Archive for December, 2009

My Journey to VBAC Now Includes an Anterior Placenta

Posted on December 30, 2009. Filed under: Anterior placenta, VBAC after inverted t incision | Tags: , , , |

I don’t know if every woman planning to VBAC considers the location of her placenta at all when preparing to birth. I don’t know if it is something commonly thought about or it is brought up by the midwife or doctor at some point. I tend to think that if the mom has an ultrasound and the placenta is posterior (on the back wall of the uterus) that nothing is ever brought up at all and most moms probably never really think much of it. On the flip side, if an u/s is done and the placenta is found to be anterior (on the front wall) then it is mentioned and the mom begins to learn about the risks associated with an anterior placenta when planning to VBAC and she begins crossing her fingers that as her uterus grows that her placenta moves up high above her c section scar. For a mom with a prior bikini cut, ‘high above the scar’ doesn’t require a whole lot of movement as the scar is in the lower segment of the uterus.

I went into my pregnancy thinking about an anterior placenta. I didn’t dwell on it, it just crossed my mind a couple of times because of my inverted t incision. I don’t think I manifested an anterior placenta or anything  but because it can create real problems and because I know (too much sometimes) this, I just thought a few times that “I really hope my placenta is not anterior because I don’t want the added worry. ” I began to suspect that it was a week ago though. I found the baby’s heartbeat with my doppler at home at 9weeks and 5 days. It was really hard to find but definitely there. Almost two weeks later I couldn’t find it. I could see it pick up briefly so I knew it was there (plus I totally still feel pregnant!). I never thought I had miscarried or anything like that, I just thought ‘hmm wonder if the placenta is in the way.’ By 11 weeks the placenta is a good size and I figured it was big enough to block the heart tones.

I had my 12 week appointment today and my doc offered to do an u/s. He is a solo practitioner and has a machine in house and I think he likes doing them himself. He would probably offer every month, of course, I have no intention of having a monthly u/s but today when he offered I told him no that I didn’t need one. I found the heartbeat with a doppler and if he wanted to check he could that way. Then I told him I found it a few weeks ago but I couldn’t find it last week and that I thought the placenta was anterior. So he said ‘let’s take a look.’ I knew immediately when I saw the screen and he confirmed. He didn’t seemed worried at all which is great. Most mainstream and American docs would have gotten nervous. He just said, it’s early and it will move and hopefully it moves way up high and out of the way. He also reminded me that scar tissue was very strong. Then he said that if it stayed in the front on top of my scar as it is now, because it is big and my uterus is still small, then it probably wouldn’t cause problems in labor but could cause detachment problems after. He said, ‘you’d still have your vaginal birth and I would take care of everything after, don’t worry.’ I really appreciate his mentality. I can’t imagine too many docs that have that kind of attitude. There are some serious complications that can occur from placentas attaching to c section scars.

AIP= accreta, increta and percreta, where the placenta attaches to the scar or grows into the scar or  grows through the scar to the outside of the uterus. It can cause massive hemorrhage and often require hysterectomy. I’m not going to go into too much detail on all this because I am not really too hung up on it. I just didn’t want the anterior placenta so that none of this would have to cross my mind. Because it has crossed my mind I will now think about it until I see that the placenta has moved up and safely away from the scar. If I find that it hasn’t moved, a 3D u/s or an MRI can detect AIP. If there is any AIP then I will obviously have a very different remainder of pregnancy and birth and I can live with it because our safety would be compromised.

Chances are it will probably move up. There is a lot of growing left to do and I know this. There is not any information to be found on VBAC with an inverted t incision and an anterior placenta so I thought I post about it and see what kind of feedback and response I got.  If anyone has VBACd with an anterior placenta, please share, regardless of incision type.

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Iron and Vit D Supplementation in Exclusively Breastfed Babies

Posted on December 19, 2009. Filed under: Iron in breast milk | Tags: , , , |

*This post originally only included info on Iron supplementation until a commenter asked about Vit D. I have edited to include an article on Vit D supplementation. The article is from Mother magazine. See below.

Here  in Korea the Army pediatricians give vitamin drops to all breastfeeding mothers at either the two day or two week check up. They generally tell the mothers that breast milk is incomplete and that their babies can develop anemia from lack of iron.  Studies have shown that healthy term newborns have enough iron stores to get to six months of age when solid foods are generally introduced. This is the information I give my clients when they ask me if they should use the vitamin drops or if I used them myself. I of course, never tell anyone not to use them but give them the information as I know it and direct them to where they can find accurate data on the topic so that they can make an informed decision. Vitamin toxicity is a side effect and the drops are generally nasty and staining. Most breastfeeding moms forego the drops because they believe their milk is complete regardless of what the pediatrician has told them.

I was also talking about iron with friend whose baby will be coming up on six months soon. I told her that with my son, who didn’t start solids until after six months, that I focused on feeding him foods naturally high in iron and continued to breastfeed and he did well. I rarely used commercially made fortified foods and he didn’t start eating meat until he could chew it himself.

I found an article today that really explains everything that I have learned in an easy to follow way with lots of references. I thought I’d pass it on. Below is the excerpt on iron absorption and the link for the whole article is HERE.

It’s “common knowledge” that iron supplements are necessary after a baby reaches the magic age of six months. But is this an accurate statement? Let’s look at some of the current research.

Anemia is uncommon in breastfed babies for several reasons
  • Healthy, full-term babies have enough iron stores in their bodies to last for at least the first six months. The current research indicates that a baby’s iron stores should last between six and twelve months, depending upon the baby.
  • The iron in breastmilk is better absorbed than that from other sources. The vitamin C and high lactose levels in breastmilk aid in iron absorption.
    Iron Source Percentage of Iron Absorbed
    breastmilk ~50 – 70%
    iron-fortified cow milk formula ~3 – 12%
    iron-fortified soy formula
    less than 1% – 7%
    iron-fortified cereals 4 – 10%
    cow’s milk ~10%
    Note: The amount of iron absorbed from any food depends greatly upon the milk source of iron (eg, human vs cow), type of iron compound in the food, the body’s need for iron, and the other foods eaten at the same meal.
  • Breastfed babies don’t lose iron through their bowels; cow’s milk can irritate the intestinal lining (resulting in a tiny amount of bleeding and the loss of iron).

The original iron stores of a full-term healthy baby, combined
with the better-absorbed iron in breastmilk, are usually enough
to keep baby’s hemoglobin levels within the normal range
well into the second six months.

THIS article also discusses why delaying solids until 6 months and not 4-6 months as many doctors suggest is important. The data is there but the advice being given by many pediatricians and many mainstream books is out of date. Below is the excerpt on iron absorption.

Delaying solids helps to protect baby from iron-deficiency anemia.
The introduction of iron supplements and iron-fortified foods, particularly during the first six months, reduces the efficiency of baby’s iron absorption. Healthy, full-term infants who are breastfed exclusively for periods of 6-9 months have been shown to maintain normal hemoglobin values and normal iron stores. In one study (Pisacane, 1995), the researchers concluded that babies who were exclusively breastfed for 7 months (and were not give iron supplements or iron-fortified cereals) had significantly higher hemoglobin levels at one year than breastfed babies who received solid foods earlier than seven months. The researchers found no cases of anemia within the first year in babies breastfed exclusively for seven months and concluded that breastfeeding exclusively for seven months reduces the risk of anemia. See Is Iron-Supplementation Necessary? for more information.

Here is an article from Mothering magazine discussing Vit D supplementation in exclusively breastfed babies:

Sunlight Deficiency: A Review of the Literature

Making informed decisions about complex and controversial health issues, such as vitamin D supplementation of breastfed infants, is inherently challenging. When evaluating information, mothers may wish to consider the goals, potential biases, and sources of funding of health organizations, researchers, healthcare providers, and vitamin manufacturers; the depth, breadth, and limitations of the information on which public health policies are based; whether a recommendation might be out of date or applicable in only some situations; whether any conflicts of interest might be involved; and whether the organization or individual making the recommendation is in full compliance with the letter-and spirit-of the WHO/UNICEF International Code of Marketing of Breast-Milk Substitutes. 1, 2 A review of the related scientific literature, though essential, is just the beginning.

What Is Vitamin D?
Vitamin D is actually not a vitamin at all, but a steroid hormone produced in the body after direct exposure of the skin to ultraviolet B (UVB) radiation in sunlight. Vitamin D plays a critical role in the maintenance of proper blood calcium and phosphorous concentrations, and in bone mineralization by stimulating the absorption of calcium and phosphorous in the small intestine. It also acts as a chemical messenger in a wide variety of other biological responses.3

What Is Vitamin D Deficiency and What Are Its Consequences? In the absence of underlying organic causes, such as prematurity or liver or kidney disease, vitamin D deficiency is sunlight deficiency. Vitamin D deficiency can lead to bone disease: osteomalacia in adults, rickets in infants and children. Research has shown that higher latitude and lower vitamin D levels are related to several cancers, type 1 diabetes, and other diseases.4-6

How Do People Get Enough Vitamin D?
The direct, casual exposure of skin to sunlight is the most common and the biologically normal way that human beings attain sufficient levels of vitamin D. However, sunlight exposure for many people around the world has been reduced by industrialization, urbanization, migration, concern about skin cancer, and social inequities. Because only a few foods naturally contain significant levels of vitamin D (e.g., the oils and livers of some fatty fish), it would be unusual for people to obtain adequate vitamin D from their diet alone without supplementation or enrichment.7

The skin has a large capacity to produce vitamin D. Exposure of the entire adult body to the smallest amount of UVB radiation that produces transient, just perceptible skin reddening is comparable to taking an oral dose of 10,000 to 25,000 IU of vitamin D.8, 9 Therefore, sufficient levels of vitamin D can be developed from partial exposure of the body to sunlight well before sunburn occurs.

Levels of vitamin D vary seasonally among people exposed to sunlight at higher latitudes, where UVB radiation is higher in the summer and lower in the winter.10, 11 With inadequate summer exposure, vitamin D deficiency and insufficiency can result, particularly during the winter.12, 13 However, with adequate exposure to sunlight in the summer, vitamin D can be stored in the body for winter use.14 The lower vitamin D stores of the spring can be replenished with exposure to the higher UVB radiation of summer sunlight.

How Do Nurslings Get Enough Vitamin D?
The natural sources of vitamin D for nurslings are primarily the stores they developed prenatally (for newborns) and the vitamin D they produce with exposure of their skin to sunlight; a smaller additional contribution is from human milk.15, 16 The concentration of fat-soluble vitamin D in human milk varies from 5 to 136 IU/L, depending on how its activity is measured and on maternal vitamin D status during lactation.17-19 This concentration provides less than the 200 to 400 IU/day commonly recommended for infants under one year of age.20 However, human milk should not be considered “deficient” in vitamin D, because the biologically normal means of obtaining sufficient vitamin D in humans is via sunlight exposure, not diet.21-23

The neonate’s stores of vitamin D depend on maternal vitamin D status during pregnancy.24, 25 A study of exclusively breastfed infants in Tampere, Finland (61° N) in winter showed that, without UVB exposure or vitamin D supplementation, vitamin D stores of fetal origin were depleted by eight weeks of age.26 Although these vitamin D-depleted infants had serum levels of vitamin D at which rickets can occur, none had active or biochemical rickets. The concentration of vitamin D in human milk increases significantly with what are currently considered pharmacological doses of vitamin D supplements.27, 28 Administration of 2,000 IU-but not 1,000 IU-to lactating mothers in another study normalized the 25-hydroxyvitamin D levels of their infants in winter.29 Supplementation with over 1,000 IU/d is currently considered to greatly exceed normal maternal vitamin D needs (200 IU/d).30

Studies have shown that children can store enough vitamin D to avoid deficiency for several months when they are exposed to only a few hours of summer sunlight.31-33 Exclusively breastfed Caucasian infants under six months of age (39° N; Cincinnati, Ohio, US) are expected to achieve adequate vitamin D status when exposed to sunlight for 30 minutes per week (diaper only) or two hours per week (fully clothed without a hat). 34 The sunlight exposure needed by darkly pigmented infants is poorly understood.35 Studies of the influence of skin pigmentation on the cutaneous production of vitamin D in adults have shown conflicting results.36, 37 However, a study by Brazerol and colleagues showed that darkly and lightly pigmented adults were equally capable of producing vitamin D when episodes of UVB exposure occurred periodically over time (i.e., biweekly for six weeks in their study).38

Who Is at Risk for Vitamin D Deficiency?
Anyone with inadequate exposure to UVB radiation in sunlight is at risk for vitamin D deficiency. Risk factors for nurslings and their mothers overlap and interact, and include indoor confinement during the day (e.g., due to exclusively indoor daycare, unsafe neighborhoods, custom),39 living at higher latitudes (e.g., essentially no vitamin D is produced with sun exposure from November to February in Boston [42° N] and from mid-October to mid-April in Edmonton, Canada [52º N]),40, 41 darker skin pigmentation,42-45 living in urban areas with pollution and/or buildings that block sunlight,46-48 sunscreen use,49-51 seasonal variations resulting in less ultraviolet radiation (e.g., late winter and early spring in the northern hemisphere),52, 53 covering much or all of the body when outside (e.g., due to custom, fear of skin cancer, cold climate),54-57 increased birth order (e.g., a mother’s sixth child has a higher risk of vitamin D deficiency than does her first child),58, 59 the replacement of human milk with foods low in calcium,60-64 the replacement of human milk with foods that reduce calcium absorption (e.g., grains and some green leaves containing phylates, oxalates, tannates, and phosphates; cereals grown in soil high in strontium),65-67 and exposure to lead (due to lead’s inhibition of vitamin D synthesis).68, 69

What Is Rickets?
Vitamin D-deficiency rickets is a disease of childhood caused by lack of sunlight exposure. Rickets can also be caused by calcium deficiency and underlying disease. The symptoms of rickets vary with age of onset and include bone deformities and fractures, muscle weakness, developmental delays, short stature, failure to thrive, respiratory distress, tetany, and, rarely, heart failure.70 Rickets that develops in breastfed infants during the first six months of life is likely to be related to maternal vitamin D and/or calcium deficiency during pregnancy, which is often asymptomatic.71, 72 Among younger infants, rickets has been reported among formula-fed infants and breastfed infants receiving vitamin D supplementation.73 In that report, no correlation was found between season of birth, breast- or formula feeding, or routine vitamin D supplementation, suggesting that maternal vitamin D status was the direct cause of rickets in that population (i.e., Asian infants living in the United Kingdom).74 In a study of African children older than six months, vitamin D deficiency appeared unlikely to be the primary cause of rickets; insufficient dietary calcium probably interacted with genetic, hormonal, and other nutritional factors to cause rickets in susceptible children.75 Many children affected by early childhood rickets come from poor socioeconomic conditions and sometimes show signs of general malnutrition.76

How Common Is Rickets in Nurslings?
There are currently no national data on the prevalence of rickets in the US,77 though case reports and descriptive studies clearly indicate that rickets is not a disease of the past. At the start of the 20th century, rickets was epidemic in industrialized cities of northern Europe and North America. Through the use of vitamin D supplementation and the fortification of cow’s milk, it was virtually eliminated in most developed countries by the 1960s. Rickets in breastfed infants has been documented among at-risk populations in northern Europe, North America, and former Soviet countries since the 1970s.78 In some developing countries it remains a serious health problem.79-82 Overt rickets is more common in children 6 to 36 months of age than in infants under 6 months of age.83-86 Findings of bone deformities suggestive of rickets are very rare in full-term or premature neonates.87

What are Current Recommendations for Preventing Vitamin D Deficiency in Nurslings?
Public health policies regarding vitamin D supplementation vary globally, reflecting different incidences of and risk factors for vitamin D deficiency, cultural practices, and financial resources.88 No global consensus exists on whether or how to screen nurslings or mothers for vitamin D deficiency or on how to prevent vitamin D deficiency among nurslings. Recommendations for prevention vary, from supplementing all breastfed infants (universal supplementation) to supplementing only at-risk infants (conditional supplementation) to exposing infants to regular small doses of sunshine. (See sidebar, “Recommendations Around the World.”)

The American Academy of Pediatrics’ policy on vitamin D supplementation for breastfed infants has been in development and discussion for two years.89 It is now before the AAP Board of Directors for consideration. If approved, it will become official AAP policy once it is published in the journal Pediatrics. In Breastfeeding and the Use of Human Milk, the AAP currently states that vitamin D may be needed for infants younger than six months whose mothers are vitamin D-deficient or for infants who are not exposed to adequate sunlight.90 However, it seems likely that the AAP will soon recommend universal supplementation for breastfed infants beginning sometime during the first six months of life.91, 92

Some policy makers, researchers, healthcare providers, and mothers in Western or Westernized countries may prefer vitamin D supplementation of all breastfed infants (rather than vitamin D supplementation of only those infants at risk of vitamin D deficiency), in part, because of culturally based discomfort with processes-such as UVB exposure-that are natural, irregular, and not easily measured.93-96 Whether recommendations are universal or conditional, breastfeeding mothers have the right to talk with their healthcare providers about their and their nurslings’ specific risks of vitamin D deficiency and about whether conducting blood tests to determine their and their children’s actual vitamin D status would be appropriate.

Are there Any Risks of Vitamin D Supplementation?
Prophylactic vitamin D supplementation is demonstrably useful for infants at risk of vitamin D deficiency. No known risks of supplementation exist with 200 to 400 IU/day. Supplementation and fortification with vitamin D has been used for decades in many countries. According to the Canadian Department of National Health and Welfare, “It seems probable that the widely accepted figure of 10 µg (400 IU) per day considerably exceeds the true requirements of the great majority of infants, but that amount can be recommended as an effective and safe prophylactic level of intake from all sources.”97 Vitamin D intoxication can occur with excessive intake of dietary vitamin D (i.e., more than 40,000 IU/day for many months in normal adults), but not with endogenous production via sun exposure.98

Many potential risks of vitamin D supplementation, however, have not been investigated. No one knows whether vitamin D supplementation has any deleterious physiological effects on the infant, such as aspiration when supplementation is not tolerated, harmful alterations of the infant gut, or increased rates of infection.99 When studies of health outcomes based on infant feeding routinely fail to define “exclusive breastfeeding” clearly and consistently or even to include truly exclusive breastfeeding (nothing other than human milk fed to the infant directly from the mother’s breasts), it is impossible to know the full effects of vitamin D or other supplementation on infant health and development.100, 101 When studies have differentiated between health outcomes for exclusively and partially breastfed babies, significant differences between the two groups have been shown. For example, in a study by Coutsoudis and colleagues, partially breastfed infants of HIV-positive mothers had a greater risk of becoming HIV-positive than exclusively breastfed infants (who had a risk similar to never-breastfed infants).102

In addition, the effects of universal recommendation of vitamin D supplementation on breastfeeding beliefs and behaviors (e.g., use of other supplements, premature introduction of other foods, weaning) have not been studied. No one knows how vitamin D supplementation affects the likelihood of other types of supplementation. Some breastfeeding mothers may see no difference between the feeding of a vitamin D supplement and the feeding of a small amount of another liquid or food. Some breastfeeding mothers may see universal supplementation as evidence that breastfeeding is inadequate. The importance of exclusive breastfeeding in the first six months of life, however, is well supported.103 If mothers-or other caregivers-see no difference between vitamin drops and other supplementation or believe that human milk is inadequate because supplements are recommended for all breastfed infants, then recommendations of universal vitamin D supplementation could indirectly serve to increase the risk of illness and disease for many infants, including those not at risk for vitamin D deficiency.

Disturbingly, vitamin D supplements are produced by formula manufacturers in some countries (e.g., D-Vi-Sol by Mead Johnson in Canada). Formula manufacturers commonly violate the International Code of Marketing of Breast-Milk Substitutes by engaging in unethical marketing practices, such as advertising formula directly to the general public.104 Mead Johnson’s marketing of D-Vi-Sol includes advertising of its formula.105, 106 Formula advertising has been shown to decrease the duration and exclusivity of breastfeeding.107 Therefore, in countries with no legislation enforcing the Code, such as the US, and in which formula companies manufacture vitamin supplements, a universal recommendation of vitamin D supplements for breastfed infants will result in the routine exposure of large numbers of breastfeeding mothers to formula advertising-with a concomitant increased risk of additional supplementation, premature weaning, and deleterious health consequences for infants and mothers.

Are there Any Risks of Producing Vitamin D via Sun Exposure?
Chronic, excessive sun exposure is strongly associated with a marked increase in the incidence of skin cancer in fair-skinned populations worldwide, as well as with the development of cataracts regardless of skin pigmentation.108 Skin cancer is the most common form of cancer in the US.109 More than a million cases of basal- and squamous-cell skin cancer and more than 53,000 cases of malignant melanoma are diagnosed in the US each year.110 Malignant melanoma occurs ten times more frequently in Caucasians than in African Americans.111 Risk factors for skin cancer include fair to light skin complexion, a family and/or personal history of skin cancer, chronic exposure to the sun, a history of sunburns during childhood, atypical moles, a large number of moles, and freckles (an indicator of sun sensitivity and sun damage).112 No research exists examining the relationship between the risk of skin cancer and a lifetime of minimal levels of sun exposure just sufficient for the endogenous production of adequate levels of vitamin D. Therefore, there currently is no evidence that such levels of sun exposure increase the lifetime risk of skin cancer.

The American Academy of Pediatrics recommends that infants under six months of age be kept out of direct sunlight.113 However, the Global Solar UV Index: A Practical Guide, a joint recommendation of the World Health Organization, World Meteorological Organization, United Environment Programme, and International Commission on Non-Ionizing Radiation Protection, states: “Small amounts of UV radiation are beneficial for people and essential in the production of vitamin D.”114 According to UNICEF, cases of vitamin D deficiency that occur outside of temperate regions with weak sunlight “are the result of the overprotection of certain individuals from the sun. “The best prevention is to change these habits, and health professionals must insist on the need to be in sunlight.”115

What is the Greater Context of Sunlight Deficiency?
The many social causes and health consequences of sunlight deficiency cannot be fully ameliorated through vitamin D supplementation. While supplements are an invaluable tool for preventing rickets in at-risk infants, they do not, for example, protect nurslings from other negative effects that poverty, pollution, unsafe neighborhoods, and crowded inner cities have on the health and development of all infants living in those contexts. Nor do they prevent the negative health consequences of inadequate sunlight on mental health (e.g., seasonal onset and remission of depressive episodes) and women’s reproductive systems (e.g., irregularities of the menstrual cycle and premenstrual syndrome).116-118

When rickets occurs in breastfed infants, it indicates that something is very wrong with the context in which breastfeeding is happening, not with breastfeeding itself. Social and environmental problems in that context warrant assessment, further research, and amelioration. Breastfeeding is the foundation of normal health and development, the original paradigm for nourishing and nurturing young human beings. Health policies and healthcare systems must first and foremost protect breastfeeding. Otherwise, they will ultimately serve to undermine the health they seek to enhance.

1. C. Good Mojab, “Breastfeeding Resource List,” in Breastfeeding Annual International 2001, D. Michels, ed. (Washington, DC: Platypus Media, 2001), 202-203.
2. International Code of Marketing of Breast-Milk Substitutes (Geneva, Switzerland: World Health Organization, 1981).
3. M. Holick, “Noncalcemic Actions of 1,25-Dihydroxyvitamin D3 and Clinical Applications,” Bone 17, no. 2 (suppl.) (1995): 107S-111S.
4. M. Holick, “Sunlight ‘D’ilemma: Risk of Skin Cancer or Bone Disease and Muscle Weakness,” Lancet 357 (2001): 4-6.
5. E. Hyppönen et al., “Intake of Vitamin D and Risk of Type 1 Diabetes: A Birth-Cohort Study,” Lancet 358, no. 9292 (2001): 1500-1503.
6. M. Holick, “Evolution, Biological Functions, and Recommended Dietary Allowance for Vitamin D,” in Vitamin D: Physiology, Molecular Biology, and Clinical Applications, M. Holick, ed. (Totawa, NJ: Humana Press, 1999), 1-16.
7. Ibid.
8. M. Holick, “Environmental Factors that Influence the Cutaneous Production of Vitamin D,” Am J Clin Nutr 61 (suppl.) (1995): 638S-645S.
9. W. Brazerol et al., “Serial Ultraviolet B Exposure and Serum 25 Hydroxyvitamin D Response in Young Adult American Blacks and Whites: No Racial Difference,” J Am Coll Nutr 7, no. 2 (1988): 111-118.
10. A. Webb et al., “Influence of Season and Latitude on the Cutaneous Synthesis of Vitamin D3: Exposure to Winter Sunlight in Boston and Edmonton will not Promote Vitamin D3 Synthesis in Human Skin,” J Clin Endocrinol Metab 67 (1988): 373-378.
11. M. McKenna, “Differences in Vitamin D Status between Countries in Young Adults and the Elderly,” Am J Med 93 (1992): 69-77.
12. D. Rucker et al., “Vitamin D Insufficiency in a Population of Healthy Western Canadians,” Can Med Assoc J 166, no. 12 (2002): 1517-1524.
13. V. Tangpricha et al., “Vitamin D Insufficiency among Free-Living Healthy Young Adults,” Am J Med 112 (2002): 659-662.
14. M. Holick, “Vitamin D and Bone Health,” J Nutr 126 (1996): 1159S-1164S.
15. H. Makin et al., “Vitamin D and Its Metabolites in Human Breast Milk,” Arch Dis Child 58 (1983): 750-753.
16. M. Ala-Houhala, “25-Hydroxyvitain D Levels during Breast-Feeding with or without Maternal or Infantile Supplementation of Vitamin D,” J Pediatr Gastroent Nutr 4, no. 2 (1985): 220-226.
17. B. Specker et al., “Effect of Race and Normal Maternal Diet on Breast Milk Vitamin D Concentrations,” Pediatr Res 18 (1984): 213A.
18. B. Hollis et al., “Vitamin D and Its Metabolites in Human and Bovine Milk,” J Nutr 111, no. 7 (1981): 1240-1248.
19. N. Butte et al., Nutrient Adequacy of Exclusive Breastfeeding for the Term Infant during the First Six Months of Life (Geneva: World Health Organization, 2002), 27.
20. See Note 6.
21. See Note 6.
22. See Note 15.
23. See Note 16.
24. B. Pal and N. Shaw, “Rickets Resurgence in the United Kingdom: Improving Antenatal Management in Asians,” J Pediatr 139, no. 2 (2001): 337-338.
25. J. Daaboul et al., “Vitamin D Deficiency in Pregnant and Breast-Feeding Women and Their Infants,” J Perinatol 1997; 17: 10-14.
26. See Note 16.
27. F. Greer et al., “Effects of Maternal Ultraviolet B Irradiation on the Vitamin D Content of Human Milk,” J Pediatr 105, no. 3 (1984): 431-422.
28. B. Hollis et al., “The Effects of Oral Vitamin D Supplementation and Ultraviolet Phototherapy on the Antirachitic Sterol Content of Human Milk,” Calcif Tissue Int 34 (suppl.) (1982): 582.
29. M. Ala-Houhala et al., “Maternal Compared with Infant Vitamin D Supplementation,” Arch Dis Child 61 (1986): 1159-1163.
30. See Note 6.
31. See Note 6.
32. E. Poskitt et al., “Diet, Sunlight, and 25-Hydroxyvitamin D in Healthy Children and Adults,” Br Med J 1 (1979): 221-223.
33. B. Specker et al., “Sunshine Exposure and Serum 25-Hydroxyvitamin D Concentrations in Exclusively Breastfed Infants,” J Pediatr 107 (1985): 372-376.
34. Ibid.
35. See Note 33.
36. C. Lo et al., “Indian and Pakistani Immigrants Have the Same Capacity as Caucasians to Produce Vitamin D in Response to Ultraviolet Radiation,” Am J Clin Nutr 44 (1986): 683-685.
37. T. Clemens et al., “Increased Skin Pigment Reduces the Capacity of the Skin to Synthesize Vitamin D,” Lancet 1 (1982): 74-76.
38. See Note 9.
39. See Note 33.
40. See Note 8.
41. A. Webb et al., “Influence of Season and Latitude on the Cutaneous Synthesis of Vitamin D3: Exposure to Winter Sunlight in Boston and Edmonton Will Not Promote Vitamin D3 Synthesis in Human Skin,” J. Clin Endocrinol Metab 67 (1988): 373-378.
42. S. Grover and R. Morley, “Vitamin D Deficiency in Veiled or Dark-Skinned Pregnant Women,” MJA 175 (2001): 251-252.
43. K. Feldman et al., “Nutritional Rickets,” Am Fam Physician 42 (1990): 1311-1318.
44. I. Sills et al., “Vitamin D Deficiency Rickets: Reports of Its Demise Are Exaggerated,” Clin Pediatr 33 (1994): 491-493.
45. M. Pugliese et al., “Nutritional Rickets in Suburbia,” J Amer College Nutr 17, no. 6 (1998): 637-641.
46. See Note 8.
47. See Note 43.
48. See Note 44.
49. See Note 6.
50. L. Matsuoka et al., “Sunscreens Suppress Cutaneous Vitamin D3 Synthesis,” J Clin Endocrinol Metab 64, no. 6 (1987): 1165-1168.
51. L. Matsuoka et al., “Chronic Sunscreen Use Decreases Circulating Concentrations of 25-Hydroxyvitamin D,” Arch Dermatol 124, no. 12 (1988): 1802-1804.
52. See Note 8.
53. See Note 41.
54. See Note 42.
55. See Note 43.
56. See Note 44.
57. See Note 45.
58. See Note 45.
59. L. Muhe et al., “Case-Control Study of the Role of Nutritional Rickets in the Risk of Developing Pneumonia in Ethiopian Children,” Lancet 349 (1997): 1801-1804.
60. See Note 43.
61. See Note 44.
62. See Note 59.
63. T. Thacher et al., “A Comparison of Calcium, Vitamin D, or Both for Nutritional Rickets in Nigerian Children,” New Engl J Med 341, no. 8 (1999): 563-568.
64. N. Carvalho et al., “Severe Nutritional Deficiencies in Toddlers Resulting from Health Food Milk Alternatives,” Pediatrics 107, no. 4 (2001): E46.
65. See Note 63.
66. I. Robertson et al., “The Role of Cereals in the Etiology of Nutritional Rickets: The Lesson of the Irish National Nutrition Survey 1943-8,” Br J Nutr 48 (1981): 17-22.
67. S. Özgür et al., “Rickets and Soil Strontium,” Arch Dis Child 75 (1996): 524-526.
68. Why Barns Are Red: Health Risks from Lead and Their Prevention (Toronto, Ontario: Metropolitan Toronto Teach Health Units and the South Riverdale Community Health Center, 1995).
69. M. Berglund et al., “Metal-Bone Interactions,” Toxicol Lett 112-113 (2000): 219-225.
70. M. Garabédian and H. Ben-Mekhbi, “Rickets and Vitamin D Deficiency,” in Vitamin D: Physiology, Molecular Biology, and Clinical Applications, M. Holick, ed. (Totawa, NJ: Humana Press, 1999), 273-286.
71. See Note 24.
72. See Note 63.
73. See Note 24.
74. See Note 24.
75. See Note 63.
76. D. Fraser, “The Physiological Economy of Vitamin D,” Lancet 1 (1983): 969-972.
77. K. Scanlon, ed., Final Report, Vitamin D Expert Panel Meeting, Atlanta, GA, Oct. 11-12, 2001;
78. See Note 70.
79. See Note 63.
80. See Note 67.
81. X. Ma, “Epidemiology of Rickets in China,” J Pract Pediatr 1 (1986): 323.
82. M. Rafii, “Rickets in Breast-Fed Infants below Six Months of Age without Vitamin D Supplementation,” Arch Irn Med 4, no. 2 (2001): 93-95.
83. See Note 70.
84. See Note 43.
85. See Note 44.
86. See Note 45.
87. See Note 70.
88. C. Good Mojab, “Sunlight Deficiency and Breastfeeding,” Breastfeeding Abstracts 22, no. 1 (2002): 3-4.
89. Lawrence M. Gartner, MD, FAAP, Chairperson, American Academy of Pediatrics Section on Breastfeeding, personal communication, December 6, 2002.
90. American Academy of Pediatrics, “Breastfeeding and the Use of Human Milk,” Pediatrics 100, no. 6 (1997): 1035-1039.
91. See Note 77.
92. M. Elias, “Breast-Fed Babies May Need Extra Vitamin D: Doctors Seeing More Cases of Bone Disease,” USA Today, October 21, 2002; see
93. C. Good Mojab, “The Cultural Art of Breastfeeding,” Leaven 36, no. 5 (2000): 87-91.
94. R. Dana, Multicultural Assessment Perspectives for Professional Psychology (Needham Heights, MA: Allyn & Bacon, 1993).
95. F. Kluckholn and F. Strodtbeck, Variations in Value Orientations (Homewood, IL: Dorsey, 1961).
96. H. Triandis, Culture and Social Behavior (New York: McGraw-Hill, 1994).
97. Bureau of Nutritional Sciences, Department of National Health and Welfare, Recommended Nutrient Intakes for Canadians (Ottawa: Health and Welfare Canada, 1983).
98. R. Vieth, “Vitamin D Supplementation, 25-Hydroxyvitamin D Concentrations, and Safety,” Am J Clin Nutr 69, no. 5 (1999): 842-856.
99. See Note 77.
100. M. Labbok, “What is the Definition of Breastfeeding?” Breastfeeding Abstracts 19, no. 3 (2000): 19-21.
101. M. S. Kramer and R. Kakuma, “Optimal Duration of Exclusive Breastfeeding (Cochrane Review),” in The Cochrane Library, no. 4, 2002 (Oxford: Update Software).
102. A. Coutsoudis et al., “Method of Feeding and Transmission of HIV-1 from Mothers to Children by 15 Months of Age: Prospective Cohort Study from Durban, South Africa,” AIDS 15, no. 3 (2001): 379-387.
103. See Note 101.
104. See Note 2.105. See Note 77.
106. Mead Johnson Canada Website Information on D-Vi-Sol,
107. C. Howard et al., “Office Prenatal Formula Advertising and Its Effects on Breastfeeding Patterns,” Obstetric Gynecology 95, no. 2 (2000): 296-303.
108. Global Solar UV Index: A Practical Guide (Geneva, Switzerland: World Health Organization, 2002).
109. Skin Cancer: Preventing America’s Most Common Cancer (Atlanta, GA: Centers for Disease Control 2001);
110. Cancer Facts and Figures 2002 (Atlanta, GA: American Cancer Society, 2002);
111. Ibid.
112. See Note 109.
113. American Academy of Pediatrics, “Ultraviolet Light: A Hazard to Children (RE9913),” Pediatrics 104, no. 2 (1999): 328-333.
114. See Note 108.
115. UNICEF, “Vitamin D: Rickets in Children and Osteomalacia in Pregnant Women,” The Prescriber: Guidelines on the Rational Use of Drugs in Basic Health Services 8 (Dec. 1993): 11.
116. M. Rao et al., “The Influence of Phototherapy on Serotonin and Melatonin in Nonseasonal Depression,” Pharmacopsychiatry 23 (1990): 155-158.
117. B. Perry et al., “Morning vs. Evening Bright Light Treatment of Late Luteal Phase Dysphoric Disorders,” Am J Psych 146 (1991): 9.
118. Diagnostic and Statistical Manual of Mental Disorders (Washington, DC: American Psychiatric Association, 1994): 389-390.

Cynthia Good Mojab, MS (clinical psychology), IBCLC, RLC, is Research Associate in the Publications Department of La Leche League International and Senior Editor at Platypus Media. She is the co-author of Breastfeeding at a Glance: Facts, Figures, and Trivia about Lactation (Platypus Media, 2001). Her publications can be accessed from her website,Ammawell, which provides breastfeeding and parenting information.

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Where My Advice Comes From

Posted on December 17, 2009. Filed under: doula | Tags: , , , |

I frequently get emails from women asking questions about pregnancy, birth, breastfeeding, circumcision and all things in between. I get phone calls from random strangers or from friends of friends.  I get approached by both women I know and do not know that know I am a doula.  I always have an open ear and I always try to the best of my ability to point these women to the direction of the best information to answer their questions.

I am both a DONA trained birth doula (CD DONA) and have trained as a Lamaze Certified Childbirth Educator (LCCE). There is extensive training and worked involved in both of these designations, but especially in the LCCE. I take my exam in April and I will tell you I am preparing for it harder than I ever worked on any high school or college exam and I have an accounting degree if that gives you any indication of the amount of work I am putting into this. While it is true that I am not medically trained I am trained and have been exposed to a variety of topics pertaining to women’s and infant’s health, birth, pregnancy and breastfeeding. I do not give medical advice. When I am asked a medical question, I may give my opinion based on what I know but it is always preceded with ‘ask your doctor.’ What I do is give information, facts, data, research results and how to find this information and decipher it.

I also have spent and do spend a good bit of time talking to both OBs, general practitioners and RNs including labor and delivery nurses. When I attend a birth I ask a lot of questions about the clinical procedures carried out during the birth even it is something as simple as a charting requirement. Of course that all depends on how friendly the staff is and how open they are to sharing information but most are. They see that I am there with the sole purpose of supporting my client and that I am in no way trying to interfere with the clinical needs of her birth and they respect that and are typically happy to answer my questions. They usually realize that I have a genuine interest in both  my client and all aspects of her birth and it makes for a much better experience overall for everyone. It also helps to plant good seeds of thought on doulas for wary staff who have not been exposed to them before me or  who may have had bad experiences with a doula in the past.

My point to all of this is that between the work I have put in to have both the CD (DONA) and LCCE designations by my name plus the practical experience of attending births and exposure to hospital staff and systems I do have a lot to offer a woman who may have questions about her pregnancy or birth or newborn.  Part of my training has included the tools and resources to provide evidence based information to women both in a class room setting and informally by email or what not. All of the information that I give women is fact based and generally given with references and resources so that they can research the information for themselves. I don’t want people to just take my word or believe what I am telling them just because I said it. I want to see people take responsibility for their bodies, births and babies and learn some things in the process.

I am a support person. I am a sharer of information. I strive to do the very best that I can to give good information and resources. It’s up to the individual to do the rest of the work. My hope is that after I have answered a question or sent and email that the asker will go forward and look into what I have told her. I know it doesn’t always happen and because I am human it frustrates me a little. I don’t want to see someone not heed my advice and have a bad experience but I am not also not on a mission to save any one either. It’s at that point I take a step back and not interfere  with what a woman chooses.

Please keep the questions coming. I am always happy to help in any way I can. Please continue to give me your feedback. It is motivating not only to me but to other women who read these blog posts or hear about your positive experience. And thank you for sharing with me, I am always honored to be a part of any birth whether directly or indirectly.

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The Importance of Labor Support

Posted on December 15, 2009. Filed under: doula, Value and Purpose of Labor Support | Tags: , , , , , , |

I actually had to write an essay about this for my doula certification. I will add it to this post later but for now I wanted to share with everyone what my friend and doula (well, one of them, I am actually having two) Karen had to say about being on my birth team.

Go HERE to read her blog post about it.

Karen is doing such great work to help women have better births. She has not formally trained as a doula but she has as a childbirth educator. She is a wealth of knowledge, especially here in Korea as far as the birth culture is concerned. She spends a good bit of time pointing women in the direction of the information that they need and because of this has helped many women have good birth experiences. I am very proud of her and proud ot have her on my birth team.

I will also have a Korean doula on my team. Her English name is Janice. She is a new doula and also trained as a childbirth educator. She works for a milk bank in Seoul, helping to get donated breast milk to mothers who do not want to use formula but cannot breast feed for some reason. She is also an RN here in Korea but does not work as a nurse any more. Her English is great as she lived in Hawaii for a few years and she is just all around a very nice person. I have referred doula clients to her and she will attend her first birth in January. Karen has also referred a client to her. By the time my birth comes around she will be fairly seasoned and experienced. Her role in my birht is different from the typical doula however, in that the will be in the background. She will be there to help communicate to the Korean hospital staff and admin and through the postpartum time at the hospital.

Because I am using Hynobabies I prefer for my support team to be in the back ground and my husband to be my main support if necessary. Karen and Janice will be there if I need them and that for  me is such a huge confidence booster. I wish every woman could have that kind of support in birth.  My hope is that one day every woman will.

The Value and Purpose of Labor Support

Labor support can be priceless to a mother. As Doulas we often times do put a price tag on our services and time but the benefits received outweigh the cost. Studies have shown that by hiring a Doula a mother can reduce her need for pain medication, increase overall satisfaction with the birth experience, drastically reduce the risk of a cesarean and reduce the risk of assisted delivery by forceps or vacuum extraction. The studies have  also shown a reduction in postpartum depression for mothers who had a Doula or continual labor support by a person trained in birth. I believe that much of this is the result of an increase in confidence levels by both the mother and the father. I have had several second time mothers tell me that their birth with a Doula was so much better than their first birth without one because they knew they had someone there whose sole purpose was to tend to her physical and emotional needs.

Part of labor support is empowering a mother to have confidence in her ability to birth. Having someone available for the entire length of labor provides security and confidence for the mother as practitioners are typically caring for multiple patients at a time or have other responsibilities such as the clinical needs of the mother and the baby. There is also paperwork that must be done and shift changes that bring in new people to the birth environment. Having a constant throughout the entire labor process provides a sense of familiarity and safety for a laboring mother. Doulas also help the mother and father both communicate with the staff which is necessary in a time such as labor when the parents are usually distracted with the labor itself. While it is not the role of a Doula to speak for the parents to the practitioner she should advocate in order to help the mother or partner speak for themselves. Helping the mother and partner ask the questions appropriate to their situation and navigating the terminology used is also often helpful.

Supporting a mother emotionally during labor and birth helps the mother to believe that she can do it. Sometimes being told that she can do it is all that a mother needs to hear to keep going strong during a long labor. Understanding that laboring women are vulnerable and that the birth space should be protected is very important. Laboring women should have peace and quiet and no unnecessary interruption and holding that space for a mother is a priority. When a Doula and a partner help create a peaceful and safe environment for a laboring mother often times practitioners will follow suite and respect that space. It allows a sense of calm for the mother that helps her to maintain stamina through labor. Emotional support doesn’t end at the birth however. Helping a mother to process her birth experience is equally important. In unforeseen complications or unexpected situations or traumas a mother needs the continued emotional support to facilitate healing. Being especially sensitive to these needs helps to reduce postpartum depression and negative feelings towards her birth.

Labor support also includes physical support for the laboring mother. Every woman has a different need in labor whether is continual touch, massage or counter pressure while other women want very little physical touch. Often times women will not know what their need will be until labor has progressed and it is important to be able to understand what the mothers needs are and at what time her needs are the greatest. Incorporating the partner into the physical aspect of labor support is often very affective as they usually already have a certain intimacy between them as a couple.

The needs of a laboring and birthing woman are very complex. Mothers deserve the continual support of a Doula, someone trained in labor support. I believe that if all women had a Doula that most of them would be able to birth without medication and with little medical intervention. The cost of maternity care would lower as a result and there would be higher success rates in breastfeeding. Postpartum depression rates would also lower. I believe that every woman deserves a Doula and that every woman that wants one should have one.

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