moral-landscapes/201109/myths-about-circumcision-you-likely-believe

http://www.doctorsopposingcircumcision.org

http://www.wholenetwork.org

http://www.drmomma.org

http://www.savingsons.org

* Technically, the Fourteenth Amendment means that laws forbidding female circumcision apply to males too.

** For Jewish people, as part of the Covenant; for Muslims, as a cultural expression rather than a requirement of the Quran.

New certification!

Hello strangers. I’m delighted to announce that I am now a Certified Lactation Educator with CAPPA. Look out for a post about group and private classes and in-home support coming soon.

In the meantime I was asked in a recent class about resources for pumping and returning to work. As with many issues I really recommend the kellymom website and this huge and helpful list of links from La Leche League.

There is also a wonderful book, available on amazon, called Nursing Mother, Working Mother, with lots of useful tips. This one is on making more milk, a common concern for working mothers – and it’s by Martha Sears!

Do you work outside the home and nurse? How do you do it?

New class coming!

Having disappeared for a time, and had my third baby (another boy! at home!) I’m emerging from the blur and I’m teaching my first breastfeeding class tomorrow. I’m working on certification as a CAPPA Certified Lactation Educator, and as part of my course I have to film myself teaching an hour long class. My good friend Heather McLees-Frazier has given me a spot in her Lamaze Class and I’m excited to work with her. I’m going to show a couple of short films during the class, and I thought I would share them here too, since they are excellent resources. The first is an Indian film of a newborn breast crawl (you can see a really interesting cultural difference too – the mama’s face is blurred out as too personal to share, but her breasts and nipples are fully visible. Which is helpful in a breastfeeding film!). The second is a film made by Ameda about how to achieve a good latch. Enjoy!

Here are another couple of great resources on getting off to a good start with breastfeeding:

Size of a newborn’s stomach (from the excellent website www.babiesfirstlactation.com owned by the Canadian IBCLC Katie Wickham)

Is baby getting enough milk (from www.kellymom.com) – I include this because it is a number one concern of nursing mamas (and their families).

Update

I’m not very good at this regular blogging thing, am I? That’s not likely to change over the next few months, since I am due any day with #3. I’ve had a lovely year so far, with five births, including two in one night for the first time ever – you can read one of those birth stories over on the ‘Birth Stories and Testimonials’ page. I’m not attending any births over the summer, but look forward to working with new mamas in the new year. What will 2015 bring?

When plans go awry

I’ve had the honour now of attending twenty births as a doula – not many by the midwifery or OB scale, but far more than most people in the US. Six of those births – close to a third! – were cesarean births. Two were planned, and four unplanned (but not emergencies). I am grateful to have had the opportunity to support the mamas and papas through the cesarean experience, and at the same time, I’m sad to have seen so many, relatively speaking. That simultaneous happiness and sadness is a strange thing, and one shared by the families I have worked with.

I had a wonderful cesarean (unplanned but not an emergency) myself with my first son. We worked extremely hard to birth him vaginally (you can read his story on this site) and when it didn’t happen, had a gentle, ‘natural’ cesarean in which my son came straight to my chest under the drapes and I breastfed him there in the OR. I was ecstatic. I was also sad to have not birthed him in the way I had dreamed. No one ever made me feel bad about this dichotomy. Everyone respected my grief. No one said ‘at least you have a healthy baby – that should be all that matters.’ Of course it matters, but it isn’t ALL that matters. I asked myself all kinds of hard questions – what could I have done differently? Did I try hard enough? If I had pushed for another hour/tried a different position/done x, y or z, could it have been different? I made peace with D’s birth (ha – then lost it, and then found it again) and he loves to hear his birth story now.

Witnessing cesareans as a doula is very similar. I’m very fortunate not to have been at any births with what we might (quietly, to one another) call ‘scalpel happy’ care providers. I can honestly say that the cesareans I’ve witnessed were medically necessary. They did not come because of premature induction or at the end of a ‘cascade of interventions’ or at 4.30pm so someone could go home. No parents were pressured into the decision; there was no fear or panic. But there was huge sadness, later of course twinned with the joy of meeting a new baby. I second-guess myself every time. Did I try – or suggest trying – everything possible to avoid this outcome? Did I translate or interpret accurately and helpfully between the parents and the caregivers? Did I guard the parents’ space to give them the most thinking and decision-making time? Did I do enough? In the moment of decision and afterwards I do my very best to help the parents find peace – and I tell them what it helped me so much to hear: you did the right thing. You acted before there was a (likely or very likely) emergency. You will be able to bond. You will be able to breastfeed. You will recover. You will be able to try for a VBAC down the road. It’s okay to be sad and to grieve the birth you didn’t have. Whatever feelings you have, they are okay, they are yours. I will walk with you. You are a mother. You are still a warrior and a birth goddess.

If you are confronting a cesarean birth, there are some things you can do to make it feel less surgical and, well, more ‘birthy’ (all on the basis that it is not an emergency and you and baby are healthy). If you anticipate a scheduled cesarean, you can ask under certain circumstances to wait until you go into labour, so that your baby still gets to pick his or her birthday. Many OB-anesthesiologist teams will allow you to have both a partner AND a doula in the OR with you, or at least to let you have your doula trade in if your baby has to be taken out and your partner goes with the baby. Keeping your birth team with you makes a world of difference, and if your baby has to go to the warmer, then your partner can go with the baby while your doula stays with you (or vice versa). You can ask to play your own music in the OR, and even have your own scent. Ideally you can ask for a ‘natural’ or ‘family cesarean’, which more and more OBs are discovering. In these births, the drapes are lowered so that you see your baby being born (don’t worry, you don’t see any of your insides!). Delayed cord clamping may be available, and your partner may still be able to cut the cord. The baby can come straight to your chest under the drapes for skin to skin contact, with all procedures done with baby on you instead of the warmer, just as in a vaginal birth. You can nurse right there on the table. Your OB may offer to swab your vagina and wipe your baby’s mouth and face in order to populate him or her with your vaginal microbiome – an increasing number of studies are indicating how important this is for long term intestinal health (see this article). All being well, you and baby need not be separated at all.

A cesarean may not  be your first choice. But there are still steps you can take to shape your experience – and your baby’s first few moments earthside.

New beginnings

Well, it turns out that writing a blog is kind of like a job – you have to keep at it! Obviously I slipped rather at that over the autumn and winter so far. The first flush of enthusiasm ebbed, I had several births, I took a neonatal resuscitation class (and was certified, yay!), and I got pregnant again myself. We are expecting our third baby in the summer. All that meant that I dropped the ball on website maintenance.

I’m a little over 15 weeks pregnant now, so I’ll be attending births for another few months as a doula before I go on leave. Every doula has her own preference for working while pregnant. Some barrel on through (which I did last time). Some have debilitating morning sickness or fatigue or risky pregnancies (I make it sound so glamorous) and stop attending births as soon as they see two lines on a stick. With my last pregnancy I attended births until 2 weeks before H was born – we didn’t plan it that way, but she was at the late end and H was early. I’m not certain I gave that mama, papa and babe my absolute best, though I thought so at the time. So this time around, I’m working until mid-April and then going on leave. In the meantime I have several births booked, and it’s my goal to post here once a week or so. Here’s a lovely image for new beginnings.skeleton

Interventions #4

I attended a mama being induced last week, and it reminded me that this post was still waiting to be written. So here it is, finally! I’m discussing medical induction here – if you are interested in ‘natural’ induction, the midwife Aviva Romm wrote an interesting piece last month.

Birth can be induced for all kinds of reasons. Some are medical – baby too small (IUGR), mama’s blood pressure too high. Some are social – dad only has the weekend off work, for example, or a loved or trusted care provider is only available at a particular time. Some reasons are better than others. The March of Dimes has a campaign to encourage parents to wait until at least 39 weeks before attempting an induction, and ACOG says the same thing. One reason is that, while a baby may technically ‘early pre-term’, he or she may not quite be ready for earthside life yet. Both the linked pages above note the increased likelihood of NICU stays for babies born between 37 and 39 weeks. Once a pregnancy reaches 41 weeks, many if not most care-givers prefer to induce, citing an increase in the likelihood of still birth as the key rationale: taken together, various studies have suggested that one still birth will be avoided for every 369 women induced between 41 and 42 weeks. The first key questions, then, when confronted with the option to induce, are ‘why?’ and ‘why now?’

Apart from the need to wait to at least 39 weeks, a factor to consider is that the mama’s body (or rather, the mama-baby partnership) may not quite be ready for labour yet, so that ‘failed induction’ is a big cause of cesarean section, especially in first time moms. If you are confronting a possible induction, it’s a good idea to ask your care provider about your ‘Bishop Score’. The Bishop Score is a number between 0 and 13, calculated by assigning points for cervical position (posterior, middle, anterior), dilation (in centimeters), consistency (firm, medium, soft), effacement, and the extent of your baby’s descent into the pelvis (from -3cm above the ischial spines to +3cm). There is a Bishop Score calculator here. With a score of 8 or higher, an induction is likely to be successful – a doctor or midwife may be able to give you a percentage likelihood. 7 or below means that an induction is unlikely to be successful. If you want to be induced, or are feeling pressure from some source to induce, this information is useful to have. It helps to answer another key question, ‘Will it be likely to work?’ It’s good to know your options if it doesn’t work ahead of time – can you go home, and try again another day (likely not if you have agreed to have your waters broken) or will you be facing a surgical birth?

Once the decision to induce is taken, there are several different options (‘how?’). Some involve causing the cervix to soften (prostaglandins) or dilate (a Foley balloon or certain types of seaweed), while others induce contractions (most commonly Pitocin, an artificial form of the oxytocin that your body naturally produces in labour). Often, artificially rupturing the membranes – breaking the water – is an option. Pitocin and rupturing the membranes can also be used to augment a labour already in progress, usually because it is considered to be going to slowly for some reason. Sometimes, if a mama is very near her time, the merest hint of induction can trigger natural labour: a ‘whiff of Pit’, as it is often known, may be given to set things in motion, but then the mother’s own body takes over and no more Pitocin is needed. For others, a combination of all these factors may be used to try to bring labour: first cervical softeners are applied, then Pitocin is started, then later the membranes are ruptured until finally, hopefully, a good labour pattern is established. Or not. What is your care provider’s preference for you? What is his or her preferred timeline?

What do we need to know about these and other methods of induction and augmentation in order to make our own best decisions? In other words, what information do we need to consider before giving or withholding consent? Please note: I am not a care provider and I have no medical advice (or advice of any other kind) to give. That said, I think we need to have, as best we can, both personal, physiological information (how will my body likely respond?) and provider information (if I dilate to 4cm with a Foley bulb, but contractions do not start, what is your plan?). For example, the cells of the uterus are equipped with oxytocin receptors that cause them to contract when that hormone is present, but they are not switched on until labour is imminent – otherwise you might have contractions every time you make out with your honey. If your labour is not imminent, and those receptors have not been activated, what effect will Pitocin have? Or, if you had plans for an unmedicated labour, but Pitocin causes the intense contractions (and sometimes fetal stress/distress) for which it is well known, how will you manage the resulting agony discomfort or fear? If you planned to move through labour, but must have continuous fetal monitoring due to Pitocin, and be in or near the bed, what will you do? If your care provider asks you to come in and have your waters broken, with the plan to ‘see what happens’, how will you, in the hospital, inform yourself sufficiently to make your best decisions when subsequent steps are suggested? If you are labouring naturally yourself, but your care provider wants to augment your labour, the same kinds of questions apply. Why do you want to do this? Why do you think I need to do it now? What effect will it likely have on me? And on my baby? What are the risks of doing it? And of not doing it? Are there other options? How long do I have to decide?

Providing yourself with good, evidence based information on options for induction and augmentation may help to make some decisions ahead of time. It may give space and time to think and make decisions. Childbirth Connection has a good article on considerations in induction. Henci Goer wrote a great article on elective induction. Evidence Based Birth has a good one on induction for ‘big baby’. And the now quiet blog ‘Birth Sense’ had an interesting series on due dates and inductions, here (click ‘next’ for the two following posts). Many of these articles have links to medical journal articles where you can read cutting edge research – and sometimes, if you feel you need to, present it to your care provider.

Interventions #3

I thought I would cover induction of labour and augmentation of labour at the same time, since similar techniques can be used for each and similar risks and benefits may apply. In order to talk about induction, however, we first need to think about how human beings gestate. It turns out that this topic requires a post all of its own!

Left alone, pregnancy normally lasts for between 37 and 42 weeks (counting from the first day of the last menstrual period or LMP – 35-40 weeks counting from ovulation/conception). This range explains the ‘E’ in ‘EDD’ – estimated date of delivery. Gestation varies more in humans than in any other mammal: it varies between women, and it also varies among the pregnancies of any given woman. It varies partly because cycle length varies in both directions from the average of 28 days. Usually, a woman ovulates about 14 days before the onset of her period. However, the number of days between the onset of the previous period and ovulation can vary a great deal. One woman’s cycle might be 20 days (with ovulation around day 6) while another’s might be 45 days (with ovulation around day 31). Calculating an EDD based on the LMP would be inaccurate for these hypothetical women, and considerably inaccurate in the second case. Of course, ultrasounds are often used to confirm fetal age, and when taken early in a pregnancy, these can be helpful. Later in pregnancy, however, they are considerably less accurate, and can be wrong by perhaps as much as 2 weeks in either direction. Here is an article that goes into greater depth.

The other aspect of an EDD is the normal variation in human gestation. An article published in the journal Human Reproduction in August this year found a variation in pregnancy length of 37 days, even after excluding pre-term births and pregnancies with complications. You can read the abstract online, although you need a subscription for the full article. A woman might have short gestations or long gestations, or vary between pregnancies. Imagine, then, two women. Betty has short cycles and a short gestation. Pam has long cycles (let’s say 35 days) and a long gestation. If both conceive today, August 25, 2013, they get the same due date of 1 June 2014. The error in estimation doesn’t affect Betty so much – she might just be surprised to go into labour in early May next year. However, in most people and very many care-practitioners’ eyes, Pam will be ‘due’ on 1 June and ‘post-dates on 14 June. Living in the United States, she will almost certainly be pressured to induce her baby long before that bundle of joy is ready to make his or her entrance. By her cycle length alone, she would not be 40 weeks pregnant until 8 June, and not post-dates until 22 June. A normal 42 week gestation would put her delivering then – 3 weeks after the due date suggested by her LMP. Conversely, if she induced at 39 weeks from LMP (for whatever reason) her baby would not only be really a 38-weeker, but could be as much as four weeks ‘under-done’.

Why does it matter? Surely in late pregnancy the baby is ready anyway? You know loads of women who have had their labours induced and they and the baby have been just fine? Why do doulas, midwives and natural birth advocates talk about ‘letting your baby choose his or her birthday’? The next post will address these questions.

I was very, very pregnant indeed. But not yet in labour.

I was very, very pregnant indeed. But not yet in labour.