tag:theconversation.com,2011:/au/topics/child-birth-31851/articlesChild birth – The Conversation2023-05-02T15:00:00Ztag:theconversation.com,2011:article/2040902023-05-02T15:00:00Z2023-05-02T15:00:00ZFour things you need to know about having a caesarean section<figure><img src="https://images.theconversation.com/files/523408/original/file-20230428-14-7wjm4k.jpg?ixlib=rb-1.1.0&rect=30%2C0%2C6669%2C4466&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's worth speaking to your doctor early in your pregnancy if you think a caesarean is right for you.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/gynecology-consultation-smiling-black-pregnant-woman-2126219357">Prostock-studio/ Shutterstock</a></span></figcaption></figure><p>If you’re pregnant or planning to have a baby soon, you’ve probably been given lots of advice and information about what you might experience during and after the birth. But less information is often given about what to expect if you should need or choose to have a caesarean section.</p>
<p>There are many reasons why a caesarean may be performed, though typically it happens for medical reasons (for example, if the baby’s or mother’s health is at risk during labour). But it’s also possible to opt to have a <a href="https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/considering-a-caesarean-birth-patient-information-leaflet/">caesarean without clinical need</a>. </p>
<p>Someone may opt for a caesarean for reasons including fear around labour and birth, previous traumatic birth experiences or to ensure their partner can be present (for example, if they work abroad or serve in the armed forces).</p>
<p>Regardless of where and how you decide to give birth, it’s important to make sure you’re also informed about what to expect when it comes to having a caesarean section. </p>
<p>Caesarean birth is a major surgery and as such is not risk free. But while we can never eliminate the risks entirely, advances in surgery and healthcare also mean caesarean births are safer now than they’ve ever been. </p>
<p>Here are four important things to know:</p>
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<img alt="Quarter life, a series by The Conversation" src="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em><strong><a href="https://theconversation.com/uk/topics/quarter-life-117947?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">This article is part of Quarter Life</a></strong>, a series about issues affecting those of us in our twenties and thirties. From the challenges of beginning a career and taking care of our mental health, to the excitement of starting a family, adopting a pet or just making friends as an adult. The articles in this series explore the questions and bring answers as we navigate this turbulent period of life.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/at-home-fertility-tests-heres-what-they-can-actually-tell-you-198639?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">At-home fertility tests: here’s what they can actually tell you</a></em></p>
<p><em><a href="https://theconversation.com/planning-for-a-baby-why-both-men-and-women-should-consider-quitting-alcohol-before-and-during-pregnancy-198118?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">Planning for a baby? Why both men and women should consider quitting alcohol before and during pregnancy</a></em></p>
<p><em><a href="https://theconversation.com/six-reasons-to-take-up-yoga-during-pregnancy-198523?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">Six reasons to take up yoga during pregnancy</a></em></p>
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<h2>1. Surgical complications are a risk</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5322852">Up to 15% of women</a> may experience post-surgery wound infections. And although less common, damage to internal organs and blood clots can also happen (though only in about less than 1% of cases), alongside <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6491146/">greater blood loss</a> compared with a vaginal birth.</p>
<p>Any surgical complications that arise may mean you have to stay in hospital longer while undergoing treatment. While this may temporarily affect infant feeding and how you <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8607887/">bond with your baby</a>, this is unlikely to have any long-term consequences for your relationship with your baby.</p>
<h2>2. It can affect future pregnancies</h2>
<p>Having a caesarean is also likely to mean a more <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)31930-5.pdf#seccestitle170">complex subsequent pregnancy</a> and birth, with research suggesting it increases chances of placental complications, greater blood loss and scar rupture, alongside scar tissue forming between your organs. </p>
<p>There is also a slightly increased chance of <a href="https://academic.oup.com/book/24938/chapter-abstract/188837524?redirectedFrom=fulltext">infertility</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/26033155/">stillbirth</a> after having a caesarean birth – although the reasons for this remain unknown, and the numbers remain very small.</p>
<p>If you have a caesarean the first time you give birth, it may also increase your chances of needing to have a caesarean at your next birth. This is due to the more complex nature of having a scar on your uterus during pregnancy and birth, and the extra care needed making you more high risk. </p>
<p>The second caesarean surgery itself may also potentially take longer due to the scar tissue from the previous surgery – which may also <a href="https://academic.oup.com/book/24938/chapter-abstract/188837524?redirectedFrom=fulltext">increase the risk of greater blood loss and infection</a>.</p>
<p>This may be worth considering if you’re planning to opt for a caesarean birth, particularly if you would like to have more than one baby as it may affect your future pregnancies. </p>
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<img alt="A pregnant woman in a hospital gown and bed holds her stomach." src="https://images.theconversation.com/files/523406/original/file-20230428-16-rgnkew.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523406/original/file-20230428-16-rgnkew.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523406/original/file-20230428-16-rgnkew.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523406/original/file-20230428-16-rgnkew.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523406/original/file-20230428-16-rgnkew.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523406/original/file-20230428-16-rgnkew.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523406/original/file-20230428-16-rgnkew.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">You may need to have a caesarean the next time you give birth.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-pregnant-woman-patient-on-drip-455693335">mikumistock/ Shutterstock</a></span>
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<h2>3. There are some potential risks to the baby</h2>
<p>Caesarean birth may also carry certain risks to the baby versus a vaginal birth.</p>
<p>For example, around 2% of babies can suffer <a href="https://journals.sagepub.com/doi/10.1177/0025802414526181?icid=int.sj-full-text.similar-articles.3">skin lacerations from the operation</a>. They also may need special or intensive care), as they’re more likely to have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2453515/">breathing problems</a> compared to babies born vaginally.</p>
<p>Some research also suggests babies born via caesarean may be more susceptible to <a href="https://www.bmj.com/content/350/bmj.h2410">developing asthma and diabetes</a>. It’s still uncertain why this is the case, but may be due to the fact that babies aren’t exposed to certain bacteria which are important for developing their microbiome.</p>
<h2>4. Scheduled birth can be a benefit</h2>
<p>If you opt to have a caesarean birth for whatever reason, there may be some benefits.</p>
<p>For example, a caesarean birth is more predictable, which can be helpful for you if you want more <a href="https://pubmed.ncbi.nlm.nih.gov/17486467/">control over your birth experience</a> – especially if you are feeling anxious about giving birth. </p>
<p>Some studies also show a potential link between lower chances of <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002494">developing urinary incontinence and prolapse</a> with a caesarean birth. But it’s important to weigh these potential benefits against the risks that come alongside caesarean birth. </p>
<h2>Making your choice</h2>
<p>While thinking about your preferences on how you plan to give birth, consider asking your midwife or doctor what your full range of options are. They will also help you to develop a specific personalised plan depending on your preferences and circumstances. </p>
<p>You may also want to ask your doctor or midwife about what can be done to minimise risks of complications to your or your baby if you need or choose to have a caesarean.</p>
<p>If considering a caesarean, it’s worth voicing your preferences at the earliest opportunity in your pregnancy to help your care providers offer you the best support, tailored to your needs.</p><img src="https://counter.theconversation.com/content/204090/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Parker-Farthing does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are many reasons you may want to opt for a caesarean section.Claire Parker-Farthing, Senior Lecturer in Midwifery, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1868272022-12-06T00:28:07Z2022-12-06T00:28:07Z1 in 10 women report disrespectful or abusive care in childbirth<figure><img src="https://images.theconversation.com/files/492044/original/file-20221027-29153-d7sx1j.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5701%2C3795&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mother-giving-birth-baby-pregnant-patient-2128065755">Shutterstock</a></span></figcaption></figure><p>Having a baby can be an empowering experience when women are treated with kindness and respect. </p>
<p>However, some women are left feeling traumatised by how they were treated. When women receive disrespectful and abusive care from health providers during pregnancy, labour and birth, or after the baby is born, it’s called <a href="https://birthmonopoly.com/obstetric-violence/">obstetric violence</a>. This includes verbal, physical and emotional abuse, threats or coercion by health providers. </p>
<p>Our <a href="https://journals.sagepub.com/doi/10.1177/10778012221140138">study</a>, published today in journal Violence Against Women, is the first to look at Australian women’s experiences of obstetric violence. Of the 8,804 women we surveyed, more than one in ten (11.6%) indicated they had, or may have, experienced obstetric violence. </p>
<p>Respondents who elaborated told us this ranged from disrespectful, abusive and coercive comments (42%) to physical abuse (7%) and vaginal examinations without consent (17%).</p>
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<strong>
Read more:
<a href="https://theconversation.com/so-your-birth-didnt-go-according-to-plan-dont-blame-yourself-89155">So your birth didn't go according to plan? Don't blame yourself</a>
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<h2>‘Dehumanised’, ‘powerless’ and ‘violated’</h2>
<p>Our <a href="https://journals.sagepub.com/doi/10.1177/10778012221140138">data</a> comes from the <a href="https://www.facebook.com/BirthExperienceStudy">Birth Experience Study</a>, a survey asking Australian women about their birth experiences over the past five years. </p>
<p>We asked participants if they experienced obstetric violence and they were able to leave comments if they wanted to. </p>
<p>Like all surveys, women who are more educated and have English as their first language tend to respond the most. To reduce this bias, we translated the survey into seven other languages.</p>
<p>Some 626 women left comments describing feeling dehumanised, powerless and violated. Some experienced psychological and emotional abuse, while others were threatened and yelled at. </p>
<p>More alarming were the experiences of physical assault, such as forcible restraint or being held down. </p>
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<img alt="Woman grimaces while in labour" src="https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492040/original/file-20221027-23886-nbnzuj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Experiences ranged from emotional abuse to physical violence.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/R5yoJSYDDfI">Jimmy Conover/Unsplash</a></span>
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<p>Some women felt the experience was like a sexual assault. This was mainly associated with rough vaginal examinations or procedures the women didn’t consent to. </p>
<p>As one woman from New South Wales explained: </p>
<blockquote>
<p>I was told by the doctor who just appeared in the room that he would need to do a <a href="https://theconversation.com/episiotomy-during-childbirth-not-just-a-little-snip-36062">vacuum delivery</a> and an <a href="https://theconversation.com/episiotomy-during-childbirth-not-just-a-little-snip-36062">episiotomy</a>, and I felt him cut me as he was speaking before [using] a numbing needle, it wasn’t during a contraction and I hadn’t had a chance to consent yet. </p>
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<p>Another woman from Queensland told us:</p>
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<p>I felt dehumanised because A) nobody told me the procedure was optional or gave me choice to opt out. B) I was very clearly highly distressed and they didn’t pause or stop the procedure to check my consent. C) there were three people I didn’t know standing and looking at my exposed naked body. D) the midwife had joked about the procedure. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/a-new-national-plan-aims-to-end-violence-against-women-and-children-in-one-generation-can-it-succeed-192497">A new national plan aims to end violence against women and children 'in one generation'. Can it succeed?</a>
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<h2>What is the law in Australia?</h2>
<p>Australia doesn’t have a <a href="https://www.humanrights.unsw.edu.au/news/human-rights-acts-around-australia">National Human Rights Act</a> or legislation addressing obstetric violence. </p>
<p>The <a href="http://www7.austlii.edu.au/cgi-bin/viewdb/au/legis/act/consol_act/hra2004148/">Australian Capital Territory</a>, <a href="https://www.legislation.vic.gov.au/in-force/acts/charter-human-rights-and-responsibilities-act-2006/015">Victoria</a> and <a href="https://www.qhrc.qld.gov.au/your-rights/human-rights-law">Queensland</a> have their own state/territory human rights acts. This protects against “cruel, inhuman or degrading treatment” and requires clinicians get the “person’s full, free and informed consent” before performing any medical treatment. </p>
<p>However, across Australia, consent is <a href="https://www.safetyandquality.gov.au/sites/default/files/2020-09/sq20-030_-_fact_sheet_-_informed_consent_-_nsqhs-8.9a.pdf">always required</a> before any medical treatment or examination, except where the woman is incapacitated or unconscious. The provider must explain the proposed treatment in a way that is balanced, truthful, timely, and free of harassment and coercion. And she can change her mind at any time.</p>
<p>Clinical guidelines don’t trump the right to bodily integrity. If guidelines suggest a vaginal examination, they need to be explained, including the reasons for the treatment and the alternatives. Then the woman has to be given an opportunity to accept or decline. </p>
<p>Yet our study detailed many instances of treatments or examinations with either no consent, no informed consent, or despite their refusal.</p>
<p>Midwives and obstetric doctors are expected to practise ethically and respect their patients’ right to refuse consent or withdraw consent. </p>
<p>Patients can make complaints about doctors or midwives, however there are a variety of different methods <a href="https://www.ahpra.gov.au/Notifications/Concerned-about-a-health-practitioner.aspx">dependent on state/territory</a> which can make the process confusing and overwhelming. </p>
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<img alt="Mother holder her newborn close" src="https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492038/original/file-20221027-19-6wwsi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The process of making a complaint can be difficult and overwhelming.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/ZTSiID1W7-o">Alexander Grey</a></span>
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<h2>How do we eliminate obstetric violence?</h2>
<p>All women deserve respectful maternity care, free from harm and abuse. To prevent obstetric violence, we first need to recognise it exists. </p>
<p>The next steps need to involve getting the main professional colleges for <a href="https://ranzcog.edu.au/">obstetricians</a> and <a href="https://www.midwives.org.au/">midwives</a>, consumer organisations, universities that train health providers, health departments and governments to work together to change policies and improve education.</p>
<p>The International Confederation of Midwives and UN Population Fund created a <a href="https://www.internationalmidwives.org/our-work/other-resources/respect-toolkit.html">RESPECT toolkit</a> to facilitate workshops for health care providers on respectful maternity care to support their strategy to create zero tolerance for disrespect and abuse. Programs such as this could be implemented across Australia.</p>
<p>In Queensland, <a href="http://www.humanrightsinchildbirth.org/">Human Rights in Childbirth</a> and <a href="https://www.maternityconsumernetwork.org.au/">Maternity Consumer Network</a> have just commenced <a href="https://www.maternityconsumernetwork.org.au/about-6">consent training</a> for maternity health professionals. Again, similar programs could be rolled out nationally.</p>
<p>Alongside education, we need legislation recognising obstetric violence as a human rights violation. This would mean women are aware of their rights and have access to legal support if needed. It would also prompt governments and health services to develop <a href="https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/clinical-governance-and-quality-improvement-support-effective-communication/action-602">quality improvement systems</a>, including repercussions for clinicians who commit obstetric violence. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-one-womans-traumatic-experience-drove-her-investigation-into-pregnancy-and-mental-health-177152">How one woman's traumatic experience drove her investigation into pregnancy and mental health</a>
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<img src="https://counter.theconversation.com/content/186827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bashi Hazard is the Chair of the Human Rights in Childbirth, a US s501(c)(3) NGO.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen and Hazel Keedle do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women described feeling dehumanised, powerless and violated. Some experienced psychological and emotional abuse, while others were threatened and yelled at.Hazel Keedle, Lecturer of Midwifery, Western Sydney UniversityBashi Hazard, Lawyer, PhD Candidate, University of SydneyHannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1876402022-08-03T06:59:03Z2022-08-03T06:59:03ZHow do epidurals work? And why is there a global shortage of them?<figure><img src="https://images.theconversation.com/files/477070/original/file-20220802-17-orrm1p.jpg?ixlib=rb-1.1.0&rect=25%2C68%2C5716%2C3716&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mid-adult-female-nurse-comforting-tensed-228783766">Shutterstock</a></span></figcaption></figure><p>More than <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/analgesia">40%</a> of people in Australia who access pain relief during labour use epidurals. That amounts to around <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/data">92,000 epidurals</a> a year. They’re also used for pain relief outside obstetrics. </p>
<p>However, Australia is feeling the effects of a global supply shortage of <a href="https://www.anzca.edu.au/safety-advocacy/safety-alerts/management-of-potential-supply-disruption-to-epidu">particular brands of epidural kits</a>. While this shortage was expected to be resolved at the end of last month, a spokesperson for the Therapeutic Goods Administration (TGA) told The Conversation it would continue beyond July.</p>
<p>Health authorities are <a href="https://www.smh.com.au/national/use-of-epidural-kits-limited-as-global-shortage-hits-australian-hospitals-20220721-p5b3i3.html?utm_medium=Social&utm_source=Twitter#Echobox=1658646526-1">reportedly</a> distributing stock to affected hospitals and working to secure additional kits, while the TGA is investigating how it can “allow [the] supply of alternative products to meet market demand”. </p>
<p>In the meantime, <a href="https://www.smh.com.au/national/use-of-epidural-kits-limited-as-global-shortage-hits-australian-hospitals-20220721-p5b3i3.html?utm_medium=Social&utm_source=Twitter#Echobox=1658646526-1">Victorian and NSW health authorities recommend</a> conserving epidural kits for obstetric patients.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1551102074137493505"}"></div></p>
<h2>Remind me, what’s an epidural?</h2>
<p>An epidural for people in labour is an anaesthetic procedure used to deliver nerve-blocking drugs, via a tiny plastic tube, into the “epidural space” in the back, through which spinal nerves travel. They’re <a href="https://www.anzca.edu.au/patient-information/anaesthesia-information-for-patients-and-carers/pain-relief-and-having-a-baby">performed by anaesthetists</a>, who are specialist doctors. </p>
<p>The doctor first identifies the epidural space using a needle and a specially designed syringe, then passes a small tube into the space. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphic of the epidural procedure and anatomy involved" src="https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=299&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=299&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=299&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=376&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=376&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=376&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nerve-blocking drugs are delivered into the epidural space in the back.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/epidural-spinal-block-anaesthesia-pinched-relieve-1769472845">Shutterstock</a></span>
</figcaption>
</figure>
<p>Medications – usually local anaesthetics and morphine-like drugs – are administered down the tube. Pain relief is usually achieved <a href="https://theconversation.com/explainer-what-is-an-epidural-for-labour-64870">within about 20 minutes</a>. </p>
<h2>Why is there a shortage of epidurals?</h2>
<p>In <a href="https://www.supplychain.nhs.uk/icn/supply-issues-smiths-medical-international-ltd-epidural-kits-multiple-products/">April</a>, one of the leading international manufacturers of epidurals <a href="https://rcoa.ac.uk/news/temporary-disruption-supply-smiths-medical-epidural-combined-epiduralspinal-products">announced a temporary disruption</a> to its supply.</p>
<p>This specific supply chain issue relates to the lack of supply of blue dye some manufacturers use to colour the special low-friction plunger-style epidural syringe. This syringe is important because anaesthetists use it to identify the epidural space in the patient’s back.</p>
<p>The syringe is usually filled with saline and connected to the hollow epidural needle, which is then slowly advanced into the back. </p>
<p>The anaesthetist places constant pressure on the syringe and when the epidural space is located, there is a “loss of resistance”. The saline passes easily into it, opening up this space so the epidural catheter can smoothly be passed into it. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Screenshot of epidural kits with blue syringe" src="https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=288&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=288&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=288&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=362&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=362&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=362&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Dye to colour the blue syringes is in low supply.</span>
<span class="attribution"><a class="source" href="https://www.smiths-medical.com/en-au/products/pain-management/epidural-anesthesia">Screenshot from smiths-medical.com</a></span>
</figcaption>
</figure>
<p>The familiar blue colour of the low-friction syringe distinguishes it from other syringes, which are clear and used for injecting medications. The colouring of the syringe ensures ease of identification and safety so the correct syringe is used for the procedure.</p>
<p>This unpredictable and sudden loss of a brand of epidural kits has put global pressure on other manufacturers of epidural kits, and their component parts, resulting in a worldwide shortage. </p>
<h2>How epidurals have changed</h2>
<p>Epidurals have been commonly used for pain relief in childbirth for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3417963/">more than 40 years</a> although the history of epidurals dates back <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3417963/">over 100 years</a>.</p>
<p>When first introduced, epidurals were known as “heavy epidurals”, where high-dose anaesthetic drugs blocked the large muscle nerves as well as the smaller pain, temperature and balance nerves. Blocking the nerves to the muscles meant patients were unable to move about their birthing bed, making it difficult to push, and making them feel heavy.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-an-epidural-for-labour-64870">Explainer: what is an epidural for labour?</a>
</strong>
</em>
</p>
<hr>
<p>Contemporary epidurals now use low doses of anaesthetic that only block pain, temperature and balance nerves. This type of epidural provides excellent pain relief while also enabling movement in bed because the muscles in the legs are not effected. </p>
<p>Modern epidurals can be “topped up” with high-dose anaesthetics to make an epidural suitable to provide anaesthesia for caesarean birth. </p>
<p>However, most <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/anaesthesia">caesarean births</a> (69%) use spinal anaesthesia. These use different equipment to epidurals, so caesareans would not be impacted by epidural supply issues.</p>
<figure class="align-center ">
<img alt="Woman in labour breathes heavily" src="https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Modern epidurals enable movement in the bed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/darkhaired-woman-giving-birth-home-pierced-2145598585">Shutterstock</a></span>
</figcaption>
</figure>
<p>Epidurals were once used for pain relief for patients undergoing a wide range of surgeries outside obstetrics. While they’re <a href="https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/abdomen/epidural-anesthesia-analgesia/">still used</a> to help very unwell patients – for example, after major high-risk cancer surgeries and trauma surgeries – they’re less commonly used and provide fewer benefits for <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)08266-1/fulltext">less ill patients</a>.</p>
<p>To manage pain, many of these patients can have a spinal morphine injection, or opioid drugs such as morphine administered via a drip. </p>
<h2>Preparing for global supply shortages</h2>
<p>In addition to nitrous oxide, and morphine injections, there are some other drug alternatives to epidurals for pain relief in labour. These include the morphine-like drugs, administered via a drip, providing person-controlled analgesia (PCA) or a very low-dose spinal anaesthetic. </p>
<p>However, global supply chain problems will remain with us for many years because of pandemics, wars and natural disasters, and we need to be prepared for them. This means having alert systems to identify sooner potential supply chain issues. Part of this process is to observe what is happening in other countries. </p>
<p>The sooner we know of problems, such as epidural kit supply issues, the sooner we can start to rationalise their distribution. In doing so, such shortages can be anticipated and mitigated. We need to lessen the impact of the supply reduction on those who need it most and ensure people don’t face the potential trauma of uncontrolled labour pain.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-simple-things-australia-should-do-to-secure-access-to-treatments-vaccines-tests-and-devices-during-the-coronavirus-crisis-136052">Three simple things Australia should do to secure access to treatments, vaccines, tests and devices during the coronavirus crisis</a>
</strong>
</em>
</p>
<hr>
<p><em>Correction: this article originally said more than 40% of people who give birth in Australia use epidurals for pain relief during labour. This has now been updated.</em></p><img src="https://counter.theconversation.com/content/187640/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alicia Dennis receives research funding from the Australian and New Zealand College of Anaesthetists (ANZCA) and the University of Melbourne. She is a member of Scientific Affairs Committee World Federation of Societies of Anaesthesiologists, the Australian Society of Anaesthetists, the Australian Institute of Company Directors, the Australian Medical Association, Women on Boards, and Society of Anesthesiology and Perinatology. Alicia Dennis previously received funding from the National Health and Medical Research Council (NHMRC) Australia
Alicia Dennis is a full time staff specialist and Director of Anaesthesia Research at the Royal Women's Hospital, Parkville,
Australia. In July 2022 she participated in a Department of Health (Victoria) Epidural Catheter Supply Chain Issue meeting as a clinical subject matter expert. </span></em></p>Epidurals deliver nerve-blocking drugs into the back for pain relief during labour and after surgeries. Epidural kits are currently in short supply, with their use prioritised for obstetric patients.Alicia Dennis, Professor MBBS, PhD, MPH, PGDipEcho, FANZCA, GAICD, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1839322022-06-20T05:37:33Z2022-06-20T05:37:33ZSupporting women with mental ill-health in pregnancy and after birth: lessons from South Africa<figure><img src="https://images.theconversation.com/files/468463/original/file-20220613-87515-8iv6cm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The mental health of mothers has important implications for children and families.</span> <span class="attribution"><span class="source">Per-Anders Pettersson/Getty Images</span></span></figcaption></figure><p>Women in low- and middle-income countries experience <a href="https://pubmed.ncbi.nlm.nih.gov/28531848/">high levels of common mental disorders</a> – anxiety and depression – during pregnancy and the first year after birth. The prevalence is estimated at nearly 20%, and is higher among women who are marginalised.</p>
<p>If left untreated, these conditions lead to profound suffering and have <a href="https://pubmed.ncbi.nlm.nih.gov/25455235/">disabling impacts</a> for income generation, caregiving and health seeking. Women with mental health conditions are particularly vulnerable to experiencing <a href="https://pubmed.ncbi.nlm.nih.gov/29973182/">domestic violence</a>. They are at greater risk of <a href="https://pubmed.ncbi.nlm.nih.gov/26707348/">unintended pregnancy</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/32009230/">food insecurity</a> and becoming infected with <a href="https://pubmed.ncbi.nlm.nih.gov/29776314/">HIV</a>. </p>
<p>The US development agency, <a href="https://usaidmomentum.org/">USAID Momentum</a>, recently <a href="https://usaidmomentum.org/resource/mmh-landscape-analysis/">published</a> an analysis of the maternal mental health landscape in low- and middle-income countries. The study outlined the social determinants of poor mental health in pregnancy and after childbirth. These include poverty, gender inequality and various forms of violence. </p>
<p>Maternal mental health conditions are a reflection of harmful social and economic factors that affect women. Further, poor maternal mental health may have impacts on the physical, emotional, and neurological development of newborns and children. </p>
<p>This public health crisis needs a response from the whole of society. Together with a group of international colleagues, we penned a <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-04645-8">call to action</a>, with seven recommendations to address issues raised in the USAID analysis.</p>
<p>To improve maternal mental health, we recommend: </p>
<ul>
<li><p>setting global standards and targets </p></li>
<li><p>government policy changes and clear budgetary allocations </p></li>
<li><p>integrating maternal mental health services into existing health system platforms </p></li>
<li><p>using research to strengthen current interventions </p></li>
<li><p>building on existing community level strengths </p></li>
<li><p>addressing social and economic risk factors to be part of any intervention</p></li>
<li><p>destigmatising mental health conditions.</p></li>
</ul>
<p>These recommendations are based on work we have done in maternal mental health in low- and middle-income countries, including South Africa. The country still has a long way to go. However, it has made significant progress. </p>
<h2>Risk factors</h2>
<p>A closer look at the findings of the USAID analysis shows that women with common perinatal mental disorders face numerous additional health issues. These include not having access to adequate nutrition and experiencing obstetric complications. Many become socially isolated and face challenges in attending routine healthcare visits. </p>
<p>Women with perinatal mental health issues may face stigma. On the other hand, women are more vulnerable to experiencing poorer maternal mental health outcomes when they face poverty, various forms of persecution, or humanitarian crises.</p>
<p>Multiple studies from low- and middle-income countries have found rates of perinatal mental illness up to three times greater among pregnant adolescents than among older women. </p>
<h2>Lessons from the South African situation</h2>
<p>In South Africa, many women are exposed to these risk factors. The prevalence of depression and anxiety during pregnancy and in the year after birth ranges from <a href="https://pubmed.ncbi.nlm.nih.gov/18571734/">16%</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/21880372/">47%</a>. About <a href="https://pubmed.ncbi.nlm.nih.gov/28032214/">10%</a> of women during this period are at high risk of suicide. Most of these women do not receive the healthcare or support they need. The COVID-19 pandemic has made the situation <a href="https://pubmed.ncbi.nlm.nih.gov/34282488/">even worse</a>. Levels of food insecurity, social isolation, gender-based violence and poverty have escalated. The links between hunger and poor mental health in pregnant women point to the need for a <a href="https://www.growgreat.co.za/wp-content/uploads/2021/03/GG-COCARE-REPORT-final-1.pdf">maternity income support grant</a>.</p>
<p>Due to <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/Indicators_infographics_SAHR21_04022022_OD.pdf">high rates</a>of uptake of maternal and child health services, there is an opportunity to integrate mental healthcare into these platforms. There are challenges, though. Here we highlight three: </p>
<ul>
<li><p>Staff capacity is not optimised. Non specialist health providers lack <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11954-8">confidence and skills</a> to provide mental healthcare. They face <a href="https://pubmed.ncbi.nlm.nih.gov/33052921/">high levels</a> of mental health conditions themselves, including compassion fatigue and burnout.</p></li>
<li><p>Lack of accountability: <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/SAHR_Chapter8_Artifacts_07052021.pdf">health information systems</a> do not include relevant indicators and there is a lack of monitoring and evaluation of providers and programmes. Staff don’t know exactly what is required of them. </p></li>
<li><p>Maternal mental healthcare doesn’t get dedicated financing.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-south-africa-is-integrating-covid-into-routine-care-for-mothers-and-babies-181114">How South Africa is integrating COVID into routine care for mothers and babies</a>
</strong>
</em>
</p>
<hr>
<p>But there has been progress over the past 10-15 years:</p>
<ul>
<li><p>Local research has yielded useful lessons. <a href="https://www.sciencedirect.com/science/article/pii/S0005796719301524">Studies</a> have found that <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08050-x">dedicated</a>, versus generalist, lay healthcare workers can deliver mental healthcare at in the community or at facilities as part of <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001222">a stepped-care system</a> where professional service providers are available, as required. Their impact is <a href="https://pubmed.ncbi.nlm.nih.gov/31733813/">limited</a>, however, when training and supervision are inadequate. </p></li>
<li><p>The <a href="https://health-e.org.za/wp-content/uploads/2014/10/National-Mental-Health-Policy-Framework-and-Strategic-Plan-2013-2020.pdf">Mental Health Policy Action Framework 2013-2020</a> describes how detection and management of common mental health conditions should be integrated into sexual and reproductive health service platforms. The next update of this document is in progress.</p></li>
<li><p>The National Department of Health <a href="https://www.up.ac.za/centre-for-maternal-fetal-newborn-and-child-healthcare/article/2819785/esmoe">curriculum</a> for training maternity care clinicians now includes a module on respectful maternity care and empathic engagement.</p></li>
<li><p>A <a href="https://pubmed.ncbi.nlm.nih.gov/31662879/">locally developed</a> mental health screening tool was <a href="https://pubmed.ncbi.nlm.nih.gov/31818326/">validated</a> and is now incorporated in the national <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjOtcKTouv3AhWMXcAKHQttDVsQFnoECAsQAQ&url=http%3A%2F%2Fwww.obstyger.co.za%2FMCR.pdf&usg=AOvVaw2FfseiQiBHA0Ex7nbuaCAf">Maternity Case Records</a>.</p></li>
<li><p>The National Department of Health’s Standard Treatment Guidelines (hospital level) now include, for pregnant or breastfeeding women, detailed antidepressant prescribing advice, as well as specific guidance for those with other mental health conditions. The updated COVID-19 Clinical and Operational <a href="https://www.knowledgehub.org.za/system/files/elibdownloads/2022-04/COVID-19%20Guideline%2004%2004%202022%20digital%20v2.pdf">Guideline</a> for Mothers, Newborns and Children now has a chapter on <a href="https://theconversation.com/how-south-africa-is-integrating-covid-into-routine-care-for-mothers-and-babies-181114">psychosocial care</a>.</p></li>
<li><p>A new <a href="https://www.knowledgehub.org.za/system/files/elibdownloads/2021-06/SA%20MPNH%20Policy%2023-6-2021%20signed%20Web%20View%20v2.pdf">South African Maternal, Perinatal and Neonatal Health Policy</a> integrates respectful maternity care and mental health considerations across several policy domains.</p></li>
<li><p>The <a href="https://www.news24.com/health24/news/public-health/in-depth-is-government-ready-to-invest-in-mental-health-20211122">Mental Health Investment Case</a> commissioned by the National Department of Health recently provided an estimated return on investment of 4.7 for interventions addressing perinatal depression. This means that for every R1 invested, a saving of R4,70 (about US$0.29) can be expected through restored productivity, health and healthcare savings. This return would likely be much higher if it factored in the impacts on early childhood development.</p></li>
</ul>
<h2>Moving forward</h2>
<p>Although there are barriers to change, there are also opportunities to build on progress made so far – as we’ve tried to show in our call to action. </p>
<p>South Africa and the rest of the world must translate evidence, policy and guidance about maternal mental health into practice. If we don’t, women, children and communities will continue to suffer. It will cost us more if we do nothing.</p><img src="https://counter.theconversation.com/content/183932/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simone Honikman receives funding from the Harry Crossley Foundation, the DG Murray Trust, The Discovery Fund. </span></em></p><p class="fine-print"><em><span>Shanon McNab receives funding from USAID MOMENTUM Country and Global Leadership through consultancy.</span></em></p>Maternal mental health conditions are a reflection of harmful social and economic factors that plague women in general.Simone Honikman, Director of the Perinatal Mental Health Project; Associate Professor, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1766702022-03-22T01:08:36Z2022-03-22T01:08:36Z7 ways to reduce perineal tearing during childbirth<figure><img src="https://images.theconversation.com/files/453220/original/file-20220321-23-w4fodc.jpg?ixlib=rb-1.1.0&rect=17%2C0%2C5708%2C4060&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>While most expectant mothers are excited, many are also anxious about giving birth, especially <a href="https://pubmed.ncbi.nlm.nih.gov/18394766/">first-time</a> mothers. Perineal trauma is something many expectant mums are fearful about. </p>
<p>It is hard to comprehend being able to give birth to an entire human, but a woman’s vagina is pretty amazing, and nature has designed it to accommodate the baby. Hormones, increased blood supply and a clever, stretchy design all play a role in making this happen. No muscles in the female body are able to stretch without rupturing as much as those of the pelvic floor.</p>
<p>The perineum is the soft tissue between a woman’s vagina and anus, and it has the capacity to stretch significantly during birth. However, it can tear, or may be surgically cut if medically indicated and consented to by the woman (called an episiotomy). </p>
<p>When women have their first baby, they are more likely to have some perineal tearing. Most tears heal well and are never thought about again, but for some women there is ongoing pain and <a href="https://bmcwomenshealth.biomedcentral.com/articles/10.1186/1472-6874-14-32">psychological trauma</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-labour-is-such-a-pain-and-how-to-reduce-it-48092">Why labour is such a pain – and how to reduce it</a>
</strong>
</em>
</p>
<hr>
<h2>Perineal trauma prevalence</h2>
<p>There are different <a href="https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf">degrees of perineal trauma</a> (1st, 2nd, 3rd and 4th). First-degree (involves skin but not muscle) and second-degree tears (involves perineal muscles) are the most common. Third- and fourth-degree tears, known collectively as “severe perineal trauma” are more serious, as they also involve the anal area and can lead to long term consequences, such as pain and <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12283">incontinence</a> for women.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding pregnant stomach" src="https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/453225/original/file-20220321-19-gtadep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many women are anxious about child birth.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>In Australia, the <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/perineal-status">latest statistics</a> show more than one in four women have no perineal tearing during the birth (more likely when not the first baby), 21% have a 1st degree tear, 30% have a 2nd degree tear and less than 3% have a <a href="https://www.aihw.gov.au/reports/mothers-babies/ncmi-data-visualisations/contents/birth-outcome-indicators/third-and-fourth-degree-tears">3rd or 4th</a> degree tear (more common with the first baby). </p>
<p>Around 24% have an episiotomy, which is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000081.pub3/full">worrying</a> as this has doubled in the past ten years (12% in 2009), and there is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000081.pub2/full">evidence</a> the recovery is more painful than if the perineum tears naturally.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/episiotomy-during-childbirth-not-just-a-little-snip-36062">Episiotomy during childbirth: not just a 'little snip'</a>
</strong>
</em>
</p>
<hr>
<p>There is little doubt the rates of perineal trauma have increased over the past 100 years, with <a href="https://pubmed.ncbi.nlm.nih.gov/21035413/">early midwife records</a> indicating most women had no tearing.</p>
<p>An increase in the use of birthing interventions such as <a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">vacuum, forceps</a> and episiotomy (which can cause further tearing), women giving birth at an older age to fewer babies, and greater vigilance by midwives and doctors when examining the perineum after birth have all played a role in the increased perineal trauma rates we see today.</p>
<p>Rates of perineal trauma vary across the country, with one <a href="https://www.safetyandquality.gov.au/our-work/healthcare-variation/atlas-2017">report</a> finding a 12-fold difference between hospitals, ranging from six per 1,000 births in some hospitals to 71 per 1,000 births in others. </p>
<p>This difference could come from varying hospital practices such as more frequent use of forceps and vacuum, or from the demographics of the women in a given area (more women having their first baby, or even the <a href="https://bmjopen.bmj.com/content/3/5/e002824">country of birth</a> of the women).</p>
<figure class="align-center ">
<img alt="Woman leaning on hospital bed" src="https://images.theconversation.com/files/453221/original/file-20220321-15-1f9x3q4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/453221/original/file-20220321-15-1f9x3q4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/453221/original/file-20220321-15-1f9x3q4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/453221/original/file-20220321-15-1f9x3q4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/453221/original/file-20220321-15-1f9x3q4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/453221/original/file-20220321-15-1f9x3q4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/453221/original/file-20220321-15-1f9x3q4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are ways to reduce the risk of perineal tearing.</span>
<span class="attribution"><span class="source">Jimmy Conover/Unsplash</span></span>
</figcaption>
</figure>
<h2>How to reduce perineal tearing</h2>
<p>There are <a href="https://www.safetyandquality.gov.au/sites/default/files/2021-04/media-infographic-acsqhc-perineal-tears-ccs-21-april-2021.pdf">recommendations</a> on how to <a href="https://www.safetyandquality.gov.au/sites/default/files/2021-04/perineal_tears_ccs_v3.pdf">reduce</a> the chance of perineal tearing and trauma, based in part on our research.</p>
<p><strong>During pregnancy</strong>:</p>
<p>1) <a href="https://pubmed.ncbi.nlm.nih.gov/32399905/">perineal self-massage</a> (or with help from your partner) after 34 weeks of pregnancy can help protect your perineum and reduce the risk of third- and fourth-degree perineal tears</p>
<p>2) <a href="https://pubmed.ncbi.nlm.nih.gov/32506232/">pelvic floor muscle training</a> may help prepare you for labour and birth and reduce the possibility of a third- or fourth-degree perineal tear.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman in hospital holding baby" src="https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/453227/original/file-20220321-21-16wyju0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Warm compresses and pre-birth exercises have been shown to reduce perineal tearing.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p><strong>During a vaginal birth</strong>:</p>
<p>3) applying <a href="https://pubmed.ncbi.nlm.nih.gov/31238205/">warm compresses</a> to the perineum during the second stage of labour (when pushing and giving birth) can <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.16276">significantly reduce</a> the risk of a third or fourth degree perineal tear</p>
<p>4) slowing the rate at which the <a href="https://pubmed.ncbi.nlm.nih.gov/27859542/">baby’s head and shoulders</a> emerge, with the help of your birth attendants, may help prevent perineal injuries</p>
<p>5) <a href="https://pubmed.ncbi.nlm.nih.gov/30107756/">perineal massage</a> performed by your health-care professional during the second stage of labour may reduce the risk of third- and fourth-degree perineal tears. However, some women may not feel comfortable with this option, and it is not recommended for everyone</p>
<p>6) listening carefully to your midwife’s voice and following their instructions can help the baby emerge from your vagina gently and slowly. For example, your midwife will tell you to breathe and not push just before your baby is born</p>
<p>7) perineal trauma is <a href="https://pubmed.ncbi.nlm.nih.gov/29727829/">less common</a> when women give birth in home-like environments such as at home or in a birth centre, where they have less medical intervention, can use water for pain relief and give birth in upright birth positions. </p>
<p>In a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00188-X/fulltext">new paper</a> we have also found having two midwives in the room in the late stage of birth, instead of one, can reduce perineal trauma by up to 31%. Our study found having a second midwife in the room meant one of them was focused on the woman at all times, and was not distracted by other things that needed to be done. It also meant they could give suggestions and <a href="https://www.sciencedirect.com/science/article/pii/S1871519222000415">reinforce</a> the first midwife’s words to the mother during the birth.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaginal-birth-after-caesarean-increases-the-risk-of-serious-perineal-tear-by-20-our-large-scale-review-shows-173249">Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows</a>
</strong>
</em>
</p>
<hr>
<h2>Treatment and recovery</h2>
<p>Following the birth, your midwife or doctor will stitch any perineal trauma that needs to be repaired in the birthing room, and these stitches dissolve over the coming weeks. Some tears are minor and do not require stitches. </p>
<p>Most perineal wounds heal well by resting, applying ice for the first day or two if swollen, changing sanitary pads and keeping the perineum clean, gentle pelvic floor exercises after a couple of days to help healing, and adequate pain relief. </p>
<p>After birth, if you have problems with your perineum, don’t just put up with it. Contact your midwife or doctor to get further advice.</p><img src="https://counter.theconversation.com/content/176670/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. </span></em></p><p class="fine-print"><em><span>Christine Rubertsson receives funding from Lund university, Regional South Funds (SUS), Government ALF research grants from Lund university and Lund university Hospital, Jan Hains Foundation. </span></em></p><p class="fine-print"><em><span>Malin Edqvist receives funding from The Swedish Council for Health, Working Life and Welfare. </span></em></p>The incidence of perineal tearing is increasing, but there are ways to reduce the risk.Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityChristine Rubertsson, Lund UniversityMalin Edqvist, Senior midwife and researcher, Karolinska InstitutetLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1257322019-10-29T19:24:15Z2019-10-29T19:24:15ZHaving a baby at a birth centre is as safe as hospital but results in less intervention<figure><img src="https://images.theconversation.com/files/299082/original/file-20191029-183136-1d1i2sm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Birth centres are a good option for women with low-risk pregnancies, but availability is limited.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/516261340?src=3JsVAt37Eq-SeAqziSP12g-1-78&size=huge_jpg">Lolostock/Shutterstock</a></span></figcaption></figure><p>Having a baby at a birth centre is as safe as giving birth in hospital, according to our research, published today in the journal <a href="https://bmjopen.bmj.com/content/9/10/e029192.full">BMJ Open</a>. </p>
<p>Women who give birth in a birth centre are also less likely to undergo unnecessary interventions such as caesarean sections, <a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">forceps or vacuum</a> deliveries, which come with increased risks for <a href="https://americanpregnancy.org/labor-and-birth/cesarean-risks/">mothers</a> and <a href="https://theconversation.com/how-birth-interventions-affect-babies-health-in-the-short-and-long-term-93426">babies</a>. </p>
<p>Some women are advised to give birth in a hospital labour ward. This includes women expecting twins, having a breech baby (coming bottom-first instead of head-first), with medical complications such as high blood pressure, diabetes, or if they have had a previous caesarean section. </p>
<p>However, women with uncomplicated pregnancies should have the option to give birth in a birth centre with the right services around them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-birth-interventions-affect-babies-health-in-the-short-and-long-term-93426">How birth interventions affect babies' health in the short and long term</a>
</strong>
</em>
</p>
<hr>
<h2>Our study</h2>
<p>In the largest Australian study of its kind, we used routinely collected data from across the country, from 2000 to 2012, and grouped women according to where they planned to give birth: in a hospital labour ward, birth centre or at home.</p>
<p>We carefully selected healthy women with uncomplicated pregnancies who gave birth to a single baby in a head-down position at term (between 37 and 41 weeks of pregnancy) and without any known major medical or obstetric risk factors. </p>
<p>We tracked 1.25 million births, most of which were planned in hospital labour wards (1.17 million or 93.6%), with just over 5% in birth centres (71,505 or 5.7%) and a small proportion at home (8,212 or 0.7%).</p>
<p>We found women who planned a hospital birth were almost three times less likely to have a vaginal birth without an epidural than those who gave birth at a birth centre. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women who give birth in hospital are more likely to have an epidural.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1143044708?src=h2CpXdg3HJvcCnx4fdd-JQ-1-6&size=huge_jpg">Kipgodi/Shutterstock</a></span>
</figcaption>
</figure>
<p>Women who gave birth in hospital were more likely than women who gave birth in a birth centre to have: </p>
<ul>
<li>a caesarean section in labour (7.8% vs 4%)</li>
<li>forceps birth (4.6% vs 2.5%)</li>
<li>vacuum extraction (7.3% vs 3.5%)</li>
<li>an epidural (13.8% vs 6.5%)</li>
<li>labour sped up with the drug oxytocin (16.5% vs 8.1%).</li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-forceps-permanently-changed-the-way-humans-are-born-125701">How forceps permanently changed the way humans are born</a>
</strong>
</em>
</p>
<hr>
<p>Rates of complications were similar among women who gave birth in hospitals and birth centres, including severe postpartum haemorrhage (bleeding) and readmission to hospital. </p>
<p>The number of stillbirths and baby deaths up to four weeks of age was stable across hospitals and birth centres. However, babies born in birth centres were slightly more likely to need admission to intensive care for more than 48 hours. </p>
<h2>What about home births?</h2>
<p>Around 0.7% of the women we tracked gave birth at home. But this didn’t include women who planned to give birth at home and transferred to a hospital during the pregnancy. Nor did it include women who gave birth at home with no health professional in attendance (known as <a href="https://theconversation.com/for-some-women-unassisted-home-births-are-worth-the-risks-5179">freebirthing</a>). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/pushing-home-birth-underground-raises-safety-concerns-6825">Pushing home birth underground raises safety concerns</a>
</strong>
</em>
</p>
<hr>
<p>Based on the available data, the proportion of baby deaths during home births (nine of 8,182 births or 1.1 per 1,000 births) was similar to hospitals (880 of 1,171,050 births or 0.8 per 1,000 births). </p>
<p>First-time mothers had a slightly higher risk of death during a home birth than those who had previously given birth, although the numbers were too small to make firm conclusions. </p>
<h2>What happens at birth centres?</h2>
<p>Birth centres are typically co-located with hospitals, though a small number are standalone facilities. The centres typically provide midwife-led care to women with uncomplicated pregnancies in a home-like environment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Birth centres provide a more home-like environment than hospital.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1033088542?src=gHLH_Z_gSvndcDGnIrYJ-A-1-17&size=huge_jpg">KieferPix/Shutterstock</a></span>
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<p>Care at birth centres is usually provided by midwives that the woman knows. This is known as <a href="https://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early">midwifery continuity of care</a>, and results in lower rates of intervention. </p>
<p>Birth centres are a more relaxed environment than a hospital labour ward; they’re usually less clinical, with a normal double bed, access to a birthing pool or bath, with soft lighting and equipment hidden out of sight. </p>
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Read more:
<a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">Explainer: what are women's options for giving birth?</a>
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<p>Different birth centres have different criteria about who can give birth there, but usually women must be having only one baby, in a head down position, and be keen to have a medication-free birth. Higher risk women, such as those who have had a previous ceasarean section, are excluded.</p>
<p>If complications in labour do arise, women in birth centres transfer to the hospital labour ward. If the birth centre is located away from the hospital, there are clear protocols on how this should happen – usually in an ambulance. </p>
<h2>Reducing unnecessary intervention</h2>
<p>The rates of intervention across Australia are generally high compared to similar countries. </p>
<p>Our national caesarean section rate, for example, is at <a href="https://www.aihw.gov.au/reports-data/population-groups/mothers-babies/overview">35%</a> – much higher than the World Health Organisation’s ideal rate of 10-15%. And there is considerable variation <a href="https://www.safetyandquality.gov.au/our-work/healthcare-variation/atlas-2017/atlas-2017-3-womens-health-and-maternity">across the country</a>. </p>
<p>Increasing women’s access to birth centres can help reduce our high rate of caesarean sections. </p>
<p>And it won’t cost the health system more: our <a href="https://www.womenandbirth.org/article/S1871-5192(19)30689-4/fulltext">past research</a> found <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0149463">birth centre and hospital births</a> both cost around A$2,100.</p>
<p>Yet currently, few Australian women have the option to have their babies in birth centres; even those who live close to a birth centre may not get a spot because many are oversubscribed and resort to waiting lists. </p>
<p>It’s time to increase access to birth centres and home birth for low-risk women.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/so-your-birth-didnt-go-according-to-plan-dont-blame-yourself-89155">So your birth didn't go according to plan? Don't blame yourself</a>
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<img src="https://counter.theconversation.com/content/125732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline Homer receives funding from NHMRC. She is a Life Member of the Australian College of Midwives and the immediate Past President. </span></em></p><p class="fine-print"><em><span>David Ellwood was a Chief Investigator on the NHMRC Birthplace in Australia project.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. I also work in a private practice in Sydney and attend hospital and home births.</span></em></p><p class="fine-print"><em><span>Vanessa Scarf works as a midwife in a hospital on a casual basis. She also worked on the NHMRC funded Birthplace in Australia Study as the Project Coordinator.</span></em></p>Compared to women who give birth in a birth centre, those who give birth in hospitals are much more likely to have interventions – from epidurals, to labour augmentation and caesarean deliveries.Caroline Homer, Co-Program Director: Maternal and Child Health, Burnet InstituteDavid Ellwood, Professor of Obstetrics & Gynaecology, Griffith UniversityHannah Dahlen, Professor of Midwifery and Higher Degree Director, Western Sydney UniversityVanessa Scarf, Lecturer in Midwifery, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082062019-01-02T09:11:52Z2019-01-02T09:11:52ZWhy improving access to surgery in childbirth makes economic sense<figure><img src="https://images.theconversation.com/files/251276/original/file-20181218-27758-j579lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women waiting to see a doctor at a hospital in Uganda. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Maternal mortality remains high around the world, with more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00838-7/fulltext">303,000</a> women dying in pregnancy, childbirth or shortly afterwards. The majority (99%) of these deaths occur in developing countries. More than half of these deaths are in sub-Saharan Africa. </p>
<p>A major reason for this is that women in developing countries have no real access to proper medical care and therefore miss out on the help required for difficult births. About <a href="http://apps.who.int/iris/bitstream/handle/10665/255760/9789241565493-eng.pdf?sequence=1">15%</a> of all women experience severe complications when giving birth. Most of these cases require major intervention, including surgery. In developed countries, emergency surgery ensures that women and their babies survive childbirth, and mothers are spared the severe physical and emotional trauma that often follows a complicated birth.</p>
<p>One potentially devastating complication in childbirth is <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">obstetric fistula</a>. This usually happens during a protracted or obstructed labour that isn’t given sufficient attention. A hole develops in the birth canal between the vagina and rectum or between the vagina and bladder. An estimated <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">50 000 to 100 000 women </a>in sub-Saharan Africa develop fistula every year. </p>
<p>If women don’t have access to quality emergency obstetric care, the fistula can cause long term damage. This can include incontinence. In turn this can lead to women being stigmatised and isolated from their families and communities among other socio-economic losses.</p>
<p>While conducting <a href="https://www.ncbi.nlm.nih.gov/pubmed/27918334">research</a> in East Africa, I personally witnessed the profound lack of safe anaesthesia. This meant that there was a delay in access to safe and immediate caesarean sections. The lack of access was due to a number of issues. These include few anaesthetists, lack of equipment and emergency drugs, shortage of blood supply and failed referral systems.</p>
<p>In my more <a href="https://academic.oup.com/heapol/article/33/9/999/5106382">recent research</a> I conducted a cost evaluation to see if it made sense to provide women with fistula repair surgery. We looked at it both from the point of view of the long-term cost to women as well as the financial cost. </p>
<p>Our study found that fistula surgery is cost-effective and can significantly reduce disability in women of childbearing age in Uganda.</p>
<p>Our findings were consistent with a previous modelled analysis on the issue in low- and middle-income countries. Increasing access to high quality obstetric and fistula surgery could improve the health of many women in resource-limited settings. </p>
<h2>What we found</h2>
<p>Our study is the first publication on the cost-effectiveness of obstetric fistula repair in the East African region. </p>
<p>We built a model to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery versus no surgery to Uganda’s national health system. </p>
<p>We assessed long-term disability outcomes based on a lifetime Markov model. This involved mapping a sequence of possible events in which the probability of each event depended only on the state attained in the previous event. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula, and mortality rates in the general population in Uganda were based on published sources.</p>
<p>We estimated that the cost of providing fistula repair surgery in Uganda was $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the number of years lost to disability from 8.53 to 1.51. </p>
<h2>What is needed</h2>
<p>Our model found obstetric fistula surgical repair to be the optimal strategy for management of this condition, and one that is highly cost-effective in Uganda. Our study provides data for policy makers to prioritise implementation of this procedure in developing countries. </p>
<p>But this will require significant social and economic attention. The lack of action to date has been because of insufficient political commitment, the low numbers of skilled healthcare providers and the inability to retain skilled birth attendants in priority areas. </p>
<p>Three vital ways to prevent obstetric fistula are to provide access to skilled care during delivery, to closely monitor progress during labour, and to provide emergency caesarean sections. But low and middle-income countries lack sufficient surgeons and resources to treat patients with obstetric fistula. </p>
<p>While the current estimates of the unmet need for fistula surgical repair in low-income countries are not well documented, 10 years ago it was estimated to be as high <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2007.06.011">as 99%</a>. Therefore, there is an urgent need to strengthen care in low income countries for better maternal and neonatal outcomes. </p>
<p>All this needs to change if countries are going to achieve the goal of making sure that every citizen – whatever their income – has access to universal health care. And priority must be given to investing in medical facilities that are able to provide adequate prenatal care as well as healthy deliveries. Strengthening the option for women to have safe surgery during birth complications would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood.</p><img src="https://counter.theconversation.com/content/108206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, University of California Global Health Institute - Center for Expertise in Women, SONKE Gender Justice.</span></em></p>If women don’t have access to quality emergency surgery, they can develop dibilitating complications such as fistula.Isabella Epiu, MD PhD, Postdoctoral Fellow Global Health, University of California Global Health Institute (UCGHI), Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/997192018-07-16T10:40:23Z2018-07-16T10:40:23ZBorn in the USA: Having a baby is costly and confusing, even for a health policy expert<figure><img src="https://images.theconversation.com/files/227510/original/file-20180712-27021-thzcs1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lukas Haeder, the author's son, on his birthday. </span> <span class="attribution"><span class="source">Simon Haeder/Author</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>It is hard to believe that it has been just over since five months since our second son, Lukas, was born on Feb. 3. His mother, Hollyanne, is doing well, which is something to be thankful for, given the <a href="https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world">excessive maternal mortality rates in the U.S.</a> Lukas is also healthy and growing, albeit sleeping little at night. What is unbelievable is the fact that I am still receiving bills for his birth. </p>
<p>Of course, I “knew” what was going to happen when we found out that my wife was pregnant. I <a href="http://simonfhaeder.wixsite.com/home">study health policy for a living</a>, and I have <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en">written extensively about the American health care system</a>. Yet for all the reading and writing, experiencing health care in America personally is a rather shocking experience. Keep in mind, our birthing experience was without any complications and we have health insurance.</p>
<p>I cannot imagine how overwhelming the experience must be for someone with fewer resources and less of an understanding about health care in America. </p>
<h2>Being pregnant and giving birth: Not what it used to be</h2>
<p>From the first doctor’s appointment, we were introduced to what to expect: lots of paperwork and lots of bills. There are of course all the monthly, then biweekly, and then weekly doctor’s visits with the corresponding bills. </p>
<p>In West Virginia, due to the <a href="https://theconversation.com/how-killing-the-aca-could-lead-to-more-opioid-deaths-in-west-virginia-and-other-trump-states-79991">opioid epidemic</a>, most doctors will also insist on a drug screen.</p>
<p>As it turned out, my wife’s doctor ordered copious amounts of blood work and ultrasounds – “outpatient diagnostic services,” totaling thousands of dollars. It is hard to question any of these when all you want is a healthy baby - and your doctor is the only one who knows which tests are necessary. </p>
<p>Like most parents, we also wanted to know whether our baby was going to be healthy. Here is the total amount of the bill for genetic testing sent to our insurance company: US$26,755.</p>
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<img alt="" src="https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A stay in the maternity ward is pricey, even if the child birth itself is quick, as is was with the birth of Lukas Haeder.</span>
<span class="attribution"><a class="source" href="https://www.healthcare.gov/glossary/flexible-spending-account-fsa/">Inked Pixels/Shutterstock.com</a></span>
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<p>Giving birth to our first son, Nico, had been quite an arduous experience for my wife. She labored for more than 30 hours. Determined not to spend hours in the hospital, my wife practically gave birth this time in the front seat of our car. Ultimately, I was able to throw my wife onto a bed in the maternity ward, and Lukas popped right out. </p>
<p>I joked to my wife: “At least they cannot charge us for delivery.” At the very least, I should file a claim with our insurance company.</p>
<p>I am still not quite sure how wrong I was, because every time I ask for a detailed bill, new items appear while others miraculously disappear. </p>
<h2>About $65 an hour, for lodging</h2>
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<img alt="" src="https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Various bills for the birth and care of Lukas and Hollyanne Haeder.</span>
<span class="attribution"><span class="source">Simon Haeder</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>The delivery room, which we used for all of one minute, cost about $7,000. Room and board for my wife for 48 hours cost just over $3,100. Two Tylenols for my wife: $25. Laboratory work: $1,200. </p>
<p>That does not account for Lukas. Room and board for him was just over $1,500. Various laboratory work charges added another $1,400 or so. The hearing test cost $260.</p>
<p>I tried to keep track of all the medical personnel coming and going, but after a while it all became a blur. The doctor, who was not present at birth, charged $4,200 for delivery and care. Pediatricians stopped by a few times to check on Lukas for $150 per look. </p>
<p>We were not able to take advantage of a tax-favored <a href="https://www.healthcare.gov/glossary/flexible-spending-account-fsa/">flexible spending account</a> for most of these expenses, because “being pregnant” does not count as a “life event.” While “giving birth” does count, the added contributions cannot be applied to previous costs associated with the birth.</p>
<h2>Bringing the baby home</h2>
<p>As demanding as giving birth is, in many ways, the real challenges of raising children start when one leaves the hospital.</p>
<p><a href="http://www.pewresearch.org/fact-tank/2017/03/23/access-to-paid-family-leave-varies-widely-across-employers-industries/">Like many American women</a>, my wife, a teacher, did not have access to paid maternity leave. Hence, we had to make do with one income for a few months. Of course, this could not have been a more inconvenient time to lose a paycheck, because literally every day we received medical bills. Many of the bills misspelled someone’s name or got another fact wrong, which led to countless phone calls with providers and our insurer. </p>
<p>Diapers and other baby items, naturally, are also not cheap.</p>
<p>Once my semester ended in early May, my wife went back to work as I watched Lukas. This brought new challenges with it. </p>
<p>For one, as a professor, I am also not getting paid over the summer.</p>
<p>Moreover, while the <a href="https://read.dukeupress.edu/jhppl/article-abstract/40/2/281/13726">Affordable Care Act provides added benefits and protections</a> for breastfeeding, there are limitations. For one, not all breast pumps are covered, and <a href="https://khn.org/news/insurer-slashes-breast-pump-payments-stoking-fears-fewer-moms-will-breastfeed/">insurance companies are getting stingier</a>. This is of course ironic given that there is <a href="https://theconversation.com/au/topics/breastfeeding-953">a whole other effort going on to encourage mothers to breastfeed more</a> because it has been found so beneficial for mother and child. </p>
<p>Finding an appropriate place and time to pump breast milk at work, even with a decent pump and <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">governmental protections</a>, comes with a slew of challenges. Currently my wife is using every free minute she can find and locks her classroom. Finding the time and space when doing continuing education or field trips is, of course, a whole other story.</p>
<p>Going forward, we are rather lucky. </p>
<p>Thanks to the Affordable Care Act, <a href="https://www.sciencedirect.com/science/article/pii/S0168851014002607">well-child visits and preventive care like immunizations will be included in our insurance</a>. Of course, should something serious happen, like a hospitalization, we will be on the hook again for potentially thousands of dollars. </p>
<p>My employer allows me to work from home during the fall semester so I can take care of Lukas at the same time. Of course, while I do not have to teach a class on campus, expectations about research and service will not diminish. </p>
<p>Yet soon, we will have to put Lukas into day care. We have been on several waiting lists since the moment we found out my wife was pregnant. Last time, I had to drive my son Nico 45 minutes one way to a <a href="http://wvpublic.org/post/parents-struggle-find-affordable-childcare-w-va">day care we were comfortable with in Pennsylvania</a>. Even if we are lucky to find a nice day care close by, fees will exceed in-state tuition at <a href="https://politicalscience.wvu.edu/faculty-staff/haeder">West Virginia University, my employer</a>. </p>
<h2>Putting our experience in perspective</h2>
<p>Our experience is, of course, not unique. </p>
<p>America’s poorest members of society are somewhat shielded from medical costs. Medicaid <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">generally does not require out-of-pocket contributions</a>. For those on the <a href="https://theconversation.com/time-to-stop-using-9-million-children-as-a-bargaining-chip-90293">Children’s Health Insurance Program</a> and those with <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/puar.12065">cost-sharing subsidies</a> on the Affordable Care Act insurance marketplaces, out-of-pocket contributions are limited. In both cases, the high costs of giving birth <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1541-0072.2012.00446.x">are passed on</a> to public sources and those of us with private insurance. </p>
<p>The <a href="https://www.nytimes.com/2015/12/18/upshot/rich-children-and-poor-ones-are-raised-very-differently.html">real struggles of the poor begin</a> as they seek to raise their children with limited resources and diminishing governmental support.</p>
<p>Yet the middle class more and more often finds itself squeezed between a rock and a hard place when it comes to health care. <a href="http://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.1406">Premiums, deductibles and co-payments continue to increase while services and choices grow narrower</a> every year. </p>
<p>With Republican efforts to undo much or all of the Affordable Care Act, <a href="https://www.sciencedirect.com/science/article/pii/S0168851014002607">even those of us with employer-sponsored insurance may lose many protections</a>.</p>
<p>Many of us are simultaneously struggling to pay back our student loans, which already forces many to <a href="https://wtop.com/local/2018/07/student-loan-debt-wealth-divide-are-harming-millennials-homeownership-dreams/">delay marriage, have kids, or buy a house</a>.</p>
<p>For us, and many others, this also meant cutting back on virtually everything, including family vacations and replacing appliances. It also meant taking up every opportunity to add income for both of us by taking side jobs. </p>
<p>Any potential future pay raises are likely to be swallowed up by premium increases and co-payments as health care cost continue to <a href="https://www.bloomberg.com/news/articles/2017-07-27/with-or-without-obamacare-health-care-costs-are-battering-the-middle-class">grow unabated</a>.</p>
<h2>Too rich for government programs, yet too poor to avoid financial hardship</h2>
<p>Given these struggles, it is perhaps not surprising that the <a href="https://www.nytimes.com/2013/12/21/business/new-health-law-frustrates-many-in-middle-class.html">frustrations of the middle class</a> breed resentment toward publicly supported programs. Support for work requirements and more punitive and stigmatizing approaches to social programs are perhaps the understandable result. </p>
<p>Our current approaches to encourage and support parenthood are willfully inadequate. Health care, parental leave, day care, parental support, education. As a country, I think that we should strive to do better to support our families.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Lukas Haeder at 5 months old.</span>
<span class="attribution"><span class="source">Simon Haeder</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure><img src="https://counter.theconversation.com/content/99719/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A routine childbirth proves expensive and complicated. Insurance company adjustments, inconsistent billing and mystery costs flummoxed even a health policy expert and his wife, a teacher.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/977782018-06-28T19:56:41Z2018-06-28T19:56:41ZAntibiotics before birth and in early life can affect long-term health<figure><img src="https://images.theconversation.com/files/225256/original/file-20180628-112601-zl2hpd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">By the time they turn one, half of Australian babies have had a course of antibiotics. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-portrait-beautiful-young-asian-mother-1047966433?src=sMG7espPHI1MPuB_UtMKOA-3-9">Shutterstock</a></span></figcaption></figure><p>Half of Australian infants have received at least one course of antibiotics by their first birthday. This is <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/jpc.13616">one of the highest rates</a> of antibiotic use in the world. </p>
<p>Although antibiotics are effective and potentially life-saving for bacterial infections in children, they are often prescribed for viral infections, for which they are ineffective. </p>
<p>Unnecessary antibiotics expose individual children to potential side effects, including diarrhoea, vomiting, rashes and allergic reactions. </p>
<p>The overuse of antibiotics also increases the risk of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4143845/">bacterial resistance</a> in the wider community. This is when commonly used antibiotics become ineffective against some bacteria, making it difficult, or even impossible, to treat some infections.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/recent-death-from-resistant-bug-wont-be-the-last-71340">Recent death from resistant bug won't be the last</a>
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</em>
</p>
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<p>Researchers are also beginning to realise there may be additional long-term health harms from antibiotic exposure in early life and before birth, including an increased risk of infection, obesity and asthma.</p>
<p>At the moment, most bacteria that cause childhood infections in Australia respond well to antibiotics. But this is likely to change, unless we use antibiotics more carefully. </p>
<h2>The role of gut bacteria</h2>
<p>We have vast numbers of bacteria in our gut, as well as viruses, fungi and other organisms. This microbial community is collectively known as the microbiome. </p>
<p>Our microbiome is essential for normal health and development and has been linked to an ever-growing list of health outcomes such as mental health, immunity, obesity, heart disease and cancer. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/i3FJkBelOQY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
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<p>An infant’s first major contact with bacteria and other microbes occurs at birth. Babies born vaginally acquire their initial microbiome from the birth canal and gut. Those delivered by caesarean section are more likely to acquire bugs from their mother’s skin and the hospital. </p>
<p>Antibiotics during pregnancy can alter the mother’s microbiome and therefore the microbial profile her baby acquires. </p>
<p>Antibiotics kill off not only the bacteria causing the infection, but also bacteria of the microbiome, including those that are beneficial. The resulting imbalance of the microbiome is known as dysbiosis. </p>
<p>The baby’s early microbiome, acquired from the mother at delivery, “educates” the infant’s developing immune system in the first weeks and months of life. </p>
<p>Antibiotics in pregnancy can alter the mother’s and therefore the baby’s microbiome, affecting early immune responses. This may increase the risk of infection in childhood. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gut-instinct-how-the-way-youre-born-and-fed-affect-your-immune-system-65104">Gut instinct: how the way you're born and fed affect your immune system</a>
</strong>
</em>
</p>
<hr>
<p>In a <a href="https://academic.oup.com/ije/article/47/2/561/4833213">recent Danish study</a>, a mother’s exposure to antibiotics in pregnancy was associated with increased risk her child would develop a severe infection (requiring hospital admission) in the first six years of life. </p>
<p>The increase in risk was greatest among children whose mothers were prescribed more antibiotics and who received them closer to delivery. </p>
<p>There was also some evidence the risk was higher in those delivering vaginally. </p>
<p>This suggests antibiotics affect the mother’s microbiome, with downstream effects for the offspring. Other genetic and environmental factors shared between mother and child are also likely to play a role.</p>
<h2>Obesity</h2>
<p>Antibiotics are widely used in meat production as a growth promoter. An estimated <a href="https://theconversation.com/we-can-beat-superbugs-heres-how-10445">80% of all antibiotic use</a> is in animals. Much of their effect is via the livestock’s microbiome, which has a major role in metabolism and energy harvesting. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/225278/original/file-20180628-112598-a3dg3y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/225278/original/file-20180628-112598-a3dg3y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/225278/original/file-20180628-112598-a3dg3y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/225278/original/file-20180628-112598-a3dg3y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/225278/original/file-20180628-112598-a3dg3y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/225278/original/file-20180628-112598-a3dg3y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/225278/original/file-20180628-112598-a3dg3y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Antibiotics promote growth in livestock.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/agriculture-industry-farming-animal-husbandry-concept-562342921?src=-5gfWCddsSbHdrjohzN-vQ-1-7">Syda Productions/Shutterstock</a></span>
</figcaption>
</figure>
<p>Antibiotics may also play a similar role in promoting growth in humans. There is some evidence antibiotic exposure in pregnancy is associated with increased birth weight and obesity in early life. But large studies are needed to account for the other important factors that may also contribute. </p>
<p>The association between antibiotics in early childhood and obesity is clearer. Antibiotic exposure within the first year of life is associated with a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4487629/pdf/nihms-703258.pdf">10-15% increased risk of obesity</a>, although the importance of the type and timing of antibiotics is less well understood. </p>
<h2>Asthma</h2>
<p>Childhood asthma has increased in parallel with antibiotic use, leading researchers to investigate a link. </p>
<p>Observational studies have shown an association between antibiotic use in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4352392/">pregnancy</a> or <a href="https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2222.2000.00939.x">infancy</a> and later risk of asthma. This supports the concept of antibiotic-induced dysbiosis (imbalance of bacteria) and the effect on the immune system. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/healthy-guts-are-swarming-with-bugs-so-what-do-they-do-65105">Healthy guts are swarming with bugs, so what do they do?</a>
</strong>
</em>
</p>
<hr>
<p>A <a href="https://www.bmj.com/content/349/bmj.g6979">large population-based Swedish study</a>, however, found the link between asthma and antibiotics was largely attributable to a number of other factors, including respiratory infections contributing to asthma and unrecognised symptoms of asthma being inappropriately treated with antibiotics.</p>
<p>But <a href="http://pediatrics.aappublications.org/content/123/3/1003.long">other studies have found</a> these factors don’t completely explain away the link between antibiotic use and asthma. A better understanding of the role of the microbiome in the development of asthma will help clarify the contribution of antibiotics. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/225280/original/file-20180628-112604-1uwraiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/225280/original/file-20180628-112604-1uwraiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/225280/original/file-20180628-112604-1uwraiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/225280/original/file-20180628-112604-1uwraiy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/225280/original/file-20180628-112604-1uwraiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/225280/original/file-20180628-112604-1uwraiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/225280/original/file-20180628-112604-1uwraiy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The science is unclear about the link between antibiotics and asthma.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/person-holding-pink-asthma-inhaler-557548876?src=BeCNrmXJ-G3N_bXe6lXI8g-1-79">D K Grove/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Other links</h2>
<p>Antibiotic use in early childhood, and particularly the first 12 months of life, is linked to gastrointestinal diseases such as <a href="http://gut.bmj.com/content/60/1/49">Crohn’s</a> and <a href="https://academic.oup.com/aje/article/180/1/76/2739114">coeliac disease</a>. The exact risk is difficult to quantify, but children receiving over seven courses of antibiotics were reported to be at a seven-fold risk of Crohn’s disease.</p>
<p>Other childhood inflammatory diseases, including <a href="http://pediatrics.aappublications.org/content/early/2015/07/15/peds.2015-0036">juvenile idiopathic arthritis</a> have shown a similar association. </p>
<p>However, as with asthma, because these are observational studies, the finding of an association does not prove causation: it’s possible these children were given antibiotics for symptoms of unrecognised gastrointestinal or inflammatory disease, or for an infection. </p>
<p>Finally, antibiotic use in early adulthood is associated with <a href="http://gut.bmj.com/content/67/4/672.long">bowel cancer</a>. The risk increases with more courses of antibiotic. Whether childhood antibiotic use is associated with adult bowel cancer risk has yet to be studied.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
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</p>
<hr>
<h2>Antibiotics have their place</h2>
<p>Antibiotics are one of the most important medical innovations and save lives when used appropriately. But inappropriate use leads to potentially untreatable resistant infections and long-term health problems in children and adults. </p>
<p>A <a href="http://www.pnas.org/content/early/2018/03/20/1717295115">recent assessment</a> predicted that without restrictions, global antibiotic use will increase three-fold by 2030. Unless we all work together to reduce antibiotic overuse, we could be assigning our children to a future of chronic ill health. Too much too young underappreciated long-term adverse effects of early antibiotic exposure</p><img src="https://counter.theconversation.com/content/97778/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Penelope Bryant receives funding from NHMRC to study the effect of antibiotics on the microbiome in children. </span></em></p><p class="fine-print"><em><span>Cheryl Jones receives funding from NHMRC CRE for Emerging Infectious Diseases (CREID). APP 1079575 </span></em></p><p class="fine-print"><em><span>David Burgner receives funding from NHMRC, National Heart Foundation Australia, National Blood Authority, HeartKids, Royal Australasian College of Physicians, Murdoch Children's Research Institute, and the DHB Foundation.</span></em></p><p class="fine-print"><em><span>Nigel Curtis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There may be additional long-term health harms from antibiotic exposure in early life and before birth, including an increased risk of infection, obesity and asthma.Penelope Bryant, Consultant in Paediatric Infectious Diseases and General Paediatrics, Murdoch Children's Research InstituteCheryl Anne Jones, Professor of Paediatrics, The University of MelbourneDavid Burgner, Clinician and Scientist, Murdoch Children's Research InstituteNigel Curtis, Professor of Paediatric Infectious Diseases, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/934262018-03-26T04:21:52Z2018-03-26T04:21:52ZHow birth interventions affect babies’ health in the short and long term<figure><img src="https://images.theconversation.com/files/211890/original/file-20180326-54872-1rpft11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intervention will sometimes be required in childbirth, but should only occur when medically necessary.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sofia-bulgariajanuary19-2018-woman-waits-give-1028955100?src=wWQCjkdxDSFNlSpANfJEmw-1-15">Circlephoto/Shutterstock</a></span></figcaption></figure><p>Medical and surgical intervention during birth continues to rise in much of the world. Nearly <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-2015-in-brief/contents/table-of-contents">one in three women</a> who give birth in Australia have a caesarean section and around 50% have their labour induced and/or augmented (sped up with synthetic hormones). </p>
<p>Our new research, published today in the journal <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/birt.12348">Birth</a>, found babies born via medical or surgical intervention were at increased risk of health problems. These include short-term concerns such as jaundice and feeding problems, and longer-term illnesses such as diabetes, respiratory infections and eczema. </p>
<p>Intervention will sometimes be required in childbirth, but should only occur when medically necessary. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/birth-intervention-and-harm-more-likely-in-private-hospitals-26801">Birth intervention – and harm – more likely in private hospitals</a>
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<h2>What did we find?</h2>
<p>Our international team, based in five countries, analysed data from nearly 500,000 healthy, low-risk women who gave birth in New South Wales between 2000 and 2013, and their children. We looked at their children’s health in the first 28 days and up to five years of age. </p>
<p>We then compared the health outcomes of children whose mothers went into labour spontaneously and gave birth vaginally, with those who were born via medical or surgical intervention.</p>
<p>Medical intervention is when labour is induced using synthetic hormones that start labour and/or augment labour by producing stronger contractions. </p>
<p>Surgical intervention includes caesarean section and instrumental delivery using forceps or vacuum. This is where metal tongs or a plastic suction cap are placed around or on the baby’s head to enable it to be pulled through the vagina.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">From barber surgeons to car mechanics: the technologies of vaginal birth</a>
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<p>We found:</p>
<ul>
<li><p>Babies who experienced an <a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">instrumental birth</a> (forceps or vacuum) following induction or augmentation had the highest risk of jaundice and feeding problems needing treatment in the first 28 days</p></li>
<li><p>Babies born by caesarean section had higher rates of being cold and needing treatment in the hospital for this compared to babies born via vaginal birth</p></li>
<li><p>Children born by emergency caesarean section had the highest rates of metabolic disorders (such as diabetes and obesity) by five years of age</p></li>
<li><p>Rates of respiratory infections, such as pneumonia and bronchitis, metabolic disorders, and eczema were higher among children who experienced any form of birth intervention than those born vaginally.</p></li>
</ul>
<p>Our study adds to the <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002494">growing scientific evidence</a> that children born by spontaneous vaginal birth have fewer short- and long-term health problems. </p>
<p>The findings hold even when you take into account the reason that might pre-empt the intervention, such as induction or caesarean section because the mother has diabetes or high blood pressure. We removed all women with such risk factors from the study.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=477&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=477&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=477&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rates of infections are higher among babies who experienced any intervention.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-sleeping-hospital-bed-1050762434?src=lp8fCCv3FEMsvu99QAfhlA-1-51">kipgodi/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Why the increased risk?</h2>
<p>This study showed an association between common forms of medical and surgical intervention and certain health outcomes for the child. It didn’t find one thing caused the other. But there are some obvious reasons for some of the links. </p>
<p>Forceps and vacuum birth, for instance, can cause bleeding and bruising in the baby’s scalp. These blood cells break down, releasing bilirubin that causes the skin to look yellow, which signals jaundice. </p>
<p>Babies born by caesarean section are more likely to be cold because the operating theatre is cold. Despite recommendations for the baby to be placed on the mother’s chest as soon as possible, this doesn’t always happen. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-need-more-freedom-during-labour-not-a-medicalised-birth-script-to-follow-92079">Women need more freedom during labour, not a medicalised birth script to follow</a>
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<p>Reasons for the increased risk of longer-term problems are much less clear, but there are a couple of interesting <a href="https://theconversation.com/can-caesarean-sections-increase-susceptibility-to-disease-12334">hypotheses</a>. </p>
<p>The first key theory is <a href="http://science.sciencemag.org/content/330/6004/611">based on epigenentics</a>: that life events affect how genes function and are passed on to the next generation. </p>
<p>Labor and birth exert a positive form of stress on the fetus, which impacts on the genes responsible for fighting off bugs, weight regulation and suppressing tumours. <a href="https://www.ncbi.nlm.nih.gov/pubmed/23414680?dopt=Abstract">Too little stress</a> (no labour and elective caesarean section) or too much stress (induced/augmented labour and instrumental birth) could impact the expression of these genes.</p>
<p>The second key theory is the <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-015-0768-9">extended hygiene hypothesis</a>. This suggests that vaginal birth provides an <a href="https://www.theguardian.com/lifeandstyle/2017/nov/06/microbiome-gut-health-digestive-system-genes-happiness">important opportunity</a> to pass gut bacteria from mother to baby to produce a healthy microbiome and protect us from illness. </p>
<p>If we have an unhealthy microbiome, we may be more vulnerable to infections, allergies, diabetes and obesity.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gut-instinct-how-the-way-youre-born-and-fed-affect-your-immune-system-65104">Gut instinct: how the way you're born and fed affect your immune system</a>
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<h2>How to reduce unnecessary birth intervention</h2>
<p>Recently released <a href="http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf">guidelines from the World Health Organisation</a> (WHO) recommend ways to reduce unnecessary intervention by encouraging evidence-based clinical care. Among the recommendations are three that can be applied in Australia:</p>
<ol>
<li><p>Women should have continuity of care, where they see the <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003766.pub6/full">same health practitioner</a> throughout pregnancy, during the birth, and in the postnatal period. This reduces the risk of unnecessary interventions.</p></li>
<li><p>Don’t intervene too early. Women progress much slower in labour than we previously thought. For 70 years, clinicians believed the cervix should dilate by 1 cm per hour. If the cervix was slower to dilate, intervention was initiated because labour was thought to have slowed. We now know labour progresses <a href="https://www.ncbi.nlm.nih.gov/pubmed/28892266">more slowly</a>.</p></li>
<li><p>Don’t use <a href="http://www.cochrane.org/CD006066/PREG_continuous-cardiotocography-ctg-form-electronic-fetal-monitoring-efm-fetal-assessment-during-labour">continuous electronic monitoring (CTG)</a> to monitor the baby, unless there are significant risk factors. Instead, listen in regularly with a small, hand-held monitor. Continuous monitoring increases intervention rates for low-risk women and healthy babies without improving outcomes for babies.</p></li>
</ol>
<p>Introducing a more evidence-based approach to care during labour and birth can increase the rates of spontaneous vaginal birth and reduce unnecessary intervention.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Child birth guidelines should be evidence based to avoid unnecessary intervention.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-infant-baby-feeding-mother-breast-1052320577?src=A1-WJ7SzoEV51-j7osNcYg-1-22">GOLFX/Shutterstock</a></span>
</figcaption>
</figure>
<h2>When intervention is necessary</h2>
<p>A certain level of intervention during childbirth improves outcomes for women and babies. But the <a href="http://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf?sequence=1">World Health Organisation recommends</a> the caesarean rate should be under 15%. </p>
<p>Babies may need to be induced when they are small and not growing well, or if they are overdue (beyond 41-42 weeks). </p>
<p>Caesareans may be necessary before labour even starts, such as when the placenta is lying across the cervix (placenta praevia), or when labour is in progress, if the baby gets distressed.</p>
<p>If you need to have your labour induced or augmented, or require an instrumental birth or a caesarean section due to complications, there are some things to help modify the long-term effect on your child. Seek uninterrupted <a href="https://www.ncbi.nlm.nih.gov/pubmed/24720501">skin-to-skin</a> contact after the birth and <a href="http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/">exclusively breastfeed</a>, if you can. </p>
<p>It is important for women and their partners to have all the information about both short- and long-term effects of intervention to make truly informed decisions about care during pregnancy and birth.</p><img src="https://counter.theconversation.com/content/93426/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. She is affiliated with the Australian College of Midwives</span></em></p><p class="fine-print"><em><span>Lilian Peters does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Our study found babies born via medical or surgical intervention were at increased risk of health problems, from jaundice and feeding issues, to diabetes, respiratory infections and eczema.Hannah Dahlen, Professor of Midwifery, Western Sydney UniversityLilian Peters, Post Doctoral Research Fellow, Vrije Universiteit AmsterdamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/842812018-03-14T18:57:05Z2018-03-14T18:57:05ZWhat to do when the baby is born before you get to hospital<figure><img src="https://images.theconversation.com/files/197479/original/file-20171204-5399-1nf3v92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The most important thing is to keep the baby warm – put her on your chest covered with a warm towel.</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Women often express a fear of giving birth en route to the hospital, and these fears have some basis. <a href="https://www.youtube.com/watch?v=WXEZ6g2WLoM">Dramatic videos</a> do the rounds on social media of women giving birth to babies in cars, on their <a href="http://www.abc.net.au/local/stories/2013/02/20/3694162.htm">front lawn</a>, or as recently happened, <a href="http://www.dailymail.co.uk/news/article-5067703/Mom-gives-birth-car-keeps-driving-hospital.html">in the car alone</a> and then driving themselves to hospital.</p>
<p>In <a href="https://www.aihw.gov.au/getmedia/728e7dc2-ced6-47b7-addd-befc9d95af2d/aihw-per-91-inbrief.pdf.aspx?inline=true">Australia</a>, around four to five in 1,000 births are recorded as “other”, meaning the birth didn’t occur in hospital, in a birth centre, or as a planned home birth. The birth may occur in the woman’s home, en route to the hospital or in ambulances where a midwife or doctor is not in attendance. More babies are born as unplanned out of hospital births than as planned home births in Australia. We often refer to these births as “born before arrival”.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2Tpt1fJlnIA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Videos of women giving birth en route to hospital go viral.</span></figcaption>
</figure>
<p>Babies born before arrival are <a href="http://doi.org/10.1136/bmjopen-2017-019328">more likely to be premature</a> (12.5% compared to 7.3%), be smaller, and most likely be a second baby, and a girl (possibly because they are smaller).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/balancing-hope-and-fear-for-babies-born-at-24-weeks-gestation-1402">Balancing hope and fear for babies born at 24 weeks gestation</a>
</strong>
</em>
</p>
<hr>
<p>In a <a href="http://doi.org/10.1136/bmjopen-2017-019328">new study</a> looking at ten years of births in NSW, we found women more likely to deliver early are women of low socioeconomic status, those living in rural or coastal areas and those living in areas with high rates of planned home birth.</p>
<p>This may be due to some women having poor levels of engagement with health services, or needing to drive big distances to get to hospital. Another factor to consider though is some of these births could be “<a href="https://www.ncbi.nlm.nih.gov/pubmed/22300611">freebirths</a>” – giving birth at home intentionally without a midwife or doctor.</p>
<p>While <a href="http://doi.org/10.1136/bmjopen-2017-019328">we showed</a> babies born unexpectedly before arrival have poorer outcomes, this is probably due mostly to prematurity which increases the risk for all babies. We also know babies born before arrival are more likely to be cold and this is even more likely to happen when they are small in size, such as when they’re premature.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/birthing-on-country-could-deliver-healthier-babies-and-communities-31180">Birthing on Country could deliver healthier babies and communities</a>
</strong>
</em>
</p>
<hr>
<h2>What to do if the baby is coming early</h2>
<ul>
<li><p>Call an ambulance and someone will be able to talk you through the birth until the ambulance arrives</p></li>
<li><p>Get down low and put a towel under you so the baby has a soft landing. Don’t sit on the toilet</p></li>
<li><p>If you have a heater put it on and get some towels on it or in the dryer to warm</p></li>
<li><p>As soon as the baby is born, put her straight on your chest and rub dry with a towel. Get whoever is there to put a second warm dry towel over the baby removing the now damp one. Your skin is the best way to warm a baby up</p></li>
<li><p>If the baby is not breathing try blowing in her face as the cold air can make her gasp and take a breath. If that doesn’t work rub the baby’s back up and down with the towel as this can stimulate her to breathe.</p></li>
<li><p>If the baby doesn’t respond to these initial steps you may need to <a href="http://raisingchildren.net.au/articles/pip_cpr_babies.html">resuscitate</a> her using <a href="https://www.youtube.com/watch?v=avYRvVHAvfM">CPR</a>, but this is rare</p></li>
<li><p>Keep the baby warm at all times and especially cover the head as this is where a lot of heat is lost</p></li>
<li><p>Do not cut the cord or attempt to tie it with string or shoelaces or anything else, just leave it attached to the baby</p></li>
<li><p>Do not pull on the cord and try to deliver the placenta as you may cause heavy bleeding or even pull the uterus out which is then a serious emergency</p></li>
<li><p>Try to stay warm and calm, and maintain skin-to-skin contact with your baby, as help will arrive soon.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/childbearing-hips-dont-make-the-difference-in-childbirth-15685">'Childbearing hips' don't make the difference in childbirth</a>
</strong>
</em>
</p>
<hr>
<p>Some other things to be aware of is that liquid (amniotic fluid) will come out as the baby is born. Be prepared – there will be some blood loss and up to a certain point this is a normal part of the process. Most importantly try not to panic – birth is a normal process.</p>
<p>It’s hard for women to always get the timing just right when making the decision to go to hospital or the birth centre, or to call the midwife for a home birth. </p>
<p>We know going to hospital too early will increase your chances of <a href="https://www.ncbi.nlm.nih.gov/pubmed/29054342">interventions</a> such as a synthetic oxytocin hormone to speed labour up, forceps or caesarean sections. These lead to more bleeding and pain for the mother, longer length of stay in hospital and a greater chance of the baby needing to be admitted to the neonatal intensive care unit. </p>
<p>Be aware if you had a reasonably quick first birth. Chances are it will be even quicker second time around.</p>
<p>It’s really important women don’t worry too much about this happening as the chances are small, and even if it does happen it usually turns out fine. Once the shock wears off, you have an entertaining birth story! </p>
<p>If you follow the steps above you can dramatically reduce the risk of problems for the baby.</p><img src="https://counter.theconversation.com/content/84281/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. She is affiliated with the Australian College of Midwives. </span></em></p><p class="fine-print"><em><span>Charlene Thornton receives funding from the NHMRC and NSW Health.</span></em></p>Women often express a fear of giving birth en route to the hospital, and these fears have some basis.Hannah Dahlen, Professor of Midwifery, Western Sydney UniversityCharlene Thornton, Post-doctoral Fellow in the School of Medicine, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/815632017-08-15T02:03:04Z2017-08-15T02:03:04ZWhat the baby bonus boost looks like across ten years<p>The baby bonus did its job, encouraging people to have more children at a time when fertility rates were low, our research finds. <a href="https://theconversation.com/australians-want-more-children-than-they-have-so-are-we-in-the-midst-of-a-demographic-crisis-81547">Given Australian men and women desire 1.5 more children than they actually have</a>, it might be time to consider policies like this again.</p>
<p>Fertility rates have fallen from 2.02 babies per woman in 2008 to 1.81 in 2015. At the same time, mortality rates have declined. All this means the proportion of people in Australia who are of working age is decreasing.</p>
<p>Since 1976, the average number of babies born to a woman throughout her reproductive lifetime in Australia hasn’t been enough to maintain current population. In 2001 the total fertility rate sank to 1.74 and in July that year the first child tax refund was introduced. </p>
<p>This initial policy was considered ineffective and in May 2004 the Australian government announced a new maternity payment, a universal cash payment - later known as the baby bonus, offering parents A$3,000 on the birth of a child. </p>
<p><a href="http://www.formerministers.dss.gov.au/13064/baby-bonus-changes-pass-the-house/">This amount was subsequently increased</a> in July 2006 and July 2008 to A$4,000 and A$5,000 respectively. However, the payment was eventually reduced to A$3,000 for a second or more birth July 2013 and finally, it was removed altogether in 2014.</p>
<p>Although the baby bonus was not explicitly a policy to encourage people to have kids, the introduction of the policy was accompanied by the often quoted rhetoric by then Treasurer, Peter Costello:</p>
<blockquote>
<p>One for mum, one for dad and one for the country.</p>
</blockquote>
<p>The payment seemed to affirm that Australian society valued children and bigger families and that there was a need to reduce the financial barriers for those wanting to start or expand their family. </p>
<p>Using data on all Victorian births from 1983 to 2014, our study considered whether the baby bonus has had a sustained effect on the fertility rate over the policy’s 10 year history. We attempted to disentangle the effects of the policy from the impact of other economic influences and underlying demographic trends on fertility.</p>
<p>Other research has identified <a href="https://pdfs.semanticscholar.org/ee92/6f71ddb7d8d6b7030041f009815e7a24694c.pdf">short term timing effects on births</a> from the policy and moderate increases in <a href="http://catalogue.nla.gov.au/Record/4807124">childbearing intentions</a> as a result of its introduction. But we found a significant increase in birth rates commencing ten months following the announcement of the baby bonus. And this increase appears to be sustained over the policy’s lifetime.</p>
<p>We conservatively estimate 24,000 additional births were associated with the baby bonus policy. Acknowledging that economic conditions can affect families’ decision to have children, we controlled for fluctuations in labour market conditions and economic expectations. We also analysed whether there was any differences in our results by age or the number of children the parents already had.</p>
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<p>We found young women in particular increased the number of children they had relative to the prevailing trends of their age groups in number of children. This showed us that the fertility increase wasn’t based solely on older women’s decision to make up for lost time and have the children they had previously delayed having. </p>
<iframe src="https://datawrapper.dwcdn.net/QUypd/1/" scrolling="no" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="347"></iframe>
<p>The increase in the rates of women having more than one child also suggests the policy encouraged families to expand. Our result accounts for a change in the timing of women having children as we measure only sustained increases in births which were not matched by a corresponding decline in later years.</p>
<p>It’s not surprising that people respond to incentives, even for the highly personal decision of when to start a family and the size of that family. What is surprising is the strength of the response of women having children as a result of the study, relative to the lifetime costs of child, including housing.</p>
<p><a href="https://aifs.gov.au/publications/fertility-and-family-policy-australia/5-australian-government-family-policies">The reasons this policy</a> gained traction with the public was due to it being simple, transparent, and not based on the working circumstances of parents. This simplicity, coupled with publicity on the policies introduction meant parents knew exactly what they were entitled to without complex calculations. </p>
<p>The baby bonus, by boosting fertility rates, will in turn affect long term population structures. However, the cost of the policy is another story.</p><img src="https://counter.theconversation.com/content/81563/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The baby bonus did its job, encouraging people to have more children at a time when fertility rates were low.Sarah Sinclair, Lecturer in Economics, RMIT UniversityAshton De Silva, Associate Professor of Economics, RMIT UniversityJonathan Boymal, Associate Professor of Economics, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/800742017-06-28T20:10:33Z2017-06-28T20:10:33ZBeing South Asian is as great a risk factor for stillbirth as smoking<figure><img src="https://images.theconversation.com/files/175794/original/file-20170627-21898-6yffki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need to change the way we monitor the pregnancies of women born in South Asia to reduce their chance of a stillbirth.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/456672769?src=ODysdIv-g4OJeDuPHMDNkA-1-30&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Australian women born in South Asia are more likely to have a stillbirth than other women, perhaps due to a rapidly ageing placenta that cannot support the pregnancy, new research suggests.</p>
<p>Our <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5460852/">study</a> looked at 700,000 births in Victoria over more than a decade. We found women born in India, Pakistan, Sri Lanka, Afghanistan and Bangladesh had a 1.5 increased chance of a stillbirth at the end of their pregnancy (known as a “term stillbirth”) compared with women born in Australia or New Zealand.</p>
<p>That’s equivalent to 2.6 term stillbirths per 1,000 births for South Asian-born women compared with 1.5 per 1,000 births to women born in Australia and New Zealand.</p>
<p>This is an increased risk equivalent to <a href="http://www.sciencedirect.com/science/article/pii/S0140673610622337">smoking, advanced maternal age or obesity</a>.</p>
<p>The risk of a term stillbirth increased earlier in pregnancy and rose more rapidly in women born in South Asia. Alarmingly, for South Asian-born women, the rate of stillbirths at 39 weeks’ gestation was almost equivalent to the rate in Australian- and New Zealand-born women at 41 weeks (when the chance of stillbirth would be higher than earlier in the pregnancy).</p>
<p>While other research has found the mother’s ethnicity places a role in the risk of a stillbirth, this has largely been put down to factors related to <a href="http://www.sciencedirect.com/science/article/pii/S014067361501020X">migration and social disadvantage</a>. What our research shows is women born in South Asia and giving birth in Australia are at increased risk even when other factors are taken into account.</p>
<p>This means we need to rethink how we monitor and manage the pregnancies of women born in South Asia, including redefining when some babies reach “term”.</p>
<h2>Why this matters</h2>
<p>About <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129557657">seven per 1,000</a> babies born each year in Australia are stillborn – when the fetus dies at or after 20 weeks’ gestation – a figure that has remained unchanged over the past two decades.</p>
<hr>
<p><em>Further reading: <a href="https://theconversation.com/reducing-the-heartbreak-and-burden-of-stillbirth-1983">Reducing the heartbreak and burden of stillbirth</a></em></p>
<hr>
<p>Advanced maternal age, maternal infections, non-communicable diseases (like pre-existing diabetes and high blood pressure), obesity and a prolonged pregnancy are known <a href="http://www.sciencedirect.com/science/article/pii/S014067361501020X">risk factors</a> for stillbirth globally.</p>
<p>Not only can a woman’s country of birth now be added to the list, our research suggests how we look after pregnant women of South Asian origin needs to change.</p>
<p>In another recent <a href="https://www.nature.com/jp/journal/v37/n2/full/jp2016190a.html">study</a>, we found that at 41 weeks’ pregnancy, South Asian-born women experienced rates of fetal distress at almost four times the rate of Australian- and New Zealand-born mothers. </p>
<p>Current <a href="https://www.ranzcog.edu.au/Statements-Guidelines">national</a> and <a href="https://pathways.nice.org.uk/pathways/antenatal-care-for-uncomplicated-pregnancies#content=view-node%3Anodes-pregnancy-after-41-weeks">international</a> guidelines recommend additional fetal monitoring and/or induction of labour for pregnancies that progress beyond 41 weeks due to the increased risks of stillbirth. </p>
<p>But for South Asian-born women this may be too late.</p>
<h2>Why might this be happening?</h2>
<p>There is growing evidence to suggest a mother’s ethnicity influences how fast her <a href="https://theconversation.com/explainer-what-is-placenta-28851?sr=2">placenta</a> ages as her pregnancy progresses.</p>
<p>For some women, they can go into spontaneous labour sooner. In our study, we found South Asian-born women went into labour a median one week earlier than Australian- or New Zealand-born women.</p>
<p>However, for others, an ageing placenta <a href="https://www.ncbi.nlm.nih.gov/pubmed/23452441">cannot meet</a> the fetus’ increasing metabolic needs at term and beyond. And this increases the risk of stillbirth.</p>
<p>We still don’t know which individual woman will go down which path.</p>
<h2>Can we spot ageing placentas?</h2>
<p>Biological markers – caps on the ends of chromosomes or “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370421/">telomeres</a>” – can help us assess ageing. Each time a cell replicates, the caps on the chromosomes get shorter. So shorter telomeres are a sign of <a href="http://onlinelibrary.wiley.com/doi/10.1016/j.febslet.2004.11.036/full">more rapid cellular ageing</a>.</p>
<p>And the length of telomeres in placentas from pregnancies ending in stillbirth are <a href="http://www.tandfonline.com/doi/full/10.3109/14767058.2015.1046045">two times shorter</a> than those from live births. In other words, the placental cells had aged faster.</p>
<p>Some researchers have also studied ethnic differences in placental telomere length.</p>
<p>In an <a href="https://www.ncbi.nlm.nih.gov/pubmed/27865975">American study</a>, placental telomeres from pregnancies in black women were significantly shorter than from pregnancies in white women (the ethnic backgrounds of the women were not further defined in the study).</p>
<p>Whether telomeres are shorter in placentas from pregnancies in South Asian-born women is unknown. </p>
<h2>Does this matter?</h2>
<p>We don’t know the cause for up to <a href="http://www.aihw.gov.au/publication-detail/?id=60129557656&tab=3">one-quarter</a> of all stillbirths in Australia. So, better understanding the role of placental ageing may help.</p>
<p>Our research is also relevant as migration from South Asian countries to Australia is <a href="https://www.border.gov.au/ReportsandPublications/Documents/statistics/migration-trends-14-15-glance.pdf">growing</a>. Almost <a href="https://www.border.gov.au/ReportsandPublications/Documents/statistics/2015-16-migration-programme-report.pdf">one-third</a> of people migrating to Australia are from South Asian countries. So, the number of women giving birth in Australia from these countries is also increasing. Now, Indian mothers make up <a href="http://www.aihw.gov.au/publication-detail/?id=60129557656&tab=3">almost 4%</a> (roughly 12,000) of all women giving birth in Australia a year.</p>
<p>It’s time this was reflected in how we manage the pregnancies of women born in South Asia, particularly at the end of their pregnancies. We may have to more closely monitor their pregnancies and, if needed, recommend their labour be induced sooner than other women to reduce their chance of a stillbirth.</p><img src="https://counter.theconversation.com/content/80074/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Miranda Davies-Tuck receives funding from the NHMRC, Stillbirth Foundation and Red Nose Foundation She also has a secondment 1 day per week to Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) at the Victorian Department of Health.</span></em></p><p class="fine-print"><em><span>Euan Wallace receives funding from from the Victorian Government Operational Infrastructure Support Program and is a CEO of Safer Care Victoria, Department of Health.</span></em></p><p class="fine-print"><em><span>Mary-Ann Davey is a part-time employee of the Clinical Councils Unit, which manages the Victorian Perinatal Data Collection data.</span></em></p>Women born in South Asian countries like India or Pakistan are more likely to have a stillbirth than women born in Australia or New Zealand.Miranda Davies-Tuck, Perinatal Epidemiologist and NHMRC Early Career Research Fellow, Hudson InstituteEuan Wallace, Chair professor, Hudson InstituteMary-Ann Davey, Senior Research Fellow, Obstetrics & Gynaecology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/651042016-10-12T19:07:26Z2016-10-12T19:07:26ZGut instinct: how the way you’re born and fed affect your immune system<figure><img src="https://images.theconversation.com/files/141364/original/image-20161012-8389-1534mob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The mode of delivery has a big impact on an infant's microbiota, the bacteria that live in the gut.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-50320798/stock-photo-baby-being-born-via-caesarean-section-coming-out.html?src=AnCMrsfQ0twnnPp1S4TOMA-1-4">Martin Valigursky/Shutterstock</a></span></figcaption></figure><p><em>Our gut does more than help us digest food; the bacteria that call our intestines home have been implicated in everything from our mental health and sleep, to weight gain and cravings for certain foods. <a href="https://theconversation.com/au/topics/gut-series-32096">This series</a> examines how far the science has come and whether there’s anything we can do to improve the health of our gut.</em></p>
<hr>
<p>We used to think foetuses had <a href="http://jn.nutrition.org/content/138/9/1791S.full">no</a> bacteria in their gastrointestinal tract (the gut) until they began to accumulate microbes (bacteria, viruses and other bugs) on their way through their mother’s vagina. </p>
<p>But this theory was challenged when bacteria <a href="http://www.ncbi.nlm.nih.gov/pubmed/19783002">was found</a> in meconium (the first poo) of premature babies. This, of course, travelled through the gut, accumulating microbes on the way. </p>
<p>What’s clear is that newborns have little (if any) diversity in their microbiota – the collection of bacteria that accumulate in the gut. This increases as they’re exposed to different environments. </p>
<p>The particular makeup of a newborn’s gut microbes is important as it has been shown to affect their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983973/">risk of developing certain diseases</a> in childhood and adulthood. </p>
<h2>Vaginal or caesarean birth?</h2>
<p>The mode of delivery has a big impact on an infant’s microbiota. During natural delivery, the direct contact with the mother’s vaginal and intestinal flora <a href="http://www.ncbi.nlm.nih.gov/pubmed/18716189">help shape a newborn’s gut bacteria</a> colonisation. Newborns delivered via caesarean section don’t have this direct contact.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/YB-8JEo_0bI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">What is the human microbiome?</span></figcaption>
</figure>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/20566857">One study</a> found that newborns born vaginally were colonised by <em>Lactobacillus</em> whereas caesarean delivery newborns were colonised by a mixture of bacteria typically found on the skin and in hospitals, such as <em>Staphylococcus</em> and <em>Acinetobacter</em>. </p>
<p>These early differences tend to be sustained. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9890463">One study showed</a> the distinct gut flora of infants born by caesarean delivery persisted at six months after birth. Faecal <em>Clostridia</em> numbers in seven-year-old children born vaginally were <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774211/">found to be significantly higher</a> than in children of the same age born via caesarean. </p>
<p>But we still don’t know how this impacts on children’s health and the risk of disease. </p>
<h2>The developing immune system</h2>
<p>We’re beginning to realise gut bacteria plays an important role in the growth of infants’ immune systems. One way this could occur is by <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4829075/">altering the development</a> of the white blood cells that provide a first-line defence against invading microbes: bugs that make us sick. </p>
<p>Research shows <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4144825">mice born in a germ-free environment</a> have fewer of these white blood cells compared to healthy mice with a normal gut bacteria population. Such mice are also more prone to bacterial infection. </p>
<p>Allergic diseases such as asthma and hay fever <a href="http://www.ncbi.nlm.nih.gov/pubmed/16297144">appear more often</a> in infants after caesarean delivery than after vaginal delivery. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/141366/original/image-20161012-8430-16k2o6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/141366/original/image-20161012-8430-16k2o6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/141366/original/image-20161012-8430-16k2o6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/141366/original/image-20161012-8430-16k2o6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/141366/original/image-20161012-8430-16k2o6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/141366/original/image-20161012-8430-16k2o6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/141366/original/image-20161012-8430-16k2o6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children who weren’t breast-fed are at higher risk of asthma.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-458352256/stock-photo-asthma-treatment-child.html?src=z56JbZJnuStNpDU6ibtKkQ-1-4">kritsada doungdao/Shutterstock</a></span>
</figcaption>
</figure>
<p>Children born by caesarean delivery are also significantly more likely to be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4847338/">hospitalised for acute gastroenteritis</a> and to develop <a href="http://www.ncbi.nlm.nih.gov/pubmed/20478942">coeliac disease</a>.</p>
<p>It’s important to note that not all caesarean deliveries are the same. Some women have caesarean sections after a long labour where her waters have broken. In this case, the infant would be exposed to quite a different microbial environment than a planned caesarean section carried out before her waters have broken. </p>
<h2>Breast- or bottle-fed?</h2>
<p>Breast-fed newborns <a href="http://www.ncbi.nlm.nih.gov/pubmed/21497661">have</a> a distinctly different gut microbiome to other newborns. They have higher proportions of the beneficial bacterial species <em>Bifidiobacterium</em> than <a href="https://www.ncbi.nlm.nih.gov/pubmed/10630441">formula-fed infants</a>. This is likely due to breast milk containing a type of prebiotic that facilitates the growth of bacteria such as as <a href="https://www.ncbi.nlm.nih.gov/pubmed/15220665"><em>Bifidobacterium</em></a>.</p>
<p>Interestingly, when breast-fed infants are supplemented with formula feeds, their gut microbiota <a href="https://www.ncbi.nlm.nih.gov/pubmed/26752321">resembles infants</a> who are exclusively formula-fed. </p>
<p>What does this mean for infants’ risk of developing disease?</p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3446306">US study</a> has shown that breast-fed babies had a gut microbiome that was richer in genes associated with “virulence”: the ability to fight off antibiotics and toxic compounds. These same babies also developed changes in the genes of their gut immune system that allowed them to better fight off infection. </p>
<p>This suggests that breast milk can promote a healthy crosstalk between the baby’s immune system and the gut microbiome. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/141365/original/image-20161012-8401-h0uaai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/141365/original/image-20161012-8401-h0uaai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/141365/original/image-20161012-8401-h0uaai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/141365/original/image-20161012-8401-h0uaai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/141365/original/image-20161012-8401-h0uaai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/141365/original/image-20161012-8401-h0uaai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/141365/original/image-20161012-8401-h0uaai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Breast-fed newborns have a distinctly different gut microbiome to other newborns.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-454381816/stock-photo-mother-breastfeeding-her-newborn-baby-girl-during-the-lunch-breastfeeding-on-demand-instagram-style-effect-applied.html?src=9MyTFDAc6WF3vRQ-HIWEfw-1-4">DeymosHR/Shutterstock</a></span>
</figcaption>
</figure>
<p>Breast-feeding has been shown to reduce the development of <a href="http://www.ncbi.nlm.nih.gov/pubmed/10232646">necrotising enterocolitis</a> (where parts of the bowel die off) in newborns, allergic and autoimmune diseases in childhood, including <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2083075/">coeliac disease</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22189253">type 1 diabetes</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24727807">asthma</a>. </p>
<h2>Vaginal seeding</h2>
<p>What if your child is born via a caesarean section and can’t be breastfed? </p>
<p>Don’t worry, not all such infants will be at a greater risk of developing autoimmune and allergic diseases. A whole host of environmental and genetic factors play a role in determining individual risk. </p>
<p><a href="https://theconversation.com/explainer-what-is-vaginal-seeding-55187">Vaginal seeding</a> has recently been proposed as one way infants born by caesarean section might gain some of the protective effects of environmental exposure for their gut microbiota. </p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/26828196">proof-of-concept study</a> in 18 infants published earlier this year showed that transferring vaginal fluid to newborns (via a swab across their mouth, nose and face) shortly after delivery by caesarean section can result in microbiome profiles resembling that of infants delivered vaginally. </p>
<p>It is unknown though whether colonisation in this way is partially or fully equivalent to the microbial transfer at labour. We also don’t know whether later health outcomes in these infants are affected by the practice. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/26906151">Some expert clinicians</a> warn against vaginal seeding because of the potential for unrecognised infections to be transmitted from mother to newborn. There is <a href="http://www.ncbi.nlm.nih.gov/pubmed/27236858">a risk</a>, for example, of transmitting undiagnosed group B <em>Streptococcus</em> to newborns, given <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/streptococcal-infection-group-b">12 to 15% of women</a> have this organism in vaginal fluid. </p>
<h2>Better ways to catch up</h2>
<p>For now, it’s more sensible to focus on the practices that <a href="http://www.utswmedicine.org/stories/articles/year-2016/c-section-microbiome.html">have been shown to</a> promote microbiome development in newborns delivered by caesarean. These include delaying the first bath until after 12 hours, placing the newborn on the mother’s skin in the first few minutes after delivery and breastfeeding in the operating room, if permissible. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/141367/original/image-20161012-8385-4zuokl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/141367/original/image-20161012-8385-4zuokl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/141367/original/image-20161012-8385-4zuokl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/141367/original/image-20161012-8385-4zuokl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/141367/original/image-20161012-8385-4zuokl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/141367/original/image-20161012-8385-4zuokl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/141367/original/image-20161012-8385-4zuokl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Skin-to-skin contact after birth is important for the development of the infant’s microbiota.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-99349961/stock-photo-newborn-baby-on-his-mothers-arms-right-after-delivery.html?src=pp-same_model-99349967-1&ws=1">Kati Molin/Shutterstock</a></span>
</figcaption>
</figure>
<p>There has been much effort made in simulating the composition of human milk through adding live gut bacteria (probiotics) as well as non-digestible fibres (prebiotics) <a href="http://www.ncbi.nlm.nih.gov/pubmed/19840609">to formula</a>. This is <a href="http://www.ncbi.nlm.nih.gov/pubmed/19770768">thought to assist</a> microbial colonisation and immune responses in formula-fed infants in a similar way to breast feeding.</p>
<p>But hard data is lacking though on whether this approach can lead to a real-life benefit, particularly when it comes to reducing the risk of allergic disorders. </p>
<p>Fortunately, a large clinical research project in New Zealand – the <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0923-y">Probiotics in Pregnancy study</a> – will soon be able to answer this question. </p>
<p>Four hundred pregnant women expecting infants at high risk of allergic disease were given either a probiotic <em>Lactobacillus rhamnosus</em> or placebo – 14 to 16 weeks into their pregnancy until they gave birth, or for six months after if they breast-fed.</p>
<p>The researchers will then check if the infant develops allergies such as eczema. The results will be available before too long and may be instrumental in helping to shape health policy. </p>
<hr>
<p><em>Read the other articles in our Gut series <a href="https://theconversation.com/au/topics/gut-series-32096">here</a>.</em></p><img src="https://counter.theconversation.com/content/65104/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vincent Ho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The particular makeup of a newborn’s gut microbes is important as it has been shown to affect their risk of developing certain diseases later in childhood and adulthood.Vincent Ho, Senior Lecturer and clinical academic gastroenterologist, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/651052016-10-10T19:03:11Z2016-10-10T19:03:11ZHealthy guts are swarming with bugs, so what do they do?<figure><img src="https://images.theconversation.com/files/141053/original/image-20161010-2596-xi09el.png?ixlib=rb-1.1.0&rect=0%2C0%2C1920%2C948&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The exact composition of each person’s microbiota is as unique as their finger prints.</span> <span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p><em>Our gut does more than help us digest food; the bacteria that call our intestines home have been implicated in everything from our mental health and sleep, to weight gain and cravings for certain foods. <a href="https://theconversation.com/au/topics/gut-series-32096">This series</a> examines how far the science has come and whether there’s anything we can do to improve the health of our gut.</em> </p>
<hr>
<p>The healthy human body is swarming with microorganisms. They inhabit every nook and cranny on the surfaces of our body. But by far the largest collection of microorganisms reside in our gastrointestinal tract – our gut. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/YB-8JEo_0bI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">What is the human microbiome?</span></figcaption>
</figure>
<p>These tiny organisms, which can only be seen with the aid of a microscope, make up our microbiota. The combination of microbiota, the products it makes, and the environment it lives within, is called the microbiome. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=580&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=580&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=580&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=729&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=729&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140404/original/image-20161005-14595-l7eper.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=729&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The gastrointestinal tract.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-376886146/stock-vector-human-digestive-system-digestive-tract-or-alimentary-canal-including-text-labels.html?src=SI78-VNDcYwFNyofukksYg-2-56">Christos Georghiou/Shutterstock</a></span>
</figcaption>
</figure>
<p>Great advances in DNA sequencing technologies have enabled us to study the gut microbiota in intricate detail. We can now take a census of all the microorganisms that are in the microbiota to help us understand what they are doing.</p>
<p>Typically, our gut microbiota consists of several thousand different types of bacteria, as well as other microbes such as viruses and yeasts. Some types will be in abundance, while other types will be rare. </p>
<p>The exact composition of each person’s microbiota is as unique as their finger prints. But unlike finger prints, the microbiota is constantly changing. </p>
<p>Microbes start to colonise our gut and skin the moment we are born. The mode of birth, either natural or by caesarean, determines the sort of microbes a baby first contacts. This <a href="https://www.ncbi.nlm.nih.gov/pubmed/9890463">can have a profound effect</a> on the early development of the microbial populations that contribute to the microbiota.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140244/original/image-20161004-20217-17lzg3f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140244/original/image-20161004-20217-17lzg3f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140244/original/image-20161004-20217-17lzg3f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140244/original/image-20161004-20217-17lzg3f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140244/original/image-20161004-20217-17lzg3f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140244/original/image-20161004-20217-17lzg3f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140244/original/image-20161004-20217-17lzg3f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tiny organisms begin to colonise the gut as soon as we’re born.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-331803158/stock-photo-midwife-holding-up-a-vernix-covered-newborn-just-after-he-was-born-in-the-delivery-room-being-peaceful-and-serene-still-attached-with-umbilical-cord-new-life-birth-experience-concept.html?src=Y3HY1QGSQzFTIgypgjbqHw-1-9">zlikovec/Shutterstock</a></span>
</figcaption>
</figure>
<p>The structure of the microbiota – that is, what microbes are present and the relative numbers of each type – undergoes significant change from its establishment at birth until it matures in early adolescence. </p>
<p>In healthy adults, changes over time are likely to be small. But major shifts in composition can occur when we radically change our diet or take antibiotics, which are, of course, designed to kill bacteria. </p>
<p>It’s also been found that, like our own body, the composition of our microbiota <a href="https://www.ncbi.nlm.nih.gov/pubmed/26785481">changes in old age</a>, including a loss of diversity. </p>
<p>Our microbiota is not an accidental, free-loading passenger living in our gut and stealing the nutrients from our food. Over the millennia we have evolved with our microbiota. We now know it can affect many aspects of our biology, from our digestive system to our brain function.</p>
<p>How our bodies develop and function is dictated by our genes. We have <a href="https://www.ncbi.nlm.nih.gov/pubmed/24939910">approximately 20,000 genes encoded</a> in our genetic material.</p>
<p>The different microbes that make up our microbiota have their own genes. As a rough estimate, the 2,000 different types of microbes may, on average, each carry 3,000 genes. That means the microbiota carries six million genes. Although many will have similar functions, it still indicates the microbiota has a much more complex =genetic complement= than we ourselves have. </p>
<p>This genetic complement of the microbiota means it can do things other parts of the body cannot. Our microbiota provides digestive enzymes to allow us to use food that otherwise we could not digest. It provides essential vitamins we cannot make ourselves. And it interacts with our hormonal and neural systems to help shape our physiology. </p>
<p>Perhaps most important of all, it helps to develop our immune system to fight off bugs. The body must be able to distinguish between the beneficial members of the healthy microbiota and invading pathogenic microorganisms that can cause disease. The immune system has to learn to live with and nurture the microbiota while fighting off pathogens. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140247/original/image-20161004-20217-d06tr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140247/original/image-20161004-20217-d06tr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140247/original/image-20161004-20217-d06tr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140247/original/image-20161004-20217-d06tr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140247/original/image-20161004-20217-d06tr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140247/original/image-20161004-20217-d06tr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140247/original/image-20161004-20217-d06tr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Microbiota help develop our immune system.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-342967553/stock-photo-morning-therapy-ill-man-with-two-pills-and-a-glass-of-water.html?src=ioJ_v07F2hpasoa8GwWa1Q-2-48">kikovic/Shutterstock</a></span>
</figcaption>
</figure>
<p>Disruption of the correct interaction between microbiota and the immune system may be one of the causes of the massive increase over the past few decades in immune-related diseases, such as diabetes, food allergies, rheumatoid arthritis, and inflammatory bowel disease. </p>
<p>Many of these diseases seem to be diseases of affluence, probably influenced by <a href="https://www.ncbi.nlm.nih.gov/pubmed/27617196">poor diets</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/27471720">excessive cleanliness</a>, affecting the early establishment of an appropriate microbiota.</p>
<p>The intimate connection between host and microbiota and the rich contribution that each brings to the partnership has resulted in the concept of a metaorganism. This recognises that as humans, we are really the product of the mutual cooperation between our own bodies and our microbiota. </p>
<p>Indeed, our microbiota is so important and has such specific functions that it’s reasonable to view it as another organ of our body. It’s just as important as our liver or kidneys.</p>
<hr>
<p><em>Read the other articles in our Gut series <a href="https://theconversation.com/au/topics/gut-series-32096">here</a>.</em></p><img src="https://counter.theconversation.com/content/65105/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Moore receives funding from the Poultry Cooperative Research Centre and the Australian Research Council. </span></em></p>The make-up of our gut is constantly changing and affects everything from our immune system and digestion, to our brain function.Robert Moore, Research Professor of Biotechnology, Head of Host-Microbe Interactions Laboratory, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/641002016-10-05T10:02:04Z2016-10-05T10:02:04ZIn parts of the world, bride price encourages parents to educate daughters<figure><img src="https://images.theconversation.com/files/140136/original/image-20161003-30459-xt0es3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cultural norms play an important role in determining whether girls will be send to schools.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/gpforeducation/16269000296/in/photolist-qMCSZ7-hHceBu-hyzfeF-dYf4Xn-88N6Bf-pmjdMD-dYzh66-94cN1F-p4P4b2-nubvJM-94fTKA-94fTRC-qxxtjM-ns8pse-i2kAZA-eaSYhN-qxxtWD-8xGceg-hGQ7od-8v7LvR-i2kHus-sE7w44-i2kS5d-hQipig-hLcQA7-nAhiGa-hLcv3w-hLcQLY-i2kBkq-hGQ7dd-6SYWDG-o9GsFa-i2mozk-i2kH7U-9qUBFR-hLcxSQ-hHcKqW-94fTpS-94cN7M-hHbNjK-eaMeCk-dYL2gK-3A8K99-94fSwu-hHd76x-pSY1Nm-94fT9h-dM8V2A-94cNfF-hHd774">Global Partnership for Education - GPE </a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Education is one of the engines of economic growth and development. More education leads to higher incomes. For individuals living in low-income countries, an additional year of education increases wages by <a href="https://www.aeaweb.org/articles?id=10.1257/aer.91.4.795">7-11 percent</a>. </p>
<p>And the benefits to education are not restricted to wages: better educated women are more likely to have <a href="http://repository.upenn.edu/cgi/viewcontent.cgi?article=1006&context=gcc_economic_returns">healthier</a>, <a href="https://www.hks.harvard.edu/fs/akhwaja/papers/WhatDidYouDoAllDay.pdf">better-educated</a> children. They are also <a href="http://unesdoc.unesco.org/images/0022/002259/225945e.pdf">less likely to die in child birth</a>.</p>
<p>As Hillary Clinton <a href="https://www.clintonfoundation.org/press-releases/no-ceilings-announces-charge-collaborative-harnessing-ambition-and-resources-girls">has said</a>, </p>
<blockquote>
<p>“When girls have access to quality education in both primary and secondary schools, cycles of poverty are broken, economies grow, glass ceilings crack and potential is unleashed.” </p>
</blockquote>
<p>Yet, primary and secondary school completion are far from universal in low income countries. This is especially true for women whose rates of primary school completion are as low as <a href="http://data.worldbank.org/indicator/SE.PRM.CMPT.FE.ZS?year_high_desc=false">30 percent in some sub-Saharan African countries</a>.</p>
<p>If education has such high returns, why isn’t educational attainment higher? </p>
<p>One possible answer is that parents often do not directly benefit from these returns. When making spending decisions, parents must think of their own old-age security as well. Parents may even worry that education will make children more likely to migrate, <a href="http://www.baylor.edu/content/services/document.php/192649.pdf">decreasing</a> the likelihood that their children care for them in their old age.</p>
<p>Cultural norms often play an important role in determining whether children are educated. Often such norms can make parents choose to educate boys over girls. However, my research suggests, culture can also play an important role in incentivizing parents to educate their girls.</p>
<h2>Here’s how:</h2>
<p>In my <a href="http://www.nber.org/papers/w22417?sy=417">paper</a> with researchers <a href="http://www.lse.ac.uk/economics/people/facultyPages/NavaAshraf.aspx">Nava Ashraf</a>,<a href="http://scholar.harvard.edu/nunn/home"> Nathan Nunn</a>, and <a href="https://sites.google.com/site/alevoena/">Alessandra Voena</a> –– a part of the National Bureau of Economic Research (NBER) working paper series –– I studied one such cultural norm: the effect of bride price in Zambia and Indonesia on girls’ education. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140138/original/image-20161003-20230-tu2k24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140138/original/image-20161003-20230-tu2k24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140138/original/image-20161003-20230-tu2k24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140138/original/image-20161003-20230-tu2k24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140138/original/image-20161003-20230-tu2k24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140138/original/image-20161003-20230-tu2k24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140138/original/image-20161003-20230-tu2k24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Bride price can help girls in some ways. A girl from Zambia.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/dfid/14704200941/in/photolist-opmSDT-o8aB5k-onBibs-opqS3C-pACEb4-o89tKz-o8aBqv-pyA8ss-d6dT8w-opmSr8-opD99c-o89tYk-pj8URJ-oZgsaX-d6dF71-pACCqv-oZhj5K-pgJzm3-d6dWL7-pgJDFf-cTSTGN-pgur4D-pyA5J1-d6dLG7-d6dRgQ-pAmpWk-d6dDQ9-d6dXXb-EukVE7-d6dMTQ-pwbxi-d6dBFL-BCQpWm-B7Cx8H-AHBYYL-scosUx-BF9yAX-oZhQDn-pgMWsZ-oZhKuz">DFID - UK Department for International Development</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Bride price is a custom whereby the groom pays the parents of the bride at the time of marriage. Many commentators think that bride price payments are an <a href="http://www.irinnews.org/report/59032/tanzania-study-links-payment-bride-price-abuse-women">abusive practice</a> since they believe these traditions are equivalent to buying and selling girls.</p>
<p>However, we find that bride price can benefit women as well.</p>
<p>In both Indonesia and Zambia, educated girls attract higher bride prices. For example, women who have completed primary schooling receive approximately 60 percent higher bride prices in Indonesia. </p>
<p>Indeed, females who belong to ethnic groups where traditional bride price amounts are larger are more likely to be enrolled in school than females who do not belong to these groups.</p>
<h2>What our studies show</h2>
<p>Moreover, we find that two large programs that built thousands of new primary schools in Indonesia and Zambia interact with bride price traditions in important ways. </p>
<p>In low income countries, <a href="http://econweb.ucsd.edu/%7Ekamurali/papers/Working%20Papers/Cycling%20to%20School%20(NBER%20WP%2019305).pdf">distance strongly affects school enrollment</a>, particularly for girls. School construction programs reduce the costs of attending school by building new schools that reduce the distance to schools.</p>
<p>We used census data to estimate the effect of these programs on female education by comparing growth in educational attainment for girls in districts where many schools were built to the growth in educational attainment for girls in districts where fewer schools were built. </p>
<p>We found that girls from ethnic groups with a strong bride price custom were more likely to respond to the school construction programs by enrolling in school.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140140/original/image-20161003-27269-aecpn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140140/original/image-20161003-27269-aecpn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140140/original/image-20161003-27269-aecpn3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140140/original/image-20161003-27269-aecpn3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140140/original/image-20161003-27269-aecpn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140140/original/image-20161003-27269-aecpn3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140140/original/image-20161003-27269-aecpn3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A girl taking a numeracy test at a primary school in Zambia.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/gpforeducation/28459097735/in/photolist-KmQjfT-KeU9Rn-KeU9HM-KmQiE4-s9teyX-s9TPh7-sodfxu-s2YFio-mC8MhY-6CwUkm-2WBkwX-8DJQeq-zkXo4-7gwM3Y-97AEYb-97xyrH-97xyKM-cVZ9xo-djT9dv-oMFC1d-9DZLJ-97xySF-mu8DZt-97AFtG-9DZCr-zkDsb-6K7LV9-97AFrG-87dFSA-uMWga2-6K3ELv-WnQ21-eDD2R2-97xyyR-2WBkwP-zkDs5-zkDrX-97xyJZ-xt1yUE-xt2rY3-5xAw98-97xyLX-97AFsG-D9Q7ap-97xyFK-HTb5CY-HTb5ns-CKVFR4-HTb5bf-zkZ1Z">Global Partnership for Education - GPE</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>In both countries, we found that education increased more for girls from ethnic groups with bride price customs in districts where more schools were built: In Indonesia, an additional school per 1,000 students increased the probability of a girl from an ethnic group with a traditionally high bride price completing primary school by 3 percent. In contrast, the school construction had no effect on education for girls who did not belong to ethnic groups with strong bride price traditions. </p>
<p>While 3 percent may seem small, the effect of an additional school per 1,000 students on girls’ education is enough to close 20 percent of the gap in primary school completion between boys and girls. Moreover, 3 percent is the effect on the average girl, and it likely masks larger effects for girls in areas with few schools and smaller effects for girls who lived near a school already. </p>
<p>In Zambia, we find that school construction had similar effects on school enrollment for girls from ethnic groups with strong bride price traditions. Again, for girls in the non-bride price ethnic groups, the effect is close to zero. </p>
<p>My <a href="http://scholar.harvard.edu/files/nbau/files/norms_policy_draft.pdf?m=1458321879">study of another custom</a> –– matrilocality, shows how other cultural norms can provide incentives to parents to invest in their daughters’ education. Matrilocality means that newly-weds stay with the parents of the bride after marriage and care for them in their old age. In such cases parents can benefit directly from their investments in their daughter’s education. </p>
<p>Indeed, I found that matrilocal ethnic groups in Indonesia are more likely to enroll daughters in school relative to sons when compared to non-matrilocal ethnic groups. On the flipside, I found that in patrilocal ethnic groups, where sons stay with their parents and care for them in their old age, boys are more likely to be enrolled in school relative to their female siblings.</p>
<h2>Unintended consequences</h2>
<p>But what happens when parents no longer rely on their children as much for old age support? </p>
<p>When parents have other ways of supporting themselves in their old age, they may invest less in their children’s education. <a href="http://scholar.harvard.edu/files/nbau/files/norms_policy_draft.pdf?m=1458321879">Studying</a> the introduction and expansion of two pension plans in Indonesia, I found that women who were young when the pension plans were put into effect, and who would traditionally be expected to care for their parents, received less education. </p>
<p>Women who were born after the pension plan was put into place and came from matrilocal ethnic groups were 13 percent less likely to complete secondary school. The effect was stronger in places where more pension plan offices, which likely enrolled more people, were built.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140147/original/image-20161003-20213-hfwak2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140147/original/image-20161003-20213-hfwak2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140147/original/image-20161003-20213-hfwak2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140147/original/image-20161003-20213-hfwak2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140147/original/image-20161003-20213-hfwak2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140147/original/image-20161003-20213-hfwak2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140147/original/image-20161003-20213-hfwak2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A junior high school in Ghana.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/eifl/27074126790/in/photolist-HfrYDu-4LK2yD-odJPuS-nQyxwF-7ZetsF-ogQ3fA-5mN1TL-7ZeuSt-pVgRU-myQ3L7-ggG9uS-myNmyM-b8dBPv-b8dBqH-myPQ8m-evmMjq-7LkN6F-4v1K1R-myQ1eJ-7XG6DB-pVgRT-myPhJt-myNDEZ-6aojhj-myPYdu-myNnYv-8Fr5Ge-82LndH-kghoE-785APS-myPiN2-myQsGd-52vqQM-myNKwk-5zWkHy-8Fr69k-7Zvc9J-myPZhd-kb5nYp-dDBzRD-myNKue-DX2VoY-787Swj-6n4qve-a5NAAE-784aZB-myNCoa-8jmv8X-49WVS-8cbtV4">EIFL</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Comparing patrilocal boys to non-patrilocal boys in Ghana, I found similar results. Patrilocal parents educated their sons less in response to the pension plan. A patrilocal boy born after the creation of the pension plan was 8 percent less likely to complete primary school. </p>
<p>So, the expansion of pension plans –– a well-intentioned policy –– had an unintended negative consequence. It reduced female education in Indonesia and male education in Ghana.</p>
<p>Parents’ expectations about old-age support may affect other decisions besides education. Research suggests that parents’ expectations that boys will support them in their old age may lead to son preference. This has already led to unbalanced sex-ratios in <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1728-4457.2010.00317.x/abstract">China</a>, as well as <a href="https://scholars.huji.ac.il/sites/default/files/avrahamebenstein/files/patrilocality_and_missing_women_april_2014.pdf">other countries</a>.</p>
<p>All this shows that culture matters. While bride price traditions may have other significant downsides, our findings suggest that bride price helps ensure that daughters are educated. </p>
<p>If we neglect the importance of culture, policies designed to increase female education and boost female welfare may be less effective than they could otherwise be. They may even have negative unintended consequences.</p><img src="https://counter.theconversation.com/content/64100/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natalie Bau receives funding from the Canadian Institute for Advanced Research and the International Growth Centre. </span></em></p>Here’s how cultural practices are playing a role in many countries in incentivizing parents to educate their girls.Natalie Bau, Assistant Professor of Economics, University of TorontoLicensed as Creative Commons – attribution, no derivatives.