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Volume 5, No. 11, December 2007
Features
American College of Obstetricians and Gynecologists
Use of Psychiatric Medications During Pregnancy and Lactation
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- Lithium exposure in pregnancy may be associated with a small increase in congenital cardiac malformations, with a risk ratio of 1.2–7.7.
- Valproate exposure in pregnancy is associated with an increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome, and long-term adverse neurocognitive effects. It should be avoided in pregnancy, if possible, especially during the first trimester.
- Carbamazepine exposure in pregnancy is associated with fetal carbamazepine syndrome. It should be avoided in pregnancy, if possible, especially during the first trimester.
- Maternal benzodiazepine use shortly before delivery is associated with floppy infant syndrome.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Paroxetine use in pregnant women and women planning pregnancy should be avoided, if possible. Fetal echocardiography should be considered for women who are exposed to paroxetine in early pregnancy.
- Prenatal benzodiazepine exposure increased the risk of oral cleft, although the absolute risk increased by 0.01%.
- Lamotrigine is a potential maintenance therapy option for pregnant women with bipolar disorder because of its protective effects against bipolar depression, general tolerability, and a growing reproductive safety profile relative to alternative mood stabilizers.
- Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medication or herbal remedies, increased alcohol and tobacco use, deficits in mother–infant bonding, and disruptions within the family environment.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Whenever possible, multidisciplinary management involving the patient’s obstetrician, mental health clinician, primary health care provider, and pediatrician is recommended to facilitate care.
- Use of a single medication at a higher dose is favored over the use of multiple medications for the treatment of psychiatric illness during pregnancy.
- The physiologic alterations of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium levels during pregnancy and postpartum is recommended.
- For women who breastfeed, measuring serum levels in the neonate is not recommended.
- Treatment with all SSRIs or selective norepinephrine reuptake inhibitors or both during pregnancy should be individualized.
- Fetal assessment with fetal echocardiogram should be considered in pregnant women exposed to lithium in the first trimester.
Use of Psychiatric Medications During Pregnancy and Lactation. ACOG Practice Bulletin No. 87. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:1179-98
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978143
Cesarean Delivery on Maternal Request
ABSTRACT: Cesarean delivery on maternal request is defined as a primary cesarean delivery at maternal request in the absence of any medical or obstetric indication. A potential benefit of cesarean delivery on maternal request is a decreased risk of hemorrhage for the mother. Potential risks of cesarean delivery on maternal request include a longer maternal hospital stay, an increased risk of respiratory problems for the baby, and greater complications in subsequent pregnancies, including uterine rupture and placental implantation problems. Cesarean delivery on maternal request should not be performed before 39 weeks of gestation or without verification of lung maturity. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and the need for gravid hysterectomy increase with each cesarean delivery.
Cesarean Delivery on Maternal Request ACOG Committee Opinion no. 386. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1209-12.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978146
Colonoscopy and Colorectal Cancer Screening and Prevention
ABSTRACT: Most colorectal cancer can be detected by screening modalities and treated at a preinvasive or early invasive stage, before it has developed to a fully invasive and potentially fatal disease. Obstetrician–gynecologists should counsel all patients aged 50 years and older about the benefits of colorectal cancer screening and should encourage colonoscopy as the preferred method of screening for women at either average risk or high risk. The advantages and limitations of other appropriate colorectal cancer screening methods also should be discussed so that women may choose to be tested by whichever method they are most likely to accept and complete.
Colonoscopy and Colorectal Cancer Screening and Prevention. ACOG Committee Opinion No. 384. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1199-1202.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978144
The Limits of Conscientious Refusal in Reproductive Medicine
ABSTRACT: Health care providers occasionally may find that providing indicated, even standard, care would present for them a personal moral problem—a conflict of conscience—particularly in the field of reproductive medicine. Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient’s health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities. Conscientious refusals that conflict with patient well-being should be accommodated only if the primary duty to the patient can be fulfilled. All health care providers must provide accurate and unbiased information so that patients can make informed decisions. Where conscience implores physicians to deviate from standard practices, they must provide potential patients with accurate and prior notice of their personal moral commitments. Physicians and other health care providers have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request. In resource-poor areas, access to safe and legal reproductive services should be maintained. Providers with moral or religious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient’s physical or mental health, providers have an obligation to provide medically indicated and requested care.
The Limits of Conscientious Refusal in Reproductive Medicine ACOG Committee Opinion no. 385. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1203-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978145
Supracervical Hysterectomy
ABSTRACT: Women with known or suspected gynecologic cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for a supracervical procedure. Patients electing supracervical hysterectomy should be carefully screened preoperatively to exclude cervical or uterine neoplasm and should be counseled about the need for long-term follow-up, the possibility of future trachelectomy, and the lack of data demonstrating clear benefits over total hysterectomy. The supracervical approach should not be recommended by the surgeon as a superior technique for hysterectomy for benign disease
Supracervical Hysterectomy. ACOG Committee Opinion no. 388. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1215-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978148
Pharmaceutical Compounding
ABSTRACT: Compounding is the preparation of an individualized drug product in response to a physician’s prescription to create a medication tailored to the specialized needs of an individual patient. There are currently no specific prohibitions by the U.S. Food and Drug Administration on what constitutes a legitimate claim for compounded drug products, even if there is no efficacy, risk, or safety evidence to support an advertised claim. Physicians and patients should exercise caution in prescribing and using products that are largely untested for safety and efficacy.
Pharmaceutical Compounding. ACOG Committee Opinion no. 387. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1213-4 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978147
American Family Physician**
Predicting the Likelihood of Successful Vaginal Birth After Cesarean Delivery
Clinical Question
Which patients are likely to have a successful vaginal birth after a previous cesarean delivery?
Evidence Summary
The American College of Obstetricians and Gynecologists and the American Academy of Family Physicians recommend that pregnant women with a single previous cesarean delivery and a low-transverse incision be offered a trial of labor. Although the rate of vaginal birth after cesarean delivery (VBAC) increased from 19 percent of all deliveries in 1989 to a peak of 28 percent in 1996, the rate decreased to only 9.2 percent of all deliveries in 2004. The decline has been partially driven by concerns about the small but measurable risk of uterine rupture with VBAC, particularly when labor is induced or augmented.
At the same time, the total number of cesarean deliveries has been increasing, largely because of an increase in primary cesarean deliveries. A screening tool to help predict whether a woman will have a successful VBAC may help patients and their physicians make more informed shared decisions.
A 2003 evidence review by the Agency for Healthcare Research and Quality found overall VBAC success rates between 60 and 82 percent in published studies, with an estimated overall success rate of 75 percent at teaching institutions and tertiary medical centers. The risks of perinatal death or hysterectomy from uterine scar rupture were low (1.5 and 4.8 per 10,000 births, respectively). The review identified factors associated with an increased likelihood of vaginal delivery (i.e., maternal age younger than 40 years, previous successful vaginal delivery, and favorable cervical factors). The review also identified factors that decreased the likelihood of vaginal birth (i.e., more than one previous cesarean delivery; induction of labor; birth weight greater than 4,000 g [8 lb, 13 oz]; and gestational age greater than 40 weeks).
A number of researchers have attempted to develop clinical decision rules to predict the likelihood of a successful trial of labor after a previous cesarean delivery. A 2004 systematic review identified six of these clinical decision rules, two of which were validated (i.e., tested in a new population to confirm accuracy of the rule). Three subsequent rules were developed and validated. These five validated rules are summarized in Table 1 (see link below)
Although the Troyer rule was validated, the number of patients in the validation group was small. The Hashima rule was also prospectively validated; however, only three out of 5,414 women had a score of 0, and only 101 had a score of 1 (low probability of success). The remaining 5,310 women had scores of 2 (53 percent success rate) or 3 (67 percent success rate), which provides little useful information for decision making.
The remaining three scores were well validated and were shown to be accurate in a large, representative population. The Flamm rule (Table 2) (see link below) is the simplest to use, although it is limited by its age (data were gathered between 1990 and 1992) and by the requirement of cervical effacement information, which makes it unhelpful for antepartum planning.
The Smith rule is well validated but is based on a multivariate equation, making it too complex for practical use at the point of care. Although the Grobman rule is also based on a complex multivariate equation, a nomogram (Figure 1) (see link below) is provided for use at the point of care.
The Grobman rule has been well validated and all of the needed variables are available to the patient and physician before the onset of labor.)
Applying the Evidence
A 25-year-old, non-Hispanic, white woman with a body mass index (BMI) of 25 kg per m2 is in labor. Her cervix is 3 cm dilated and about 30 to 40 percent effaced. She has had one previous pregnancy, which resulted in cesarean delivery because of failure to progress. She wonders how likely it is that a trial of labor will be successful.
Answer:
Using the Flamm rule (Table 2) (see link below) the patient receives two points for age and one for cervical effacement. The total score of 3 gives her a 60 percent probability of vaginal delivery. Using the Grobman nomogram (Figure 1), (see link below) the patient receives 10 points for age, 30 for body mass index, points each for being non-African American and non-Hispanic, and 0 for no history of vaginal birth or recurrent primary indication. The total score of 54 points gives her a 68 percent probability of vaginal delivery. You advise the patient that her chance of a successful trial of labor is about two out of three. http://www.aafp.org/afp/20071015/poc.html Point-of-Care Guides
Effectiveness of Insulin Sensitizing Drugs for Polycystic Ovary Syndrome
Clinical Question
Do insulin sensitizing drugs with or without oral contraceptive pills improve clinical outcomes in women with polycystic ovary syndrome (PCOS)?
Evidence-Based Answer
Insulin sensitizing drugs are more effective than oral contraceptives alone at improving fasting insulin levels in patients with PCOS. Compared with metformin (Glucophage) alone, oral contraceptives alone better control irregular menstrual cycles and reduce androgen levels. There is insufficient evidence to recommend insulin sensitizing drugs alone or in combination with oral contraceptives to decrease the risk of diabetes, cardiovascular disease, or endometrial cancer.
Practice Pointers
PCOS is defined by the presence of two of the following criteria: oligomenorrhea or amenorrhea, clinical or biochemical hyperandrogenism, or polycystic ovaries visible on ultrasonography. Family physicians routinely treat symptoms of irregular menstrual cycles and excessive androgen levels with combination oral contraceptives. The benefit of using insulin sensitizing drugs is unclear. Ideally, treatment of PCOS would improve clinical symptoms such as hirsutism and infertility and decrease the risk of type 2 diabetes, cardiovascular disease, or endometrial cancer.
In this Cochrane review, the authors searched the literature for randomized controlled trials (RCTs) comparing treatment of PCOS with insulin sensitizing drugs with or without oral contraceptives. They found six RCTs that included 226 total patients, 20 to 52 years of age. Patients were followed for four to 12 months, with a median study duration of six months. Metformin, 500 mg orally three times per day, was the only insulin sensitizing drug studied.
Oral contraceptives were more effective at improving menstrual cycle regularity and lowering androgen levels compared with metformin. Although these findings were statistically significant, only 104 participants in three trials were analyzed for these outcomes. Metformin lowered fasting insulin levels and did not impact triglyceride levels compared with oral contraceptives. However, metformin did not lower fasting glucose levels in patients without impaired glucose tolerance and did not reduce the risk of type 2 diabetes when used alone. Combined therapy improved hirsutism in a single RCT with 34 participants.
No combined RCTs with acne as primary outcome were available. None of the trials analyzed the primary outcomes of stroke, myocardial infarction, or endometrial cancer.
This review was limited by small study sizes. Because outcomes addressed chronic disease, the studies may not have followed patients long enough to show prevention benefits. No studies were available comparing alternative insulin sensitizing drugs such as rosiglitazone (Avandia) or pioglitazone (Actos). There was insufficient evidence on the outcomes of hirsutism, acne, body mass index, blood pressure, and other cholesterol parameters.
Evaluating fertility rates as a primary outcome could provide practice-modifying information for many physicians. Expert consensus by the American Association of Clinical Endocrinologists states that metformin should be considered in the initial treatment of PCOS, especially for patients who are overweight or obese. The 2002 American College of Obstetricians and Gynecologists guideline recommends metformin as one measure to improve ovulatory frequency and to treat risk factors for diabetes and cardiovascular disease. Cochrane Briefs
Costello M, Shrestha B, Eden J, Sjoblom P, Johnson N. Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome. Cochrane Database Syst Rev 2007(1):CD005552.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17253562
Second Trimester Pregnancy Loss (See also Patient Education)
Second trimester pregnancy loss is uncommon, but it should be regarded as an important event in a woman's obstetric history. Fetal abnormalities, including chromosomal problems, and maternal anatomic factors, immunologic factors, infection, and thrombophilia should be considered; however, a cause-and-effect relationship may be difficult to establish. A thorough history and physical examination should include inquiries about previous pregnancy loss. Laboratory tests may identify treatable etiologies. Although there is limited evidence that specific interventions improve outcomes, management of contributing maternal factors (e.g., smoking, substance abuse) is essential. Preventive measures, including vaccination and folic acid supplementation, are recommended regardless of risk. Management of associated chromosomal factors requires consultation with a genetic counselor or obstetrician. The family physician can play an important role in helping the patient and her family cope with the emotional aspects of pregnancy loss. (Am Fam Physician 2007;76:1341-6, 1347-8.
http://www.aafp.org/afp/20071101/1341.html
AAFP and ACP Publish Recommendations on Diagnosis and Management of VTE
There are 600,000 cases of venous thromboembolism (VTE) in the United States every year. Of all persons with undetected or untreated pulmonary embolism, 26 percent will have a fatal embolic event, and another 26 percent will have a recurrent embolic event that could become fatal. Therefore, an early diagnosis of VTE is important to prevent mortality and morbidity in this population.
This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.
Qaseem A, et al Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007 Jan-Feb;5(1):57-62.
Methamphetamine Abuse (See also Patient Education)
Methamphetamine is a stimulant commonly abused in many parts of the United States. Most methamphetamine users are white men 18 to 25 years of age, but the highest usage rates have been found in native Hawaiians, persons of more than one race, Native Americans, and men who have sex with men. Methamphetamine use produces a rapid, pleasurable rush followed by euphoria, heightened attention, and increased energy. Possible adverse effects include myocardial infarction, stroke, seizures, rhabdomyolysis, cardiomyopathy, psychosis, and death. Chronic methamphetamine use is associated with neurologic and psychiatric symptoms and changes in physical appearance. High-risk sexual activity and transmission of human immunodeficiency virus are also associated with methamphetamine use. Use of methamphetamine in women who are pregnant can cause placental abruption, intrauterine growth retardation, and preterm birth, and there can be adverse consequences in children exposed to the drug. Treatment of methamphetamine intoxication is primarily supportive. Treatment of methamphetamine abuse is behavioral; cognitive behavior therapy, contingency management, and the Matrix Model may be effective. Pharmacologic treatments are under investigation. Am Fam Physician 2007;76:1169-74, 1175-6
http://www.aafp.org/afp/20071015/1169.html
Outpatient Care of the Premature Infant (See also Patient Education)
An increasing number of infants in the United States are born prematurely, with current statistics estimating about 13 percent of all births. Although survival rates and outcomes for premature infants have dramatically improved in recent decades, morbidity and mortality are still significant. Infants born prematurely are at increased risk of growth problems, developmental delays, and complex medical problems. To account for prematurity, growth and development monitoring should be done according to adjusted age (age in months from term due date). Premature infants should gain 20 to 30 g (0.71 to 1.06 oz) per day after discharge from the hospital. Growth parameters may be improved in the short term with the use of enriched preterm formula or breast milk fortifier. Each well-child examination should include developmental surveillance so that early intervention can be initiated if a developmental delay is diagnosed. Routine vaccination should proceed according to chronologic age with minor exceptions, and respiratory syncytial virus immune globulin is indicated in preterm infants who meet the criteria. Am Fam Physician 2007;76:1159-64, 1165-6. http://www.aafp.org/afp/20071015/1159.html
Somatoform Disorders (See also Patient Education)
The somatoform disorders are a group of psychiatric disorders that cause unexplained physical symptoms. They include somatization disorder (involving multisystem physical symptoms), undifferentiated somatoform disorder (fewer symptoms than somatization disorder), conversion disorder (voluntary motor or sensory function symptoms), pain disorder (pain with strong psychological involvement), hypochondriasis (fear of having a life-threatening illness or condition), body dysmorphic disorder (preoccupation with a real or imagined physical defect), and somatoform disorder not otherwise specified (used when criteria are not clearly met for one of the other somatoform disorders). These disorders should be considered early in the evaluation of patients with unexplained symptoms to prevent unnecessary interventions and testing. Treatment success can be enhanced by discussing the possibility of a somatoform disorder with the patient early in the evaluation process, limiting unnecessary diagnostic and medical treatments, focusing on the management of the disorder rather than its cure, using appropriate medications and psychotherapy for comorbidities, maintaining a psychoeducational and collaborative relationship with patients, and referring patients to mental health professionals when appropriate. Am Fam Physician 2007;76:1333-8 http://www.aafp.org/afp/20071101/1333.html
Mind-Body Therapies for Headache (See also Patient Education)
Headache is one of the most common and enigmatic problems encountered by family physicians. Headache is not a singular entity, and different pathologic mechanisms are involved in distinct types of headache. Most types of headache involve dysfunction of peripheral or central nociceptive mechanisms. Mind-body therapies such as biofeedback, cognitive behavior therapy, hypnosis, meditation, and relaxation training can affect neural substrates and have been shown to be effective treatments for various types of headache. Meta-analyses of randomized controlled trials show that the use of mind-body therapies, alone or in combination, significantly reduces symptoms of migraine, tension, and mixed-type headaches. Side effects generally are minimal and transient. Am Fam Physician 2007;76:1518-22, 1523-4.
http://www.aafp.org/afp/20071115/1518.html
Ulcerative Colitis: Diagnosis and Treatment (See also Patient Education)
Ulcerative colitis is a chronic disease with recurrent symptoms and significant morbidity. The precise etiology is still unknown. As many as 25 percent of patients with ulcerative colitis have extraintestinal manifestations. The diagnosis is made endoscopically. Tests such as perinuclear antineutrophilic cytoplasmic antibodies and anti-Saccharomyces cerevisiae antibodies are promising, but not yet recommended for routine use. Treatment is based on the extent and severity of the disease. Rectal therapy with 5-aminosalicylic acid compounds is used for proctitis. More extensive disease requires treatment with oral 5-aminosalicylic acid compounds and oral corticosteroids. The side effects of steroids limit their usefulness for chronic therapy. Patients who do not respond to treatment with oral corticosteroids require hospitalization and intravenous steroids. Refractory symptoms may be treated with azathioprine or infliximab. Surgical treatment of ulcerative colitis is reserved for patients who fail medical therapy or who develop severe hemorrhage, perforation, or cancer. Longstanding ulcerative colitis is associated with an increased risk of colon cancer. Patients should receive an initial screening colonoscopy eight years after the onset of pancolitis and 12 to 15 years after the onset of left-sided disease; follow-up colonoscopy should be repeated every two to three years. Am Fam Physician 2007;76:1323-30, 1331. http://www.aafp.org/afp/20071101/1323.html
Nonspecific Low Back Pain and Return to Work (See also Patient Education)
As many as 90 percent of persons with occupational nonspecific low back pain are able to return to work in a relatively short period of time. As long as no "red flags" exist, the patient should be encouraged to remain as active as possible, minimize bed rest, use ice or heat compresses, take anti-inflammatory or analgesic medications if desired, participate in home exercises, and return to work as soon as possible. Medical and surgical intervention should be minimized when abnormalities on physical examination are lacking and the patient is having difficulty returning to work after four to six weeks. Personal and occupational psychosocial factors should be addressed thoroughly, and a multidisciplinary rehabilitation program should be strongly considered to prevent delayed recovery and chronic disability. Patient advocacy should include preventing unnecessary and ineffective medical and surgical interventions, prolonged work loss, joblessness, and chronic disability. Am Fam Physician 2007;76:1497-1502, 1504.
http://www.aafp.org/afp/20071115/1497.html
AHRQ
Study documents the health costs of being a woman
http://www.ahrq.gov/research/nov07/1107RA2.htm
Death and complications after breast cancer surgery are rare, with
wound infection the most common problem
http://www.ahrq.gov/research/nov07/1107RA3.htm
Women suffer fewer postoperative problems after vascular surgery
at Veterans Administration than at private hospitals
http://www.ahrq.gov/research/nov07/1107RA4.htm
A skin condition may identify young patients at risk for developing
type 2 diabetes
http://www.ahrq.gov/research/nov07/1107RA8.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
The Healthy Heart Handbook for Women '07 - 20th Anniversary Edition
This newly revised handbook, with a special message from First Lady Laura Bush, provides new information on women’s heart disease and practical suggestions for reducing your own personal risk of heart-related problems. The handbook presents the latest information on how to live a healthier and longer life, by taking action steps to prevent and control heart disease risk factors.
You’ll also find new tips on following a nutritious eating plan, tailoring your physical activity program to your particular goals, quitting smoking, and getting your whole family involved in heart healthy living. The Healthy Heart Handbook for Women is part of The Heart Truth for Women, a national public awareness campaign for women about heart disease sponsored by the National Heart, Lung and Blood Institute (NHLBI) and many other groups.
http://www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf
Breastfeeding - Amy Patterson, California Area Indian Health Service
Getting it Right
Breastfeeding Promotion: Good Public Health Policy (Part 2 of 2)
During pregnancy, the mother’s body changes to prepare itself for lactation so that she can successfully nurse her infant. There are truly very few cases in which a mother is physically unable to breastfeed.
Breastfeeding is natural, but it takes some time to learn to do it correctly. With few exceptions-discussed below- all pregnant women should be encouraged to breastfeed, and to learn about breastfeeding through classes run by hospitals or lactation consultants. Hospital policies can also make a difference; in particular, “rooming-in” and encouraging nursing within the first hour of birth both increase the chance of breastfeeding success. After birth, nursing mothers should receive help from their hospital’s lactation consultant to make sure they and their babies are getting off to the right start. If a nursing mother is having problems with latching or is concerned about milk supply, a lactation consultant can evaluate and help. An IBCLC (International Board Certified Lactation Consultant) credential represents the “gold standard” for lactation counseling. IBCLCs are certified after hundreds of hours of consulting and academic training; they must also pass a rigorous, comprehensive exam. To find a certified consultant, go to www.ilca.org , and click on “Find a Lactation Consultant in Your Area.”
Newborn babies who are breastfed need to eat frequently; it is not uncommon for them to wake many times a night to nurse. Providers can let new parents know that while this will interrupt their normal sleep cycles for a while, it is temporary; as a baby gets older they go longer in between feedings. Night waking is a normal feature of newborns; even formula-fed babies wake at night to eat. There are also special advantages to breastfeeding; although a nursing baby may wake a bit more frequently than a formula-fed baby, the nursing mother has no bottles to prepare in the middle of the night and can comfort her infant immediately. Remind mothers that this is also true during the day when they are out of the house, and means they will not have to carry bottles or formula around. California law also protects the rights of mothers to nurse in public.
Also, remind new mothers that there are significant health benefits from nursing. Nursing infants also get sick less often, which means fewer trips to the doctor, and fewer nights spent caring for a sick baby. The longer a woman nurses, the greater the health benefits for her baby. Breastfeeding can continue as long as it is beneficial for both mother and child- there is no time limit on how many months or years a woman should nurse.
Nursing can also continue after a mother returns to work. A nursing mother can nurse her baby in the evenings, overnight, and in the mornings. Then, she can pump her milk while at work and store it for caregivers to give to her baby while she is at work. Nursing mothers have rights under California State Law for break time and privacy to pump milk while at work.
However, there are some women for whom breastfeeding is not advised. Women who are HIV positive should not breastfeed because of the risk of transmitting the virus to the baby. Also, women with active, untreated TB (tuberculosis) or who are receiving any kind of chemotherapy should not breastfeed.
Women who are breastfeeding should not take illegal drugs. Some drugs, such as methamphetamine, cocaine and PCP, can affect the baby and cause serious side effects. Other drugs, such as heroin and marijuana can cause irritability, poor sleeping patterns, tremors, and vomiting. Babies can become addicted to these drugs. If a mother is addicted and can not get off these drugs, she should not breastfeed. However, mothers undergoing methadone treatment may breastfeed.
Mothers who smoke should be encouraged to quit as soon as possible. However, even if they cannot, it is still better to breastfeed, as long as they do not smoke near their infants.
Most common illnesses, such as colds, flu, or diarrhea, can not be passed through breast milk. In fact, when a mother is sick, her breast milk will have antibodies in it that will help protect infants from getting the same sickness.
GPRA
The Indian Health Service has a developmental GPRA measure on exclusive and near exclusive breastfeeding rates among 2 month old infants, with the goal of increasing breastfeeding rates among these and older infants. RPMS users can use a PCC Infant Feeding Tool to record infant feeding status; this information is captured in RPMS and extracted by the Clinical Reporting System (CRS). Sites using PCC, RPMS and CRS can monitor the feeding status of their infant population by running CRS reports.
The Indian Health Service uses Healthy People 2010 objectives whenever possible for its GPRA targets. The Healthy People 2010 goal is to have at least 75 percent of mothers breastfeeding during the early postpartum period and 50 and 25 percent breastfeeding at 6 months and 1 year, respectively. In 1998, 64 percent of all mothers breastfed their infants during the early postpartum period. 29 and 16 percent of mothers breastfed their infants at 6 months and 1 year, respectively. This data is for all races; no comprehensive national data on breastfeeding rates among American Indians and Alaska Natives yet exists.
For More Information:
Indian Health Service Breastfeeding Page
http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
California State Breastfeeding Program
http://www.mch.dhs.ca.gov/programs/bfp/
LaLeche League International
http://www.lalecheleague.org/
Centers for Disease Control Breastfeeding Page
http://www.cdc.gov/breastfeeding/
National Women’s Health Information Center (DHHS Breastfeeding resources
page)
http://www.4woman.gov/Breastfeeding/index.cfm?page=227
International Lactation Consultant Association
http://www.ilca.org/
World Alliance for Breastfeeding Action
http://worldbreastfeedingweek.org/downloads.htm
Other
Rare Side-Effect of Codeine in Nursing Mothers: Ultra-rapid metabolizers
FDA is alerting healthcare professionals about a very rare but serious side effect that can affect the babies of nursing mothers who are taking drugs that contain codeine. The problem affects mothers who are "ultra-rapid metabolizers" of codeine. Ultra-rapid metabolizers have a specific genotype that causes them to convert codeine to its active metabolite, morphine, more rapidly and completely than other people. This can result in the mother having unusually high morphine levels in her serum and breast milk, and this can put her nursing infant at risk of morphine overdose.
A recent report in the literature described a healthy, 13-day-old breast-feeding baby who died of a morphine overdose. His mother was taking codeine at less than the usual analgesic dose.
The prevalence of the ultra-rapid metabolizers of codeine varies for different populations. Among Caucasians, the figure is about 1 to 10 percent. Among African-Americans, about 3 percent are ultra-rapid metabolizers of codeine, and among Asians and Hispanics, about 1 percent. The highest prevalence is among some groups of North Africans, Ethiopians and Saudis, where it can be as high as 28 percent.
It is important to note that nursing mothers have used codeine safely for many years. Many women are sent home after having a baby with analgesics such as acetaminophen with codeine to relieve episiotomy pain or abdominal cramping and many of these women are also breast feeding. Despite this widespread use, FDA was able to find only the one case where the baby clearly died as a result of morphine overdose from breast milk. This means that many breast fed babies born to mothers who are ultra-rapid metabolizers and who are taking codeine will not have a problem, but some babies may.
FDA has cleared a genetic test that can determine whether someone is a rapid metabolizer of a number of drugs, but there's only limited information on using it for codeine. Which means at this point, the test result alone may not correctly predict whether the mother is an ultra-rapid metabolizer of codeine. In other words, the test is not a substitute for a doctor's judgment.
FDA recommends that clinicians who prescribe codeine for a nursing mother do so in the lowest dose for the shortest period of time in order to relieve pain. Clinicians should also educate nursing mothers who may be taking codeine about the signs of morphine overdose in themselves or their infants.
Mothers should understand that they don't need to go without pain relief if they're breast feeding, but they should know what to look for if there's a morphine overdose. For the mother herself, the signs include extreme sleepiness and constipation. The mother should also watch for increased sleepiness in her baby, keeping in mind that breastfed babies usually nurse every two to three hours and shouldn't sleep more than four hours at a time. She should also watch for trouble breast feeding, breathing difficulties and limpness. Mothers should also be aware that morphine may remain in the infant's body for up to several days after the last codeine dose.
Finally, in order to help the FDA understand and quantify this problem, it's important to report possible cases of morphine overdose in mothers and infants. To report an adverse event to the FDA please see the below link.
Additional Information :
FDA MedWatch Safety Alert. Codeine Products Used By Nursing Mothers. August
17, 2007
http://www.fda.gov/medwatch/safety/2007/safety07.htm#Codeine
FDA MedWatch. Reporting Adverse Events to FDA. April 19, 2007
http://www.fda.gov/medwatch/how.htm
Nicotine In Breast Milk Disrupts Infants’ Sleep Patterns
Infants spent less time sleeping overall and woke up from naps sooner when their mothers smoked prior to breastfeeding,
CONCLUSIONS: An acute episode of smoking by lactating mothers altered infants' sleep/wake patterning. Perhaps concerns that their milk would taste like cigarettes and their infants' sleep patterning would be disrupted would motivate lactating mothers to abstain from smoking and to breastfeed longer.
Mennella JA, et al Breastfeeding and smoking: short-term effects on infant feeding and sleep. Pediatrics. 2007 Sep;120(3):497-502
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766521
Formula free zone - Sion Baby Friendly Hospital
The Sion municipal hospital in Mumbai, which featured in the Yorkshire TV film "Bottle Feeding in India" (contact Baby Milk Action for copies of this), broadcast in the UK in 1995, is of more than 900 Baby Friendly Hospitals in India. The Sion hospital caters for some of the poorest families in Mumbai, including residents of Asia's largest slum, Dharavi. Approximately 6,000 babies are born in the Sion every year, 30 - 40% of them premature or low-birth weight. Between 1979 1986, the Sion used invasive medical techniques such as prelacteal and supplementary bottle feeds, assisted ventilation devices, frequent blood investigations, etc. However, these practices have changed and the hospital has not used any baby milk for the last 10 years. Breastfeeding has been as one of the key factors in a reduction in infant morbidity. When bottle feeding was routine 7 out of 10 premature babies died, now at least 8 out of 10 survive. Like all hospitals, the Sion Hospital is badly in need of cash - but any suggestion that they take money from the baby food or drug industry was dismissed by the staff as unthinkable.
Indian doctors reject baby food sponsorship
Aware that parents are receiving confusing messages from doctors; a number of professional organizations in India are tackling the issue of commercial sponsorship head on. After a thorough debate at its annual conference in January 1997, the Indian Academy of Pediatrics overwhelmingly passed a Resolution saying: "The IAP shall not accept the sponsorship in any form from any industry connected directly or indirectly with the products covered by the [Indian] Act."
The Federation of Obstetrics and Gynecological Societies of India (FOGSI), with 12,000 members throughout India, also rejects baby food sponsorship, even though massive amounts have been offered. The Federation has declared 1997 to be the FOGSI Breastfeeding Year.
J & J apologizes and withdraws
The Indian Act includes all the articles of the International Code and one of its most unique and innovative aspects is its authorization of voluntary organizations to bring criminal complaints for prosecution. Over the last few years the ACASH has filed criminal complaints against Nestle, Johnson and Johnson and more recently, Wockhardt. The company reaction to these charges has been revealing: As Update readers will know, Nestle has so far refused to apologize and has challenged the validity of the Indian Act.
Johnson & Johnson, in contrast, has submitted a letter of apology to ACASH and has stated that because bottle feeding may not be appropriate in the Indian context it is withdrawing from the market. The Wockhardt case involves its labeling of Dexolac, and the company has issued an apology to ACASH and to the courts. Judith.Thierry@ihs.gov
The yeast connection: is Candida linked to breastfeeding associated pain?
CONCLUSION: C. albicans is found more often in breastfeeding mothers who report pain as compared with asymptomatic breastfeeding mothers. Further studies, including treatment trials, are needed to determine whether Candida plays an etiologic role in breastfeeding associated pain.
Andrews JI, The yeast connection: is Candida linked to breastfeeding associated pain?
Am J Obstet Gynecol. 2007 Oct;197(4):424.e1-4.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904988
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
- Hospital brought rapid cesarean delivery times into range of 10.9 minutes: Can you?
- Let’s clear up any confusion over the availability of the HPV vaccine
- SBE prophylaxis not recommended for cesarean delivery and other GU procedures
- 2006 consensus guidelines for the management of abnormal cervical cancer screening
- Traumatic events and alcohol use disorders among American Indian adolescents
- Aging and prevalence of CVD risk factors in American Indians: the Strong Heart Study
- Viral Hepatitis in Pregnancy
- The HSR Library- a branch of the NIH Library Provides Access to Many Online Journals
- Breastfeeding Promotion: Good Public Health Policy
- Coaching Boys Into Men AI/AN Poster
- Transdermal hormonal contraception: benefits and risks
- EHR graphical user interface (GUI) application, version 1.1. – National Release
- Treating schizophrenia in poorer countries: Old dilemmas and new directions
- Having more family meals during adolescence is associated with improved diet quality
- Child passengers are exposed to secondhand smoke
-Endometriosis: Where is the real truth? It’s here
- Hormone therapy had no effect on memory, but increases sexual interest
- If you have to use something, nitrous oxide might be better than narcotics and epidurals
- Acute Appendicitis and Pregnancy
- Nurses and physicians have different perspectives in medical decisions
- Training for Shoulder Dystocia
- Ordinary Doses of Vitamin D Linked to Lower Mortality
- No, I don’t mean THAT Dating Game
- Magic Pill Improves Glycemic Control and Decreases Death by 25% for Type 2's
- Planning Group - conference on midwifery models of care
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_10.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence - Denise Grenier, Tucson / Rachel Locker, Warm Springs
Adolescent primary prevention programs for domestic violence which are school based
I have put together some slides that while not the clearest will have you looking at the html versions. I adapted this chart into a ppt slide “Breastfeeding, TV viewing and smoking in household by race and ethnicity” And many more files. recent years, a number of evaluations of primary prevention programs targeting partner violence have been published. This article presents a systematic review of recent interventions for primary prevention of partner violence. A total of 11 programs met inclusion criteria for the review. All 11 studies used some combination of feminist theory and social learning theory as a basis for the intervention.
- All targeted middle- or high-school aged students, and all but one were set in a school setting and were universal interventions (i.e., were not targeted to an at risk group).
- Interventions tended to be brief, with only two using interventions totaling more than 5 h in duration.
Although a majority of studies were randomized trials, study quality was generally poor due to relatively short follow-up periods, high attrition rates, and poor measurement. Of the four studies that measured behavior, two found a positive intervention impact. Those two studies had the most comprehensive interventions, using both individual-level curricula and other community-based interventions. Both also employed rigorous designs.
Conclusions about the overall efficacy of dating violence interventions are premature, but such programs are promising. We discuss recommendations regarding the content and evaluation of dating violence prevention programs. Judith.Thierry@ihs.gov
Elder Care News
Postdischarge care management that integrates medical and social
care can improve outcomes of the low-income elderly
http://www.ahrq.gov/research/nov07/1107RA10.htm
Principles of Effective Pain Management at the End of Life
http://www.medscape.com/viewarticle/545562
Family Planning
A novel acid buffering gel is safe and acceptable and has contraceptive efficacy
CONCLUSION: An acid buffering gel used with a diaphragm is a safe, acceptable contraceptive with efficacy comparable to that of a common commercial spermicide with diaphragm. LEVEL OF EVIDENCE: I.
Barnhart KT et al Contraceptive efficacy of a novel spermicidal microbicide used with a diaphragm: a randomized controlled trial. Obstet Gynecol. 2007 Sep;110(3):577-86.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766603
Featured Website - David Gahn, IHS MCH Portal Web Site Content Coordinator
Lack of VZIG and new prenatal assessment of varicella immunity addressed: New module
New Perinatology Corner Module: Varicella (Chickenpox) in Pregnancy
-Unfortunately, the manufacturer has discontinued production, so the availability of VZIG is rapidly declining, since the only manufacturer of this product has ceased production.
What should you do about the lack of available VZIG?
-The CDC has recommended the use of “VariZIG”, a purified lyophilized
human immune globulin preparation prepared from plasma with high levels of anti-varicella
antibodies. It is only available however under an “investigational new
drug application expanded access protocol” from the sole U.S. distributor.
And informed consent must be obtained prior to use. Turn around time for your
laboratory is obviously critical to stay within the 4-day window.
How readily available is VariZIG at your service unit?
Where will you obtain it ad how quickly can it arrive?
-Prenatal assessment of women for evidence of varicella immunity is recommended. Birth before 1980 is not considered evidence of immunity for pregnant women because of potential severe consequences of varicella infection during pregnancy, including infection of the fetus.
How should that be implemented?
Go to this link. Get the free CME or just use the many resources
http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VC01.cfm
and
It was low hanging fruit before: Now it is even easier - Perinatology Corner
The Perinatology Corner, a great Indian Health resource on many obstetric topics, plus free CME, has just gotten easier to use. Once you create an IHS login username and password (which takes about 30 seconds) the system will remember you and make it easier each time you want to take another module.
Submitting a Posttest
To take a posttest, log in with an IHS login now
The link to log in is in the leftside menu of each module's posttest page. (You will only need to log in once to any page that provides the link in the IHS site.) Once you fill in the registration information on the posttest page of one module, the demographics will self populate all future modules, thereby saving you time and effort.
You can take and retake any posttest. Any time you take a posttest, an email will sent to you with answers. You only get credit for the first time you take a module's posttest.
You can change your contact information (except their email address, through this system) in the form of any module's posttest once you've submitted your contact information in the first posttest you take.
You can update your contact information on the form when you're submitting a new posttest, when retaking a test with or without retaking the posttest.
Here is how to complete the Posttest and Evaluation
It is easy. Ptease log in and the Posttest page will become available
-If you have logged into the to the Indian Health registration before, then go directly to Login (choose the "Login" link):
Hit Login or Register
-If haven't completed the Registration process before, it is easy, secure,
and relatively quick.
-It will also allow you to take future modules without having to repeat your
contact information each time.
Choose the "Register" link:
Once you have successfully logged into your web account, then hit the Return
button on the
Successful Login page and it will take you to the Posttest and Evaluation
Perinatology Corner
http://www.ihs.gov/MedicalPrograms/MCH/M/perCrnr.cfm
Frequently asked questions
Q. Where can I get copies of the lecture notes from the 2007 Women’s Health and MCH
Conference that was held in Albuquerque on August 15-17 th ?
A. The lecture notes are posted on the MCH Meeting Notes web site, as are the professional group reports. Go here http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
December 2007
- No more cough syrup says the FDA
- No more cavities says Dr. Esposito
- Not enough Hib vaccine says Dr. Singleton
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1207b.doc
Information Technology
Patient-Physician Email Communication May Be Effective
CONCLUSIONS: Patient-physician e-mail is a service that patients will use given the opportunity. The e-mail service enables physicians to answer medical questions with less time spent compared with telephone messaging. In our experience in an academic pediatric subspecialty practice, patients reported enhanced communication and access with the e-mail service.
Rosen P, Kwoh CK. Patient-physician e-mail: an opportunity to transform pediatric health care delivery. Pediatrics. 2007 Oct;120(4):701-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17908755
Frequently Asked Questions: Clinical Performance Measurement, GPRA and CRS
-How does GPRA performance affect IHS and Tribal Programs
-What is clinical performance measurement?
-How does the Government Performance and Results Act (GPRA) relate to clinical performance measurement
-These and many other questions are answered and are available
Contact: Francis.frazier@ihs.gov or Stephanie.klepacki@ihs.gov
Is more information available? Yes, CRS has its own web site and contains a variety of information, such as the CRS User Manual, Fact Sheet, and past training presentations.
The web site is: www.ihs.gov/cio/crs
Medicine Dish - Broadcast Schedule
Rodger Goodacre, Tribal Affairs Group/ CMS
Please note that the Medicine Dish broadcasts are routinely scheduled for the second Wednesday of every month at 1:30 Eastern.
Broadcast Schedule
Note: Broadcast topics are subject to change. Please review the individual Program Announcement prior to each broadcast for the most recent program information
|
Date |
Topic |
Presenters |
|
October 10, 2007 |
Maximizing reimbursement for Medicare Part D |
|
|
November 14, 2007 |
Medicare 101 for Tribes |
|
|
December 12, 2007 |
Medicaid 101 for Tribes |
|
|
January 9, 2008 |
Survey and Certification 101 for Tribes |
|
|
February 13, 2008 |
Coding and Billing for M/M, including the All Inclusive Rate |
|
|
March 12, 2008 |
How to access CMS tribal health care resources |
|
|
April 9, 2008 |
Medicare Part B: requirements, processes for enrollment & participation |
|
|
May 14, 2008 |
Cost reports for I/T/U: how to do them, what is in them, how they are used |
|
|
June 11, 2008 |
Electronic medical records |
|
|
July 9, 2008 |
CMS website: a tour and how to use it |
|
|
August 13, 2008 |
Federally-Qualified Health Centers (FQHC) billing basics |
|
|
September 10, 2008 |
Information about the treatment of specific diseases |
|
If you have any questions, please contact Rodger Goodacre, Tribal Affairs Group/ CMS at Rodger.goodacre@cms.hhs.gov
International Health Update - Claire Wendland, Madison, WI
I wanted to draw some attention to the Special Global Issue of Obstetrics and Gynecology, 11/07
Ghana postgraduate training program: 37 or 38 OB/GYNs remained in the country
The Safe Motherhood Initiative has highlighted the need for improved health services with skilled attendants at delivery and the provision of emergency obstetric care. "Brain drain" has hampered this process and has been particularly prevalent in Ghana. Between 1993 and 2000, 68% of Ghanaian trained medical school graduates left the country. In 1989, postgraduate training in obstetrics and gynecology was established in Ghana, and as of November 2006, 37 of the 38 specialists who have completed the program have stayed in the country, most working in the public sector providing health care and serving as faculty. Interviews with graduates in 2002 found that the first and single-most important factor related to retention was the actual presence of a training program leading to specialty qualification in obstetrics and gynecology by the West African College of Surgeons. Economic and social factors also played major roles in a graduates' decision to stay in Ghana to practice. This model deserves replication in other countries that have a commitment to sustainable development, human resource and health services capacity building, and maternal mortality reduction. A network of University partnerships between departments of obstetrics and gynecology in developed and developing countries throughout the world sharing internet resources, clinical information, training curriculum and assessment techniques could be created. Grand rounds could be shared through teleconferencing, and faculty exchanges would build capacity for all faculty and enrich both institutions. Through new partnerships, creating opportunity for medical school graduates to become obstetrician-gynecologists may reduce brain drain and maternal mortality.
Anderson FW, et al Who Will be There When Women Deliver?: Assuring Retention of Obstetric Providers. Obstet Gynecol. 2007 Nov;110(5):1012-1016.
Traditional birth attendant training for improving health behavior and pregnancy outcomes
AUTHORS' CONCLUSIONS: The potential of TBA training to reduce peri-neonatal mortality is promising when combined with improved health services. However, the number of studies meeting the inclusion criteria is insufficient to provide the evidence base needed to establish training effectiveness. - COCHRANE UPDATE
Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Obstet Gynecol. 2007 Nov;110(5):1017-8.
Vaginal and neonatal chlorhexidine wipes applied in home settings are well tolerated
CONCLUSION: Use of 0.6% chlorhexidine vaginal and neonatal wipes for the prevention of neonatal infection is well-tolerated and seems safe. A trial of this intervention by traditional birth attendants in a home-delivery setting is feasible. LEVEL OF EVIDENCE: I.
Saleem S, et al Chlorhexidine Vaginal and Neonatal Wipes in Home Births in Pakistan: A Randomized Controlled Trial. Obstet Gynecol. 2007 Nov;110(5):977-985.
Everybody has a story
Women's struggles in Malawi, Africa, lead to unacceptably high levels of maternal morbidity and mortality. Everybody has a story. Every woman in Malawi has her version of the common theme of struggling to survive, raise her children, and keep them alive. This spring, I had the privilege to care for many Malawian women as they sought help at their local hospital. I was able to bear witness to the myriad challenges they face and capture pieces of their stories along the way….
Lathrop E. Everybody has a story. Obstet Gynecol. 2007 Nov;110(5):986-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978108
Investment in family planning reduces global poverty and improves both maternal and child health
Family planning plays a pivotal role in population growth, poverty reduction, and human development. Evidence from the United Nations and other governmental and nongovernmental organizations supports this conclusion. Failure to sustain family planning programs, both domestically and abroad, will lead to increased population growth and poorer health worldwide, especially among the poor. However, robust family planning services have a range of benefits, including maternal and infant survival, nutrition, educational attainment, the status of girls and women at home and in society, human immunodeficiency virus (HIV) prevention, and environmental conservation efforts. Family planning is a prerequisite for achievement of the United Nations' Millennium Development Goals and for realizing the human right of reproductive choice. Despite this well-documented need, the U.S. contribution to global family planning has declined in recent years.
Allen RH. The role of family planning in poverty reduction. Obstet Gynecol.
2007 Nov;110(5):999-1002. http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17978110&dopt=AbstractPlus
The 12-month probability of pregnancy for injectable and pill users is 0.6% and 9.5%
CONCLUSION: The overall risk of pregnancy for injectable contraceptive users was substantially lower than for oral contraceptive pill users. However, Thai participants had similarly low cumulative pregnancy probabilities for both methods. Women receiving contraceptive counseling should be informed that their experience with a given method may differ from the average or typical-use pregnancy rates often discussed during contraceptive counseling. Tailored counseling is necessary for women to make informed choices. LEVEL OF EVIDENCE: II.
Steiner
MJ, Pregnancy Risk Among Oral Contraceptive Pill, Injectable Contraceptive,
and Condom Users in Uganda, Zimbabwe, and Thailand. Obstet Gynecol. 2007 Nov;110(5):1003-1009. http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17978111&dopt=AbstractPlus
Safe motherhood strategies should include evidence of effectiveness
After two decades of the Safe Motherhood Initiative, meaningful reductions in maternal mortality and disability during pregnancy and childbirth in developing countries have not been realized. Herein, we present an overview of the Initiative and review the reasons for this lack of impact, focusing on the issue of strategic effectiveness. An appraisal of strategies that are currently recommended reveals a lack of strong evidence to support their effectiveness. Drawing from the Initiative's history, we propose that, among essential elements to achieve safe motherhood, recommended public health strategies should be supported by good evidence of effectiveness, through (cluster) randomized trials when feasible, before their widespread implementation.
Tita AT, et al Two Decades of the Safe Motherhood Initiative: Time for Another Wooden Spoon Award? Obstet Gynecol. 2007 Nov;110(5):972-976.
A Skirt for a Life?
Julia was a beautiful, young Ugandan woman, straight and graceful as she walked along the dusty road, balancing a load of bananas on her head.
Her steps were light these days. She had recently met the man of her dreams. He was from a far off town called Hoima. He came from a different tribe than hers, but she felt she could live with that. And her mother would soon stop grumbling about it.
Froese JC. A skirt for a life? Obstet Gynecol. 2007 Nov;110(5):1010-1.
HIV infection was not associated with increased stillbirth risk in a large African cohort
CONCLUSION: In this large cohort, HIV infection was not associated with increased stillbirth risk. Further work is needed to elucidate the relationship between chorioamnionitis and stillbirth in African populations.
Chi
BH, et al Predictors of Stillbirth in Sub-Saharan Africa. Obstet Gynecol.
2007 Nov;110(5):989-997 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17978109&dopt=AbstractPlus
MCH Alert
Tightening the "holes" in the Swiss cheese model of patient safety in obstetrics
Most health care professionals who are involved in efforts to improve patient safety are aware of James Reason’s "Swiss cheese" model of how accidents occur. Some elements and pressures of current obstetric practice may weaken defenses and safeguards against perinatal injury. Several components of obstetric care in labor and delivery units can be used as targets for tightening the "holes" in the Swiss cheese model. These include improving communications, preparing for rare critical events through simulation training, developing protocols for administration of important medications used in labor and delivery (oxytocin, misoprostol, and magnesium sulfate), increasing the in-house presence of obstetricians, developing an effective departmental infrastructure that includes effective peer review, providing risk management education about high-risk clinical areas that have the potential to result in catastrophic injury, and staffing the unit for all contingencies during all hours, day and night. Acceptance by the obstetric medical staff is critical to the implementation of these patient safety elements.
Veltman LL. Getting to havarti: moving toward patient safety in obstetrics. Obstet Gynecol. 2007 Nov;110(5):1146-50.
Electronic resource updates state action on HPV Vaccine
HPV Vaccine Legislation 2007 presents information on the June 2006 recommendation by the national Advisory Committee on Immunization Practices (ACIP) for routine vaccination against Human Papillomavirus
(HPV) for girls ages 11-12, as well as on state activity to require, fund, or educate the public about the HPV vaccine. The electronic resource, produced by the National Conference of State Legislatures (NCSL), addresses key issues such as school vaccine requirements and financing. A table provides a state-by-state summary of 2007 legislation introduced to date. Related resources from NCSL, the Centers for Disease Control and Prevention, the Journal of the American Medical Association, and the Kaiser Family Foundation are included. http://www.ncsl.org/programs/health/HPVvaccine.htm
Improving the health of women and children benefits an employer’s bottom line
Investing in Maternal and Child Health: An Employer's Toolkit provides information
and resources employers can use to improve the health of employees and their
families. The toolkit, published by the National Business Group on Health with
support from the Maternal and Child Health Bureau, outlines the unique opportunity
that employers' have to improve the health of women and children through health
benefit design, beneficiary education and engagement, and health promotion programs.
The toolkit is divided into seven sections. Topics include recommendations on
evidence-informed, comprehensive health benefits to support child, adolescent,
and pregnancy health; cost-impact assessments of recommended benefit changes;
data on the cost of maternal and child health (MCH) care services; the business
case for investing in child and adolescent health, healthy pregnancies, and primary
care services for all beneficiaries; tools employers can use to develop an MCH
strategy, communicate the value of their MCH benefits, and link MCH outcomes
to organizational performance; strategies employers can use to effectively communicate
with beneficiaries and to tailor existing health programs and policies to the
unique needs of children, adolescents, and pregnant women; and health education
information specifically developed for beneficiaries. http://www.businessgrouphealth.org/healthtopics/maternalchild
/investing/docs/mch_toolkit.pdf
Lower socioeconomic status and poor perinatal outcomes: Even with universal access
INTERPRETATION: Lower family income is associated with increased rates of gestational diabetes, small-for-gestational-age live birth and postneonatal death despite health care services being widely available at no out-of-pocket expense
Joseph KS et al Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services. CMAJ. 2007 Sep 11;177(6):583-90.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17846440
MCH Headlines - Judy Thierry HQE
Frequently Asked Questions about Infant Feeding Choice
BACKGROUND INFORMATION
Why collect this data? Because it is used in the clinical performance measure called Breastfeeding Rates that is reported in the RPMS Clinical Reporting System (CRS). While this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure Childhood Weight Control with the goal of lowering the incidence of childhood obesity in the IHS patient population. Additionally, facilities can use this data to track infant feeding patterns and breastfeeding rates within their own patient population.
Research indicates that children who were breastfed have lower incidences of overweight or obesity. For additional information, please click the link below to review the article in the March 2007 IHS Primary Care Provider.
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0307.pdf
How is this data used? It is used in the CRS Breastfeeding Rates topic in several measures that report:
- How many patients approximately 2 months through 1 year of age were ever screened for infant feeding choice.
- How many patients were screened at the approximate ages of 2 months, 6 months, 9 months, and 1 year.
- How many patients who were screened were either exclusively or mostly breastfed at those age ranges.
Users may run the CRS Selected Measures (Local) Reports to view all of the breastfeeding performance measures. The report also provides the option to include a list of patients and identifies the dates and ages they were screened and their infant feeding choice values. Click the link below to learn how to run this report in CRS, starting on page 206 (as numbered in the document itself, not in Adobe).
http://www.ihs.gov/misc/links_gateway/download.cfm?doc
_id=10716&app_dir_id=4&doc_file=bgp_070u.pdf
Is Infant Feeding Choice data the same as the data included in the Birth Measurements section of the EHR and with the PIF (Infant Feeding Patient Data) mnemonic in PCC? No, it is different. The information collected in these sections are intended for one-time collection of birth weight, birth order, age when formula was started, breastfeeding was stopped and solid foods started, and linking to mother/guardian. Shown below is a screen shot of this section from EHR. While this information is important, none of it is used in the logic for the CRS Breastfeeding Rates measure; only the Infant Feeding Choice data is used.
What are the definitions for the Infant Feeding Choices? The definitions are shown below and are the same definitions used in both EHR and PCC.
- Exclusive Breastfeeding: Formula supplementing less than 3 times per week (<3x per week)
- Mostly Breastfeeding: Formula supplementing 3 or more times per week (>3x per week) but otherwise mostly breastfeeding
- ½ Breastfeeding, ½ Formula Feeding: Half the time breastfeeding, half the time formula feeding
- Mostly Formula: The baby is mostly formula fed, but breastfeeds at least once a week
- Formula Only: Baby receives only formula
Who should be collecting this information and how often? It depends on how your facility is set up but any provider can collect this information. At a minimum, all providers in Well Child and Pediatric clinics should be collecting this information for patients 45-394 days old at all visits occurring during that age range. Public Health Nurses should also be collecting this information. This data can be entered in EHR or PCC/PCC+, as described below.
ENTERING INFANT FEEDING CHOICE DATA IN EHR
In which version of EHR is Infant Feeding Choice data able to be entered? EHR Version 1.1, which was deployed nationally on October 3, 2007.
How do I enter Infant Feeding Choice in EHR?
- After you have selected the patient and the visit, go to the Personal Health section. For some EHR sites, this may be included on the Wellness tab.
- From the Personal Health dropdown list, select Infant Feeding, then click the Add button.
NOTE: The age of the patient must be five years or less to be able to select Infant Feeding; otherwise, Infant Feeding will not be listed in the dropdown list.
- At the Add Infant Feeding Record window, click the appropriate checkbox to select the type of infant feeding, and then click the OK button to save the value.
- The patient’s value for Infant Feeding Choice for this visit is now displayed in the Personal Health section, as shown below.
ENTERING INFANT FEEDING CHOICE DATA IN PCC/PCC+
Which data entry patch do I need? You will need to have data entry patch 8 (apcd0200.08k) installed, which was released on October 19, 2005.
How do I enter Infant Feeding Choice in PCC?
- Create a new visit or select an existing visit to append.
- At the Mnemonic prompt, type “IF” (Infant Feeding Choices) and press Enter.
- Type the number corresponding to the type of feeding and press Enter. If you do not know the number, type “??” and press Enter to see a list of choices.
- You are returned to the Mnemonic prompt. Continue with data entry of other items.
Stephanie Klepacki
CRS Project Manager/Lead Analyst
November 2, 2007
MCH Coordinator Editorial comment:
The infant feeding choice functionality is supported in the newly released EHR 1.1
The clinical performance measure called Breastfeeding Rates reported in the RPMS Clinical Reporting System (CRS) is a measure of interest. We wish to emphasize that while this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure Childhood Weight Control with the goal of lowering the incidence of childhood obesity in the IHS patient population. Additionally, facilities can use this data to track infant feeding patterns and breastfeeding rates within their own patient population in the first year of life.
To capture this data Stephanie Klepacki, the CRS Project Manager/ Lead Analyst has developed: Frequently Asked Questions: Infant Feeding Choice in EHR. A team of analysts and clinicians have been involved in developing and testing this functionality. Kudos go to Phoenix Indian Medical Center’s Department of Pediatrics, to Sherry Allison, Information Processing Supervisor and her staff for getting the data entered pre EHR, and the ever diligent and nurturing Suzan Murphy, RD, IBLCE who have done the lion’s share of the clinical testing.
From an MCH standpoint expanding this functionality into toddler and early childhood feeding choices seems a natural next step as later versions are developed.
We look forward to your feedback, comments and use of this functionality in the universal documentation of feeding choice during the first year of life for our American Indian and Alaska Native families.
Lastly, new to the Indian Health Breastfeeding page* is the Lactation Support in the Workplace Toolkit. This document includes information on: how to get started, drafting local policy, evaluation tools, resources available on the Indian Health Breastfeeding page, as well as FAQs.
Lactation Support Policy in the Workplace
*Indian Health Breastfeeding page
http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
First Nations and Inuit Health Health Canada HHS and Indian Health Service MOU
A signing ceremony between HHS Secretary Mike Leavitt and the Canadian Minister of Health, Tony Clement, is scheduled for November 1, 2007 in the HHS Humphrey Building Great Hall. The signing of a Memorandum of Understanding (MOU) is to improve the health status of indigenous communities in the U.S. and Canada. Mr. Robert McSwain, Acting Director of the Indian Health Service (IHS), will deliver a speech at the ceremony. The MOU will foster enhanced international collaborations, identification and reinforcement of best practices, and innovative approaches to learning opportunities. The MOU, which continues the work of a similar five-year MOU signed in 2002 and completed this year, will focus on improving health care delivery and access to health services for American Indians and Alaska Natives of the U.S. and the First Nation and Inuit people of Canada.- Verna N. Miller, Office of the Director, Public Affairs, Indian Health Service , (301) 443-3593
A focused collaboration on midwifery training, practice, traditions and community awareness and outreach is being planned for year I.
IHS Behavioral Health with First Nations and Inuit Health Branch (FNIHB) collaborated on a FASD work group under the 2002 MOU. Contact Judith.Thierry@ihs.gov
New Guidelines on Fish Consumption for Females of Childbearing Age,
Young Children
Alaska State health officials released new guidelines on the amount of local
fish women and girls of childbearing age, and young children should consume,
the Anchorage
Daily News reports. According to the recommendations, these groups can eat
salmon from local waters in unlimited amounts without risking overexposure to
mercury but should limit consumption of large halibut, shark, large lingcod,
yelloweye rockfish and spiny dogfish because of mercury levels found in the fish.
The state previously said that females of childbearing age and young children could eat an unlimited amount of local fish but changed its guidelines because of mercury levels reported this year in certain fish that never had been tested and in larger specimens of previously tested fish, according to the Daily News. The state's fish tissue testing program, which began in 2001, shows that most of Alaska's five species of salmon and pollock contain safe levels of mercury, based on the state's health standards. According to the Daily News, the state has tested the hair of 359 pregnant women for mercury since 2002 and has extended the studies to all females ages 15 to 45. The tests found that hair mercury levels in all of the women were well below 14 parts per million, which the World Health Organization says can cause harm to the health of a fetus.
Differing Guidelines
Alaska's guidelines on fish consumption differ from FDA and Environmental
Protection Agency guidelines, the Daily News reports (Bluemink, Anchorage
Daily News, 10/17). FDA and EPA in 2005 issued warnings that advise young children,
pregnant women, nursing women and women of childbearing age to avoid consuming
swordfish, king mackerel, shark and tilefish because of high mercury levels.
The warnings also recommend that those groups eat no more than 12 ounces of fish
weekly and no more than six ounces of canned albacore tuna weekly (Kaiser
Daily Women's Health Policy Report, 10/11). Alaska officials said that fish
from local waters are less contaminated than fish from other areas and may be
consumed in greater amounts. According to the Daily News, the state on Monday
also unveiled a "fish diet calculator" Attached to help families
gauge how much of the riskier fish they may consume weekly without health risk. http://www.epi.hss.state.ak.us/eh/fish/FishDietCalculator.pdf
26th Annual “Protecting Our Children”
- April 20-23, 2008
- Minneapolis , MN
- National American Indian Conference on Child Abuse and Neglect
- http://www.nicwa.org/
Early child health caries reduction tool kit
Into the Mouths of Babe’s Oral Health Tool Kit
(Scroll to bottom)
http://www.communityhealth.dhhs.state.nc.us/dental/
Child-Oriented Clinical Practice in Process
-Call new mothers at home 1-2 days after they leave the hospital. (designate person(s), have simple script or prompts, make a chart note)
-Check immunizations at every patient visit
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable
- Plot accurate heights & weights on an appropriate growth chart http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm
Solicit feedback and acknowledge a parent’s effort at all visits.
Are patient encounter environment(s) infant, child and teen appropriate? (mobiles, toys, games, books, posters, Audio/visuals, passive referral information and health literacy for 0 –