Bacteria swabbing trend for newborns medically in doubt

By
February 29th, 2016

‘re getting ready to give birth. Should the mother get an epidural? Is saving umbilical cord blood worth it? They may even ponder eating the placenta.

Now add to the list whether to follow a trend known as “vaginal seeding.” The practice involves swabbing the vagina of women who are going to have a cesarean delivery and then wiping the fluids on the baby. The hope is to give the baby the bacteria it would have been exposed to during vaginal delivery and help kickstart a healthy gut microbiome.

Although few doctors in the United States seem to be offering this simple procedure, a growing number of women are inquiring about it.

“It’s certainly happening more frequently (whereas) maybe like five or 10 years ago, I don’t think anybody really asked about this,” said Dr. Leonardo Pereira, chief of maternal-fetal medicine at Oregon Health & Science University.

Interest in the practice seems to be percolating overseas as well. “(By) taking a straw poll amongst colleagues at our hospital and other hospitals (in the United Kingdom), it seems in the last year or two almost all of the obstetricians and neonatologists here have encountered women asking for this to be done,” said Dr. Aubrey J. Cunnington, a pediatrician at Imperial College London.

large body of research points to an association between C-section delivery and increased risk of asthma, obesity and other health conditions. On the other hand, there has been an “absolute explosion of research on the role of the microbiota in health and disease,” Cunnington said.

However, experts say it is far too soon to say whether the vaginal microbiome gives babies a healthier start, and if so, whether seeding has the same beneficial effect as a vaginal delivery. Of greater concern is whether the practice could expose babies to some disease-causing bacteria in the bypassed birth canal.

In spite of the growing interest in vaginal seeding, there is a lack of data on its safety and benefits, and a lack of guidance for women and their doctors, Cunnington said. He and his colleagues in the United Kingdom and Australia took a close look at the issues surrounding the practice in an article that was published on Tuesday in the British Medical Journal.

“I think it would be helpful to have some guidelines on this, [but] it’s very hard to make guidelines when you have almost no evidence,” said Cunnington, who delivered babies before he started specializing in pediatric infectious disease. “Hopefully (the article) will help the medical profession to feel they have a little support,” whether they decide to practice vaginal seeding or not, he said.

Seeding a bad infection?

 

The main qualm doctors have with vaginal seeding is that it could infect babies with dangerous bugs at the same time it is bestowing them with potentially healthy bacteria. Topping the list of pathogens of concern are group B streptococcus, chlamydia and gonorrhea.

The Centers for Disease Control and Prevention recommends testing all pregnant women for these bacteria, as well as a number of other pathogens. About a quarter of all women harbor group B streptococcus, and while they may not experience symptoms, the bacteria could cause pneumoniaand meningitis in their newborns.

All women should get screened, even those planning to have a C-section, in case they end up having an unexpected vaginal delivery, Pereira said. If they are infected, women can receive antibiotics during labor to prevent passing the infection to their baby. However, some women decline screening, even those who are interested in vaginal seeding, Pereira said. “(In those cases) there’s a concern of taking group b strep from the birth canal and wiping it all over the baby,” he added. In addition to bacterial infections, experts worry vaginal seeding could infect babies with herpes virus if the mother has genital herpes.

While it is true that vaginal seeding probably only exposes babies to the same pathogens they would have gotten had they been delivered vaginally, these pathogens could have been avoided by C-section delivery. “If they had [a C-section] because it was the way they had to be delivered for the safety of the baby or the mother, why would you want to impose on them an increased risk of infection if it’s not going to benefit them?” Cunnington said.

What doctors should tell mothers

 

While doctors might not be doing a lot of vaginal seeding themselves, some mothers are taking the matter into their own hands. In one report, a woman in Brooklyn planned to insert a piece of gauze in her vagina before her C-section operation that her husband would wipe on their newborn shortly after delivery. Although there are no guidelines for how to perform vaginal seeding, the studies of the practice generally insert the gauze one hour before delivery and then wipe the fluids around the baby’s mouth, face and body.

It is important to tell these mothers that seeding might not have any benefit and might be increasing the risk of infection, Cunnington said. If they still want to do it, “They just need to be very aware that if their baby is unwell and they go to see a doctor, they should tell them they have performed vaginal seeding because it may change the doctor’s assessment,” he said. For example, a doctor may otherwise have ruled out the likelihood of a group B strep infection knowing that the baby was delivered via C-section.

Even though there is little evidence so far, it is also too soon to close the book on vaginal seeding. A small study recently provided the first evidence the practice might be able to give babies gut microbiomes that more closely resemble those of vaginally delivered infants.

However, “even if you can show their gut is colonized preferentially with labtobacillus or other organisms if you do that swab, you don’t really know if that really has any clinical health benefits, or if in a year from now that really matters,” Pereira said. More studies are needed, following babies who received vaginal seeding for years, to answer that question.

“It’s a fascinating area of research and it holds a lot of promise,” said David Hackney, assistant professor and medical director of labor and delivery at University Hospitals Case Medical Center.

“If someone said to me 10 to 15 years down the road this would be a routine thing we’ll be doing, that would be great and I don’t even know that I’d be surprised. But you can also imagine that in 10 to 15 years, we’ll look back and say what is that crazy thing we were doing,” Hackney said.

Giving babies healthier microbiomes

Until we have more answers about vaginal seeding, the potential for passing along healthy bacteria from the birth canal — while treating women to avoid passing along disease-causing bugs — could be just one more reason to encourage vaginal deliveries, Hackney said. C-sections are known toincrease the risk of complications for both mother and baby, and increase the recovery time for the mothers.

And while vaginal seeding might not be ready for prime time just yet, there are other well-studied practices that could help ensure babies start life with a healthy microbiome. Breastfeeding and skin-to-skin contact between mother and baby are known to “help newborns be colonized with healthy bacteria pretty quickly,” Pereira said.

Cleveland Clinic performs first uterus transplant in the U.S.

By
February 29th, 2016

A team of surgeons at the Cleveland Clinic performed the first uterus transplant in the United States this week.

A 26-year-old woman received the new womb in a nine-hour operation, the hospital said in a statement. She was reported in stable condition Thursday.

The transplanted uterus came from a deceased organ donor.

Clinical trial

The Cleveland Clinic announced a research study in November in which it would perform uterus transplants on 10 women with uterine factor infertility.

UFI is a condition where a woman cannot carry a pregnancy because she was born without a uterus, has lost her uterus, or has a uterus that no longer functions. It’s an irreversible condition affecting 3% to 5% of women worldwide.

“Women who are coping with UFI have few existing options,” Tommaso Falcone, chairman of the Department of Obstetrics-Gynecology at Cleveland Clinic, said when the clinical trial was announced. “Although adoption and surrogacy provide opportunities for parenthood, both pose logistical challenges and may not be acceptable due to personal, cultural or legal reasons.”

The transplant is one of many steps in a complex process.

Before it takes place, the woman’s eggs are harvested, fertilized and frozen for implantation later in the new uterus.

These are some of the other steps, according to the Cleveland Clinic:

– Over 12 months, the transplanted uterus fully heals.

– One year after transplant, the frozen embryos are then thawed and implanted, one at a time, into the patient until she becomes pregnant.

– During her pregnancy, she takes anti-rejection drugs.

– She is monitored by a high-risk obstetrics team throughout pregnancy and delivery.

– She has a monthly cervical biopsy to check for organ rejection.

– The baby is delivered by cesarean section.

– After one to two babies, she has a hysterectomy to remove the transplanted uterus.

– Her anti-rejection drugs are stopped after the hysterectomy.

Pioneered in Sweden

 

While this is the first uterus transplant in the United States, a team of doctors at the University of Gothenburg in Sweden has performed nine of them.

Five of the women have gotten pregnant, resulting in four live births.

The Cleveland Clinic is hopeful for its own program after taking part in the Swedish trials.

“The exciting work from the investigators in Sweden demonstrated that uterine transplantation can result in the successful delivery of healthy infants,” said Andreas Tzakis, the lead investigator in the Cleveland study.

Let’s talk about sex to save lives

By
February 24th, 2016

Ariela Zibiah

Monday, February 22, 2016

A REPORT on sexual and reproductive health of young people in Asia and the Pacific released last month affirms that a significant proportion of young people, 15 to 24-year-olds, are sexually-active, and premarital sex is more common in the Pacific.

The report which was collaboratively produced by the UNFPA, UNESCO and WHO provides analysis based on several variables but among other factors, the report states young people in urban setting are more likely to have earlier sexual debut than their rural counterparts and those who leave schools are more likely to commence rather than those who are still in school.

The report affirms how adolescents across the countries discussed in the report remain discriminated against by gate keepers of essential services particularly the health services and/or those who are supposed to ensure timely and correct sexual and reproductive health and reproductive rights information.

Adolescence in limbo

Adolescence is a minefield of emotions that will require a lot more open discussion around sexual and reproductive health and reproductive rights issues. It is a critical time of self-defining processes when influencers of world views crowd thought-processes, and in this day and age, parents, guardians and or teachers compete with the rush of the information highway.

Adolescence has historically referred to those between 10-19 and youth between 15 to 24-year-olds. It is a time of transition from childhood to adulthood. For the United Nations Population Fund, UNFPA, this is also a time when good sexual and reproductive health and reproductive rights fundamentals must be established.

It is not only a basic human right to ensure our young people are able to achieve the highest attainable sexual and reproductive health standards, but investing in it will eventuate in inclusive national progress.

The report found an increasing number of young people are initiating sexual debut before marriage. A clash between the diverse factors which inform young people’s world views and the sociocultural realities of their communities are inevitably becoming barriers to good sexual and reproductive health.

The region is home to numerous communities where faith-based ideals give power to moral policing without serious consideration or acknowledgment to what is actually driving attitudes, decision-making processes and behaviour of young people in relation to sexual and reproductive health and reproductive rights. The religiosity is compounded by gender dynamics that not surprisingly tilts the burden of poor sexual and reproductive health and reproductive rights to girls and women.

It should be no surprise therefore that in the region we are part of, one in seven girls in the region would have given birth by the age 18 in the context of high unmet need of contraceptives (failure to access vital reproductive health service to ensure a lived reproductive right to decide for herself if she wants to have children, how many and at what intervals), in terms of child marriages (a despicable cultural practice with irreparable damage to girls with a rippling effect which impacts national indicators of development) and also in relation to the lack of access to critical information (age-appropriate comprehensive sexuality education delays sexual debut as opposed to popular belief that it encourages sexual debut).

Norms as barriers

Entrenched sociocultural practices and attitudes to issues around sexual and reproductive health and reproductive rights are the reason why less than half of the 15 to 24-year-olds are reporting not using a condom at the last high-risk sexual encounter.

Taboos which disallows frank discussions around reproductive health and rights is an example of sociocultural barrier to a safer space for our young people. A faith-based consideration should allow the discussion of sexual and reproductive health as a gift for pro-creation and a symbol of love between two people, as Reverend Jeremaia Waqainabete, superintendent minister of the Wesley Division of the Fiji Methodist Church, describes it.

The report emphasises how gender norms have a “profound influence” on young people’s sexual and reproductive health. Most countries indicate a more relaxed attitudes to young men having premarital sex then young women but both sexes are permissive of male premarital sex rather than female premarital sex.

High-risk behaviour which includes multiple sex partners, intergenerational sex and/or sex under the influence of alcohol will increase the likelihood of sexually-transmitted infection including HIV.

The report states: “Young men are more likely to report multiple sexual partners particularly in the Pacific where up to half of young men who have ever had sex reports two or more partners in the last 12 months.”

The relationship between alcohol or substance use and risky sexual behaviour is well-documented. For countries with national data, young men reported much higher rates of sex while drunk than young women “most significantly in the Pacific”.

The Pacific is also well-represented in binge drinking data in the report (entitled Sexual and reproductive health of young people in Asia and the Pacific: A review of issues, policies and programmes) with the highest rate reported in Fiji (21 per cent), PNG (18 per cent) and Solomon Islands (16 per cent). In all countries, risky alcohol use is more common among males than females, with binge drinking rates two-three times higher among adolescent boys.

It is evident that high-risk behaviour has successfully lodged itself into our collective psyche as “normal”. Depriving one of critical sexual and reproductive health information and services like the provision of contraceptives from nurse posts based on socioculturally-influenced reasoning is “normal”.

Serious consideration of these norms which are becoming barriers to both life-saving information and services is urgent for a population that is fundamentally unhealthy cannot be a resilient and productive population.

Family support

and gender equality

The report affirms that families can be important protective influences on our youths. Studies in Indonesia, Thailand and Philippines ascertained a relationship between delayed sexual debut and a close relationship with parents.

Family support will be particularly important for girls. Studies in India, Vietnam, Cambodia and the Philippines suggested a connectedness between adolescent girls and their parents, particularly their mothers, and a family environment that supported gender equality corresponded with delayed first sex among girls.

The Pacific is part of a region that is home to 60 per cent of 1.8 billion people aged 10 to 24-year-olds in the world today.

We may not be a landlocked area but there is significant interaction by air and sea. If the lack of forthrightness in issues related to sexual and reproductive health and the rather high levels of sexually-transmitted infections is anything to go by, then an underlying albeit inconspicuous consequence awaits.

The inability to accept the fact that our children are being exposed to issues around sexual and reproductive health and reproductive rights at a much earlier age will continue to throw back data as reported in the report like 10 per cent of males and 20 per cent of females in the age group of 15-24, report having a sexually-transmitted infection or its symptoms in a period of 12 months.

It is a sociocultural and economic imperative to shed ourselves of the façade of taboo. The consequences of inaction is unfathomable and a deadly legacy to leave behind as a people.

* This is the first article in a series of four.

* Ariela Zibiah is the communication analyst at the UNFPA Pacific subregional office.

Indonesian Youths Want to Be Heard on Family Planning

By
February 24th, 2016

Jakarta. Years ago, when Angraini Sari Astuti was diagnosed with ovarian cancer, she experienced first-hand how difficult it can be for Indonesian adolescent girls to visit a qualified health professional when they desperately need one. Not because there were no doctors where Angraini lived, near Solo in Central Java, but because of the stigma associated with anything related to premarital sex in the world’s most populous Muslim-majority nation.

“In 2008, when I checked into [the office of] a gynecologist in preparation of my tumor surgery, other patients stared at me,” now-25-year-old Angraini said at a youth event on the sidelines of the International Conference on Family Planning held in Nusa Dua, Bali, late last month. “They were wondering: why would such a young girl come to a gynecologist?”

Angraini, who fully recovered, is now an energetic and outspoken youth activist working with the United Nations as a volunteer to call on the Indonesian government to give youngsters a seat at the table when policies are made that directly affect them.

Activists like her say empowerment and education are more necessary now than ever before, because while the country’s family planning program has been widely hailed as a great developing-world success story, the numbers on adolescent sexual and reproductive health in Indonesia remain disheartening.

65 million young people  

Indonesia’s successful family planning program, which lowered the country’s total fertility rate from 5.6 in 1967 to 2.6 in recent years, has cleared the way for a much-anticipated demographic dividend.

There are over 65 million people in Indonesia today aged between 10 and 24: almost 30 percent of the population. But even as this may be good news in terms of economic growth potential, illegal abortions abound and HIV transmission rates are on the rise, while the government is not legally allowed to provide any means of contraception to people who are not married. Regular health clinics tell youngsters that abstinence until marriage is the only way to stay out of trouble.

According to data from the United Nations Population Fund (UNFPA), people between the ages of 20 and 29 account for almost 40 percent of newly confirmed cases of AIDS in Indonesia. These numbers suggest that many get infected with HIV between the ages of 15 and 24.

UNFPA also notes that more than half of reported HIV cases in the country are due to unprotected sexual intercourse, with intravenous drug abuse being another major cause.

Maternal mortality

Reliable numbers are hard to come by, but experts estimate there are at least two million abortions per year in Indonesia. The fact that these abortions mostly involve married women in Indonesia indicates that access to contraception is hardly something that only affects adolescent girls.

As abortion is illegal in Indonesia except in cases of rape, foetal abnormality or when the pregnancy threatens the mother’s life, most of these procedures are carried out unsafely. Indonesian girls and women with an unwanted pregnancy ingest menstruation-inducing herbs, are given a uterine massage or even have foreign objects inserted into their uterus.

Indonesia’s maternal mortality ratio (MMR), or the number of maternal deaths per 100,000 live births, remains high, at an estimated 126, and unsafe abortions cause an estimated 16 percent of these deaths.

In other words: some 6,400 women died from pregnancy-related causes throughout the archipelago last year, and over 1,000 of these women died because of an unsafe abortion.

Even though Southeast Asia’s largest economy is performing better than countries like Laos (197) and Cambodia (161) in terms of MMR, it still lags far behind neighbors such as Vietnam (54), Malaysia (40), Thailand (20) and Singapore (10).

Child marriage

One of the ways Indonesian authorities are trying to prevent unwanted pregnancies and stem the rise of sexually transmitted infections such as HIV/AIDS, is by promoting abstinence until marriage, for instance by limiting the availability of contraceptives for unmarried people.

However, one of the consequences of this policy – which is generally accepted by people across the country because it is considered to be in line with religious teachings and tradition – is that many people marry young.

In many parts of Indonesia, unmarried girls are being labeled perawan tua, or “old virgin,” as early as in their late teens andchild marriage remains very common, despite the many dangers associated with the practice.

Humairah Samad, a senior high school student from Makassar, in South Sulawesi, confirmed that where she lives, too, many tie the knot at a young age.

“Our culture has been like that for generations,” she told the Jakarta Globe at the family planning conference in Bali, citing the need for better education on issues of sexual and reproductive health to break that tradition.

Another Indonesian youth activist, Nanda Fitri Wardani, a young MD from Lampung who studied at Bandung’s Padjadjaran University, says many girls in Indonesia have plenty of dreams but are often not empowered by their parents and sometimes end up getting married as early as age 13.

Such a young marriage usually means the end of school and any prospect of a career beyond motherhood.

Harm reduction

Nanda says she believes the Indonesian government should be supported in its decision to not provide contraceptives to unmarried people, citing the state ideology of Pancasila and its first principle: belief in God.

“Having sexual intercourse before marriage is forbidden based on the religions that we follow here,” Nanda said in Bali, stressing that abstinence remains the best way to stop the spread of HIV/AIDS among young people.

Siswanto Agus Wilopo, a professor of reproductive health at Gadjah Mada University (UGM)’s faculty of medicine, however, says the government needs to approach the issue differently.

Siswanto told the Globe he was quite confident that the legal situation would not change anytime soon, as a majority of legislators in the House of Representatives believes that the law can prevent unmarried people from engaging in sexual intercourse.

Faced with such unfavorable odds, the professor says the country needs a harm reduction policy, because the numbers suggest there clearly is a problem, regardless of what politicians say. A start would be the provision of contraceptives to unmarried couples, as part of an emergency regulation, he said.

“You have to go step by step,” said Siswanto.

“One kind of harm reduction policy is the availability of ECP [emergency contraception pills] which will prevent unprotected sex ending in abortion. It is better to use a pill compared to having an abortion, isn’t it?”

“We start with that, campaign about it. If you present the facts, if you present the data – people in Indonesia are smart … I believe that at least harm reduction can be promoted.”

For now, however, the Indonesian government is adopting a hands-off approach. Although some believe the sale of such prophylactics needs to be limited to prevent people from engaging in premarital sex, condoms are still available in supermarkets and convenience stores in major urban areas.

Youth-friendly services

UNFPA in 2014 launched an initiative in cooperation with the private sector that is aimed specifically at helping adolescents. As part of the Unala program, which is being piloted in Yogyakarta, affiliated clinics specialize in providing youth-friendly physical and mental health services.

At the Unala clinics, selected GPs offer health services for youngsters who might be afraid of the social stigma attached to extramarital sexual activity, real or perceived. One way of doing this, for instance, is by using an appointment-only system – which is very unusual in the Indonesian health sector – to avoid prying eyes in the waiting room.

Besides Unala, there are other initiatives to help people in need, such as a hotline run by Yogyakarta-based activists that allows girls and women with an unwanted pregnancy to discuss – free of charge and judgment – what options are available.

Such sessions are aimed at preventing tragic but all-too-common situations where girls or women end up having unsafe abortions at one of the many illegal clinics in Jakarta or at the hands of a local midwife.

Meaningful participation

Babatunde Osotimehin, the executive director of UNFPA, says youngsters all over the world should be given the space to express themselves, so that governments and NGOs understand what they want, and what they need.

And one of the most important things that young people need, is comprehensive sexuality education (CSE), he says, stressing that this in fact is the right of every young person.

In Indonesia, only few schools offer such programs, however. Some others do teach children about sexuality, but take a fear-based approach instead of one that stresses a young person’s rights.

Apart from CSE, another important step is greater involvement of men, the UN under-secretary-general said, speaking at the family planning conference in Bali.

“There is no man in this world who would like to see his daughter die,” said Babatunde, “or see his wife die.”

Angraini, the Indonesian youth activist, told the Globe that for family planning and sexual and reproductive health programs to work, meaningful participation of young people at all levels of the policy-making process is essential.

“Listen to the young people themselves,” she said. “Don’t just ask them to attend a seminar when everything is already settled.”

Apart from empowerment, there is a clear need for adequate, youth-friendly health services across the country, she said, to clear all hurdles for young people “concerned about confidentiality and judgmental opinions from others.”

“Involving young people, both married and unmarried, in family planning education, and raising their awareness on this issue, will have a positive impact in lowering maternal and child mortality and morbidity,” Angraini said, “as well as equip young people with the information they need to make their own decisions.”

But she stressed that young Indonesians should not just remain passive while waiting for change to happen.

“Let us … work together with parents, families, government health personnel, teachers [and] educational institutions … [so that they all] fully recognize young people’s need for non-judgmental understanding, the right information, adequate health services and comprehensive sexuality education,” Angraini said.

“We are the future of family planning.”

C.D.C. Investigating 14 New Reports of Zika Transmission Through Sex

By
February 24th, 2016

Health authorities in the United States said they were investigating 14 new reports of the Zika virus possibly being transmitted by sex, including to pregnant women. If confirmed, the unexpectedly high number would have major implications for controlling the virus, which is usually spread by mosquito bites.

Scientists had believed sexual transmission of Zika to be extremely rare. Only a few cases have ever been documented. But if all the women in the cases the Centers for Disease Control and Prevention is examining test positive for the virus — as two women already have, and four others have done in preliminary lab tests — officials believe there is no way other than sex that they could have contracted it.

The specter of so many cases — all in the continental United States — brings fresh complexity to the medical mystery of Zika. The virus is suspected to cause birth defects and a rare condition of temporaryparalysis.