The Other Cost of Crises Pregnancy Centers

This week’s ruling by California’s Supreme Court that crises pregnancy centers can omit information from their counseling of pregnant women has many well documented outcomes. The primary goals of these centers are to deter women from accessing abortion care and to restrict their rights to autonomous reproductive healthcare decisions. In cities like the one I am living in there are enormous billboards, bus signs, and benches covered in ads for these centers. They read, “Don’t harm your baby! We can help!”, “Free Ultrasounds!”, and “Free Prenatal counseling, we will help you with your decision.” Women are lured to these centers through promises of seemingly unbiased guidance and support. These centers have been found guilty of, and defend their right to omit information about the availability of birth control and access to abortion care (including Plan B medication). They have proudly affirmed that they often tell women they are further along in pregnancy than they are. This helps convince women that they are not eligible for an abortion. It also causes them to imagine a fetus that is more like a baby than a few cells to make it emotionally harder to decide to terminate.

What no one talks about is what happens next if a woman decides to keep her baby. As a midwife in the South I have received these women into care many weeks after their first visit to one of these clinics. Most of them receive regular prenatal care from the clinics. However:

  • If they miss any appointments, they are kicked out of care and left to fend for themselves.
  • Sometimes they do not want to relinquish their baby for adoption through the clinic agency and they are harassed and pursued by agency representatives who prey on their vulnerability and try to shame them into submission.
  • Sometimes women come to a place where they embrace the idea of motherhood and want to do all they can to prepare and learn about birth and parenting. Their newfound power is threatening to the relationship with the crises center and they are pushed away from resources.
  • Sometimes they are violently ill from the pregnancy and ignored completely as long they remain pregnant. Their health really does not matter as long as the vessel of their body continues to carry the pregnancy.

I’m sure somebody out there has documented all of the pathways these pregnancies and women can take—they are varied and many, with complexities and layers we dissect and maneuver through with individuals who wind up in our care. I have sat in stunned silence on my own after these visits many times because the level of depravity and lack of compassion that rises up from these centers and the staff and providers who work in them is frankly unfathomable. It is a lifetime movie gone horribly terribly wrong but it’s no movie—these are very real lives with very real consequences.

What I never heard about, and I wager very few have considered, is this scenario: A woman goes to a clinic for a free ultrasound and prenatal assessment. She may or may not have ever considered abortion. She may be happy about the pregnancy or ambivalent or miserable. She arrives at the crises clinic not knowing the date of her last menstrual period. They do an ultrasound, give her a due date and print out an image for her to take home. They put the little black and white photo into a small white envelope with illustrations of a real baby, looking happy and fat and healthy, surrounded by blue and pink ribbons.

These are the questions we must ask:

  • Is the due date they gave her accurate or is it based on dating that will ensure she will not receive access to abortion care in her area?
  • Is the image they give her of her own baby or one who is more developed than the one she carries?
  • Do they explain how she can access Medicaid, social services, housing, job training, or food for herself and her baby or do they only share resources that exist in their clinic and lead to adoption by a family that pays hefty fees to that same agency?
  • What do we need to unwind to discover her true wishes? She comes to us over-exposed to the subtle and brutal art of shame, devaluing, and tinkered religious ideology all driven straight into her most vulnerable fears and emotions.

I know no one has ever come into our office from this care knowing what resources they have the right to access. Most don’t know they can easily sign up for Medicaid which will guarantee them perinatal healthcare at a variety of locations. I don’t know which clinics give the right dates and which give falsified dates.

But here’s what I want to share in this post: When the only ultrasound a woman has gives her a certain due date, and she does not know when her last period was, that is the only and best information we have to work with. Keep in mind that when a woman comes in late to care with no known date of her last menstrual period and no early ultrasound, we do an ultrasound and measurement of fundal height immediately and work off of that information. A baby who measures 33 weeks by ultrasound and fundal height will be approached as a 33 week old baby. A baby who measures 33 weeks when the early crises clinic ultrasound says it should measure 37 will not. For that baby, with a prior early ultrasound who measures small for that date, here is what we wonder:

  • Why is this baby so small?
  • Why isn’t this baby growing as it should be?
  • How long can we afford to keep this baby inside to try to prove interval growth before we are compromising it?
  • Can we prevent harm from intrauterine growth retardation or another syndrome, disorder, or anomaly by causing an early delivery?
  • Will we cause harm by causing an early delivery of a normal healthy 33 or 34-week-old fetus who would have done perfectly had it been allowed to stay inside and finish growing for a few more weeks?

There is no easy answer to these questions. We use technology to try to measure and assess the actual size of the baby, the flow of blood from the placenta to the baby, anything that is measurable, is measured. But all of our measurements are relative to the first and best known date of any pregnancy. Normal and abnormal interval growth can vary by just enough to give no good answers. We do the best we can. We use all of the power in the maternal-fetal medicine world to try to make the right decision. Sometimes we will get it right, and sometimes we will get it all wrong.

From the March of Dimes:

  • The average cost of a NICU stay for each baby born too early is $55,000. The average cost of a hospital stay for a normal birth is just over $4,000.
  • Babies born too early are at high risk for disabilities and developmental delays including physical, thinking, communicating, social and self-help skills.
  • Day-to-day life for the parent(s) and family is completely disrupted during and after the NICU stay as they navigate interventions and attend appointments and therapies.
  • Parent(s) spend hours in the NICU, and then at therapies, away from their other children and often lose their jobs.
  • The NICU stay can last for months, and often the facility is located miles from home.
  • There is tremendous emotional, physical, and financial stress with premature birth

Families deserve access to healthcare information, research, and guidance that leads to shared-decision making with their provider. The presentation of options that utilize provider skills and local resources to best serve a patient’s needs for their life is a fundamental right.

The cost of lying to patients is high in all directions—for negligent prenatal care, for the delivery of shame as a tool of coercion, for leading a woman to believe that there is help and then abandoning her if she asks questions or changes her mind, for the mother who is induced for a too-small baby who was really just fine but now faces a life of developmental challenges. Frankly the cost of stress to the multitude of providers who gather around a woman and her unborn baby struggling to make the right decisions with bad information is high, too. Yet these clinics are never held to account for those costs. And now the government has decided that they should be encouraged to carry on and pursue their right to lie which supersedes the rights of the mother and the baby to the truth and of society to the health of its most vulnerable people. Money and power are on the side of these clinics, but justice is not. It is one more unjust and unnecessary barrier for those most at risk for adverse outcomes.

A question just crossed my mind and I will close with it: What would happen to our maternal child outcomes if all of the resources being poured into these clinics, all of the concern, time of staff and providers, and faith-based communities was instead poured into the delivery of services designed to promote the good health of these women regardless of what their decision might be about their pregnancy and future?

A Layered Question: Midwifery Philosophy 101

“How do we address public health outcomes while caring for one family at a time as if all public health depends on only their outcome?”

Let’s take a look at this multifaceted question:

How does a person navigate the stormy waters of pregnancy healthcare if you are anything other than a 5’7 140lb white, married (to a man) woman who identifies as such, hovering in the middle to upper class?

As you can see we are dealing with multiple layers of the human experience and their effects on pregnancy healthcare: your health before pregnancy even starts, BMI/Obesity, race, sexual and partnership identification, lifestyle choices, and economic status. I hope to address these topics from my midwife-minded perspective in the coming posts, starting here with our general approach and philosophy regarding pregnancy healthcare.

For my friends in the north: I am going to stretch this a little further and choose to add the extraordinary complication of living in the South to this discussion. I did not know, and could not understand, as a northern midwife, that my southern counterparts and the families they serve face challenges far far far (did I say far?!) beyond what we do in the North. I knew of course that things were different but I didn’t really understand.

I have tried 85 times to write about what it’s like to live in a place where faith-based healthcare makes room for providers to decline to mention during prenatal care the option for genetic screening (taking this as one example of dozens). They do not inform patients of these options because their faith (read: the PROVIDER’s faith, not the FAMILY’s faith) does not allow consideration of options that include the termination of a pregnancy under any circumstance. So there is no option for screening given. Not even when a pregnancy poses danger to a woman’s or pregnant person’s life. Not even when that baby will live less than an hour and in terrible agony. Not even when a family would choose to live life with an intensely high medical needs child, or one affected by a genetic anomaly, but wants the opportunity to prepare their home, family, work, and resources to meet their needs. Not even when the mental health of the mother or pregnant person is in jeopardy.

I’ve read charts here with “nuchal translucency” (a screen completed prior to the 14th week) noted at 22 weeks. There’s no such thing!  But this deception is allowed and encouraged….and this is only the tip of the iceberg. Want a tubal ligation but your husband isn’t present to consent?  You may have difficulty accessing this surgical form of family planning in the south. Of important note is that there are providers in these systems who do not practice this way but the system supports those who do. There are four major healthcare systems in this city—three of those with multiple hospitals that support providers who practice faith-based medicine according to the model that the physician’s faith determines your healthcare options.

If you are a person of faith, this might sound nice on the surface, but I would put forth that it is our religious leaders who should help us navigate the decisions we are faced with in our lives. They have training and education that enables counseling and support for our spirituality.  They help us stay aligned with our religious values and belief systems in all areas, including our medical decision-making. Our physicians and providers should offer us healthcare options, discussions, consent, and treatment based on shared-decision making. We are responsible for ensuring we integrate our religious, social, and cultural outlook into our healthcare by engaging all of the systems and people that matter to us in that process. At the same time, many systems are designed to ensure that culturally relevant care is nearly impossible to acheive and it should not be the burden of the consumer to correct this but the burden of each provider, administrator, and system to make it right .

The care options that are here are not healthcare as we know it in the North. For all of you, I know, this post so far will seem frankly unbelievable and unrelatable. The posts linked to below about health and lifestyle choices will seem dated and broad. You are working on terminology, micro-aggressions, systemic racism, and deep systems issues. We are working on basic access and consent issues very much related to the ethics behind Informed Consent and the Nuremberg Code couched in overt racism packed in systemic racism, micro-aggressions, and deep systems issues.

Conversations about lifestyle, access, and health disparities are coming into the light in many corners here. Questions are being asked:  Why is it like this?  Does it have to be like this?  What it would look like if healthcare wasn’t like this?  The midwives here have been advocating and caring for families in all the ways possible—faith based and non-faith based. And even with the two of us new to practice here, there are five of us in or adjacent to the city I’m living in now. Five who are practicing in community-based settings. Five who can create protocols and follow guidelines appropriate to the profession and their community.

We need space for conversation and inquiry here, we need routes for education and change. The South is not some backwards “other”—I am not at all trying to say that the South “needs saving”. I am new here, but I’m right here where this community is at: listening, participating, wondering. Pregnancy, birth, breastfeeding, parenting, general health. These communities are rising up and looking for solutions to the very real barriers they face. I recognize that process. It has a familiar rhythm, grit, and complexity. There is tension, anger, frustration, desperation, and there are large gaps between what is known and what is understood.

For our practice it boils down to this: How do we address public health outcomes while caring for one family at a time as if all public health depends on only their outcome?

I have answered that question many times in posts and articles and interviews.  I stand by my answer.  We must be kind and use our skills to meet people where they are at.  The rest will follow. I am committed to this model of care which leaves room for so much possibility.

I have the great privilege of holding a license to practice midwifery and of being supported by a local, long-standing clinic and non-profit organization that constantly looks to be a partner in community solutions. I have my clinical experience, my willingness to learn and to meet people right where they are at. I have the fundamental belief that kindness matters and that none of us has anything that matters until all of us have access to reach our potential. This awareness and mindset allow me the opportunity to be a part of families’ lives in the very ways midwives have since the earliest days of society.  In the very ways midwives all over the south and indeed the world are a part of healthcare systems, families, and community health.

I have the unique benefit of working with a practice partner who is fierce about identifying solutions and solving problems. She is brilliant, experienced, kind, and unafraid of stepping in to dismantle the hardships families face. We are not looking at pregnancy as an isolated, siloed experience. It exists in the layers and complexities of the lives of the people and families we serve. We are working on a number of projects right now centered around how we acknowledge and prevent non-pregnancy related medical and socially generated pathologies from determining pregnancy outcomes. My practice partner states over and over again that these problems require providers to change their understanding and behaviors,  and stop promoting the false idea that “these women” and “those families” just don’t want good health badly enough.

We believe the barriers that have separated “Self” from “Other” need to fall—we are all of us people just trying our best to give our all and find love, connection, and health in our lives.  We are unique individuals with complex cultures but we share so very much. What if as providers we use our licenses to open up this conversation and create new paths to robust health for all families?  That is the work we are engaged in here in the South. And each micro-community has to find its way in the larger social construct. We want to pull apart the loaded, layered question and answer simply, “yes, I believe in you, your interest and capacity for learning is vast, and together we can find solutions that meet your needs in the right way at the right time for you.”  There is nothing to stop us from applying this philosophy of care to pregnant people of all races, sizes, orientations, cultural backgrounds, and socioeconomic truths.

Next Up:

Midwifery for All Series

Size Friendly Care

 

GBS Prevention

Read the long article

See the Infographics up-close

This post examines the role of preventative health care in the inhibition of Group B Streptococcus (GBS) infection.  It uses the term “mother” for simplicity’s sake although babies have all kinds of parents who identify in all kinds of ways and all are welcome here.

Let’s break down the long article:

Infections resulting from GBS  can be life-threatening to a newborn.  All pregnant moms are offered a test which detects this bacteria around 36 weeks of pregnancy.  If found, it can be treated through the use of IV antibiotics during labor, which significantly reduces the rate of infection and resulting meningitis and/or sepsis in newborns. While this article does not focus on the treatment of women who test positive, it does promote prevention, which improves the overall health of both mom and baby through the use of probiotics taken orally throughout the pregnancy.  These come in tiny capsules or a liquid packed with powerful lactobaccili (among other gut-friendly bacterium) that usually cost between five and twenty dollars per bottle or package).  It’s a small price to pay for so many amazing benefits.  As a midwife, I often pay for them for clients because of the massive health benefits of these supplements to every mom and baby, including avoiding a host of obstetric complications that would increase risks to mom and baby and often require transfers out of my care.  Great midwifery promotes the intrinsic health of mother and baby through programs like this which lend greatly to positive birth outcomes.

Let’s explore just some of the many benefits:

The Mother

Take a look at what the microbiota is if you aren’t already familiar with it.  The use of probiotics promotes this system that does a bit of everything good in the body including prevent the over-colonization of “bad” bacteria like GBS.  It also happens to prevent diabetes and keep your mood even.  It exists in the mouth, gut, and vagina of the mom and the placenta (and some studies found evidence in the fetal gut as well).

Over the course of pregnancy, the levels of good bacteria in the microbiota change.  By the time you give birth, you have an over-growth of lactobacilli which ensures that your baby will get exposure to this important “good” bacteria during vaginal birth.  When the system is supported right it will also prevent yeast infections, and keep the bacteria that cause UTIs and GBS in check.

The Baby

Impaired levels of probiotics have been correlated to preterm birth.   They are correlated because “bad” bacteria like GBS and candida (yeast) cause cellular damage to the cervix.  It loses its integrity and is not able to hold in the pregnancy as long as it should.  There are dramatic consequences for being born too early—the March of Dimes was founded because of babies born too early or too small.

When mothers take probiotics, they are found in the placenta and fetal gut and stay with the baby after birth to help regulate the baby’s microbiota.  That’s profound!!  You can help your baby synthesize vitamins and amino acids, regulate immune function, have smoother transitions between emotional states, and get a balanced healthy start just by taking probiotics during pregnancy.  After pregnancy, breast milk takes over the important function of populating the baby’s microbiota with everything it needs.

What Matters

  • Take probiotics throughout pregnancy to help keep your body hostile to “bad” bacteria and to strengthen the integrity of your tissue (muscles and skin included), especially uterine tissue like the cervix (and to boost your immune system, keep your mood even, etc., etc., and etc.!)
  • If you are planning a VBAC this winds up mattering a lot. Infections like candida and GBS can wear down the tissue that you are relying on to keep the scarred area strong and healthy.  Take a full dose of 4 probiotic capsules per day for your entire pregnancy.  I have supported an extremely high percentage of VBACing moms in my practice and this statement is NOT a judgment about your scar.  It is part of a recipe that will contribute to your overall success.  Check out this article for more ideas from the VBAC playbook or contact me to discuss further.
  • Have a vaginal, antibiotic free birth for maximum exposure to lactobacilli
  • Ask your provider ahead of time about swabbing your vaginal tract during labor prior to any antibiotics if you need them for any reason (including a planned or unplanned cesarean birth)
  • Regardless of how you deliver your baby, spend time skin to skin with her or him. Allow them to touch your breasts and arm pits with their hands.  You have lactobacilli on your skin that they will benefit from
  • Breastmilk feeds babies and promotes the growth of healthy bacteria in baby’s own microbiota, boosting their immune system and setting them up for good health
  • Babies born to a mom who had to take antibiotics or who were born by cesarean or who drink formula exclusively or as a supplement can all be given oral probiotics. They are available with a dropper or can be mixed into breast milk or formula and given through a bottle or made into a paste (just break open a capsule and add one drop of water at a time, mixing with your finger) and applied to mom’s nipples which is both soothing and healthy for the breast

Some disclaimers and information of note

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can eliminate or greatly reduce the high colonization. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Capture

You can see the source for these infographics and get an up-close view by clicking here

Share your thoughts on preventative health care during pregnancy and your comments and questions below!

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/

GBS Infographics

Read the Short-winded blog post

Read the full article

Read The Notes

microbiome changes of pregnancy

PMC full text:Front Microbiol. 2016; 7: 1031. Published online 2016 Jul 14. doi:  10.3389/ fmicb.2016.01031

microbiome changes at birth and feeding

PMC full text:Front Microbiol. 2016; 7: 1031. Published online 2016 Jul 14. doi:  10.3389/ fmicb.2016.01031

The Notes

Read the Complete Article

Read the shorter Blog Post

See The Infographics

The Notes.

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can get the high colonization in check. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Got Questions?

GBS Prevention: The Real Deal (an article)

The stakes are high. With all of the science supporting the idea that we can impact outcomes through simple and inexpensive measures, we cannot disregard the first and best options we have to address a disease. And especially where that prevention, aimed at reducing illness for the baby will also dramatically improve the health of the mother.

This is a long article y’all and way past the normal blog length acceptable in the blogosphere….however, you’ll find all of the background information, standards of care, reasoning for examining a new model and solutions for dramatically improving the health of mother and baby long after the relatively brief moment of pregnancy and birth have passed. This model is the real deal.  It provides preventative, protective, and health sustaining treatment for all instead of treating a disease process when symptoms become present in some.  I hope you enjoy the ideas and look forward to your thoughts and input.

If you are already worried I am going to recommend against treating GBS+ moms you can take a quick look at these important notes.

Looking for an upclose of those infographics?

Looking for a short-winded version of this article?

The Issue

Over colonization of the bacteria Group B Streptococcus (GBS) can cause a life threatening infection in newborns.  Most expecting families hear about this at the 36 week visit when they are asked to consent to a test for this bacteria.  If found, antibiotics are delivered through an IV during labor which greatly reduces the baby’s chance of exposure.  Many midwives share the fact that this bacterium is transient and can come and go so the test may be unreliable.  They may offer alternative treatments and discuss the low odds of babies who are exposed actually getting sick in an effort to consider antibiotic over-exposure.  Some providers might scare the living daylights out of their patients with images of weak, mewing infants suffering from high fevers and a very difficult disease to treat in an effort to ensure treatment is given.  Neither is wrong.  On one end the use of antibiotics reduces bacterial diversity in both mother and baby and can cause resistance to antibiotics later in life.  On the other end is the prospect of a disease where the only option once infection sets in is antibiotics and sometimes they are not enough to save the life of a sick newborn.  The cost to a newborn who experiences GBS disease is extraordinary.  The cost to a family who has a seriously ill baby or who lose a baby is immeasurable.  This disease starts with the presence of normal bacteria, progresses to an overgrowth of those bacteria, which progresses to exposure and then transfer and then a normal or a sick newborn.  Every baby at the start of pregnancy is looking a road that might lead to a GBS infection.  So one must ask, is there an answer that might keep babies safely at the start of that road with no progression on the continuum?  This article seeks to look at one answer that gives each baby a high chance of avoiding the long walk towards infection.

The Platform

I would like to reframe how we view testing and treatment of GBS and look at front-line prevention as first-line treatment.  This is to say that medical providers are trained to diagnose and treat, but as the keeper of your and your baby’s body (or your client’s or patient’s for providers), prevention is actual medicine.  The stakes are high.  With all of the science supporting the idea that we can impact outcomes through simple and inexpensive measures, we cannot disregard the first and best options we have to address a disease process.  And especially where that prevention, aimed at reducing illness for the baby will also dramatically improve the health of the mother. Our checklist for GBS management and testing in pregnancy should be:

  1. Recommend quality probiotics high in lactobacilli at first encounter, 1 cap 3-4 times daily
  2. Swab as normal between 35-37 weeks
  3. If antibiotics are given in labor advise to start probiotics as soon as possible.

The Mother

There are hundreds of articles available that help explain and define the microbiome, but in short each of us has a unique microbial population that includes bacteria, archaea, fungi, and viruses.  This whole system is referred to as the microbiota and is located in the mouth, gut, vagina, and placenta.  It is responsible to:

  • Digest and absorb nutrients
  • Synthesize vitamins and amino acids
  • Prevent pathogenic colonization (this is important to our discussion of GBS)
  • Regulate immune function
  • Modulate hormone release in the gastro-intestinal tract which for example helps prevent diabetes
  • Regulates mood and behavior through production of serotonin

(Kristensen et al. Genome Med. 2016; 8:52)

From this short list, one can easily see the massive importance of working right from the start of pregnancy (or long before, ideally) on balancing the microbiota in order to achieve optimal health in the mother.  Additionally, the changes in a healthy microbiota that occur from the first to the third trimester are dramatic and much needed for the health of mother and baby.  While the baby is often the focus of GBS discussions, the mother is a worthy and whole person, deserving of high regard for all that she is and does.  She is far too often viewed merely as a vessel we must sustain until she delivers the human baby who is the real focus of pregnancy and birth.  I have seen first-hand over and over again that when we take excellent physical and emotional care of the mother, the baby thrives.    Even in high risk pregnancies, carrying a baby does not supersede a woman’s autonomy over her own body, her needs, or her desire to be heard, felt, and understood.   It’s an archaic rite of passage that we feel compelled to remind her that, “it’s not about her anymore.”  It is deeply, deeply about her.  It is deeply, deeply about baby.  It is deeply, deeply about how they are together, and how they are separate.  The mother provides the building blocks of the placenta through her well-being.  The baby relies on that placenta for his or her well-being.  The baby experiences the hormones of the mother’s emotional states and learns from the patterns of stress and recovery she teaches during pregnancy.   A mother’s mental health has long term effects on both her and baby.  The question is, how can we promote the optimal physical and mental health of both?  How can we prevent disease for both?

Addressing gut-flora health will absolutely improve the fundamental health of the mother and therefore the health of the placenta and the baby.  During the third trimester levels of lactobacilli naturally rise and even over-grow to ensure exposure for the baby while protecting against bacterial and viral infections in the vaginal tract.  This entire system is its own natural pharmacy when supported correctly.

The Baby

Several studies suggest that impaired levels of probiotics in the vagina correlate with preterm birth.  This is because of the cellular damage that an abundance of harmful bacteria can cause to the strength and integrity of the cervix.  This includes yeast infections and GBS infections as well as STI’s.  Babies born too early or too small are at risk for a number of poor outcomes, including being three times as likely to die within the first year of life than a baby born at term.  You can read more about the effects of preterm birth here.

In her talk entitled “No Guts, No Glory: The Microbiome in Diabetes,” Meghan Jardine, M.S., M.B.A., R.D., L.D., D.D.E. notes that the critical shapers of gut biology are:

  • Natural delivery
  • Breast milk fed babies have probiotics
  • Formula fed babies have reduced/missing probiotics
  • By the time the child is 3 years old the gut composition is established
  • Over time, our environment continues to change our microbiota

A well designed 2012 study showed that taking probiotics during pregnancy affected the placenta and fetal gut and even the regulation of the infant’s microbiota. (Rautava S, Collado MC, Salminen S, Isolauri E. Neonatology. 2012; 102(3):178-84.)  Exposure also seems to correlate with reduced allergic diseases like eczema.

Mode of Birth and Feeding

Exposure to probiotics taken orally by the mother can be seen in the placenta and meconium of the fetus during pregnancy.  That said, the two most important factors found to shape the infant gut microbiota are mode of birth (vaginal vs cesarean) and feeding (breastmilk vs formula).

The overgrowth of lactobacilli in the vagina provides essential exposure for the baby to lactobacilli during vaginal births.  Babies do not get this exposure during a cesarean birth.  Many hospitals are swabbing mom’s vaginal area prior to cesarean birth in order to be able to transfer lactobacilli from the mom to the baby.  (Dominguez-Bello MG, et al. JC Nat Med. 2016 Mar; 22(3):250-3.) Be sure to swab well before the administration of any antibiotics given prior to surgery.  Exposing baby to the skin of the mother under her breasts and armpits during skin to skin time and breastfeeding over the first months of life help increase exposure. Additionally, babies born by cesarean who are breastfed should receive oral probiotics for the first four months of life.

The most abundant organisms in breast-fed infant guts are not the same as those found in formula-fed babies (Balmer SE, Wharton BA. Arch Dis Child. 1989 Dec; 64(12):1672-7.)  Breastmilk has elements which promote and nourish healthy bacteria in the baby’s gut.  Breastmilk feeds both the baby and the bacteria.  Babies who are formula fed should receive probiotics orally to help promote the growth of a healthy microbiota.

Prevention

As noted in the beginning of this article, prevention of GBS over-colonization should be seen as the first and best method to stop the long walk to full blown GBS disease.  In addition to preventing GBS exposure for babies, we can help maintain healthy microbiota and all of the benefits for mother, placenta, and baby that are the natural outcomes of that system.  In our day-to-day healthcare regimens, we should all be taking probiotics.  Every provider should be recommending probiotics along with a high quality prenatal vitamin at the first visit.  In an early release of data comparing midwifery care to OB care there was a very large difference in the number of patients who tested GBS positive between the two groups.  The numbers are still being teased out but one theory is the normalcy of midwives recommending probiotics to all patients.  (will update when final numbers are published)

The Solution

  • Take a daily form of probiotics (take 1-4 capsules per day) containing anywhere from 10-25 billion units of mixed flora but with high amounts of bacilli noted (available in grocery stores, Super Supplements or the Vitamin Shoppe).
  • Reduce the amount of sugar and refined carbohydrates you eat. GBS is a bacteria that tends to like sugary environments, and seems to colonize where there are not sufficient lactobacilli to keep it at bay.
  • Help keep your vaginal tract acidic and hostile to bacteria by taking probiotics and Azo Cranberry capsules (take one in the morning and one at night). Do not drink cranberry juice as the added sugar causes more harm than the cranberries help.

The Notes

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can get the high colonization in check. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/