I’m tossing yet another tidbit of information for Mamas on Bedrest to share and discuss with their doctors.
In a study published online on December 14, 2011 in the American Journal of Obstetrics and Gynecology, a coalition of researchers from around the world (United States, Austria, Brazil, Denmark, India, South Africa, Turkey, and the United Kingdom) concluded that vaginal progesterone, administered in the mid-trimester of pregnancy to women with shortened cervix detected via ultrasound, can cut their risks of preterm labor by as much as half.
I found this information very interesting given the current brouhaha over Makena (the progesterone injections used for prevention of preterm labor) and how progesterone is often used early in pregnancy for women with repeated miscarriages (my situation!).
The researchers reviewed data from 5 highly respected studies and evaluated the efficacy and safety of using vaginal progesterone for the prevention of preterm labor in the presence of cervical shortening with rates of neonatal morbidity and mortality. Here are their findings:
- Vaginal progesterone reduced the rate of birth at less than 33 weeks’ gestation by 42% . It also reduced the risk for birth at less than 35 weeks’ gestation by 31% and less than 28 weeks’ gestation by 50% *.
- Vaginal progesterone also improved the following outcomes: respiratory distress syndrome, a composite measure of neonatal morbidity and mortality, birth weight less than 1500 g, admission to neonatal intensive care unit and need for mechanical ventilation.
Given these outcomes, one would think that physicians and researchers across the board would be recommending that women receive progesterone if they presented with shortened cevix. But such was not the case. Two commentators felt that the data was not conclusive enough. Sarah Bradley, MD, clinical assistant professor of obstetrics and gynecology from the University of Wisconsin–Madison felt that the data was “murky”. Her position stemmed from the fact that different studies used different definitions for shortened cervix. She also noted that many women had received a cervical cerclage (surgical stitch placed to keep the cervix closed) in addition to the progesterone and felt that it couldn’t be definitively stated that the progesterone was in fact the true reason that preterm labor was averted.
Aaron B. Caughey, MD, PhD, director of women’s health and chair of obstetrics and gynecology, Oregon Health Sciences University, Portland, had a similar comment on the definition of shortened cervix. He also felt that the meta-analysis really didn’t add any new information to what is already “standard of care”.
As a result, researchers recommend that women be advised of both treatments. While it is commonly recognized that either a cerclage or progesterone alone is often enough to prevent preterm birth, many women may elect to have both treatments and that is okay. Researchers also recommend that further research be undertaken to specify “shortened cervix” and to give specific measurements at which treatments are beneficial. They also recommend research to assess the effects of race, ethnicity, socioeconomic status, and maternal age on cervical shortening and preterm labor.
While I’m all in favor of evidenced based research, sometimes I think we analyze things to death. We know that adequate progesterone levels are essential to maintaining a healthy pregnancy. We see progesterone used in early pregnancy, especially in cases where women have undergone fertility treatments and/or have luteal phase defects resulting in repeated miscarriage. We know that progesterone injections (Makena and compounded variations) are effective in prolonging pregnancy in the instances of preterm birth later in pregnancy but before 37 weeks gestation. So I am not surprised that using vaginal progesterone is effective in helping prolong pregnancy and prevent preterm birth in cases of shortened cervix.
But I am surprised that commentators are pulling up short in making the recommendation that vaginal progesterone be used in the mid-trimester. Is it really necessary to determine that progesterone alone will prevent preterm birth in the presence of a cerclage? Is it really so awful if a woman has a cerclage and uses vaginal progesterone if she has a shortened cervix? And while it will be nice to know how efficacious progesterone is in various races, ethnicities, socioeconomic levels and in women of advanced maternal age, must we wait to have all this data before making recommendations? Can’t we do the work concurrently? It has been shown that use of progesterone produces more good than harm, so why not use it as currently stated and make the specific recommendations as the study data becomes available?
Many will judge my opinion and I am fine with that. But I was a woman who had repeat miscarriages until we figured out that my progesterone levels were not adequate to support pregnancy to term (beyond 1st trimester actually!). I know women who benefited from having progesterone injections in the second and third trimesters to prolong their pregnancies. I think that I can safely say, It didn’t matter if we were white or black, rich or poor, “old” or young, if it helped us to maintain our pregnancies and have healthy babies, we were all for it! If it helps specific subgroups, even better.
But on behalf of high risk pregnant women everywhere, please don’t wait to use a treatment that has been shown to be safe and efficacious in preventing preterm birth just so that you can get “exact” data. If you know that progesterone is efficacious in preventing preterm birth in a woman who has a cervix of 20mm and has a cerclage, why not try it in a woman whose cervix is 15mm or even 10mm? If she is at such risk, why not try? As a physician and scientist, you may think that it’s a waste. But for the mama desperately hoping and praying for her baby, it’s hanging on to all hope by a thread. Please don’t cut us off.
*This post is a summary and commentary of the MedScape report and the published article in The American Journal of Obstetrics and Gynecology online journal. Statistical information was attenuated for ease of reading. To read the full study results, please read the complete texts provided here.
Have you taken progesterone during pregnancy? What was your experience? Please share you thoughts below. Sign up for our RSS feed on the upper right hand corner of our webpage and receive blog posts immediately when they are uploaded. Follow us on Twitter (@mamasonbedrest) and on Facebook.
Click to take the postpartum depression survey conducted by Case Western Reserve University http://filer.case.edu/~axp335/postpartdep.htm Thank you very much for your consideration.
On the heels of the 20/20 special segment, “Giving Life: A Risky Proposition” World Health Organization (WHO) has released Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health. This comprehensive document outlines the necessary steps and guidelines nations (developing low and mid income nations in particular) must adopt in order to further reduce maternal, infant and child mortality and to have a chance of reaching Millennium Development Goals .
Maternal, Infant and Child mortality is a global issue. According to the report,
Annually, 358,000 women die worldwide during pregnancy and childbirth. Approximately 7.6 million children die before the age of 5 years, and those in low-income countries are about 18 times more likely to die during that time than children in high-income countries. Under-5 mortality rates are highest in sub-Saharan Africa and Southern Asia.
Maternal, newborn, and under-5 mortality rates have declined in accordance with Millennium Development Goals 4 (reduce the under-5 mortality rate by two thirds between 1990 and 2015) and 5 (reduce the maternal mortality ratio by three quarters between 1990 and 2015). However, the improvements are not occurring quickly enough to reach the 2015 targets.
WHO and its partners The AGA Khan University (in Pakistan) and The Partnership for Maternal, Newborn and Child Health performed a survey of more than 50,000 review papers to determine what steps are necessary to critically impact maternal, newborn and child health. Their goal was to identify key interventions that low and middle income countries can implement that are cost effective, will maximize resources and maximize the health and mortality of women, infants and children and thus help these countries reach worldwide millennium health and development goals. Their research has revealed some 56 key evidence-based interventions that when implemented, will have a significant impact on maternal, newborn and child health.
Rather than try and list all the interventions here, I refer you to their report, Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health.
For each intervention, the authors indicated whether they recommend the intervention be delivered,
- Through the community or in the home-These health care workers are often community volunteers and/or influential outreach workers who have knowledge of the local community and are trusted by the community.
- Via healthcare professionals, outreach workers, or community health workers-Health care providers at this level are skilled professionals as well as outreach workers.
- In hospitals-Either local hospitals or regional referral hospitals that can provide higher levels of intervention and care.
The interventions were classified broadly as adolescents/prepregnancy, pregnancy, childbirth, postnatal (mother), postnatal (newborn), infancy and childhood, and cross-cutting community strategies.
Researchers believe that the recommendations in this report will help low and middle income countries’ health care workers best utilize their resources in an effort to reduce Maternal, Newborn and Child deaths. These guidelines will also help countries develop policies and regulations that will not only benefit women and children’s health, but also take into consideration the health care and policy environments of the countries so that all citizens will benefit.
Wow, I just watched Diane Sawyer’s special on ABC’s 20/20, “Giving Life: A Risky Proposition”.
First and foremost, I am really glad to see mainstream media tackling such an important global issue. Diane Sawyer and her colleagues traveled around the world to some of the most impoverished countries and witnessed some of the most horrendous conditions under which the world’s women are giving birth (and losing life!). The statistics were often staggering and disheartening,
- Girls under 15 are 5 times more likely to die in childbirth (and in many developing countries, girls even younger are giving birth!)
- In developing countries, 20% of women will give birth with no medically trained attendant.
- 1 in 21 women die in childbirth in Sierra Leon, more than in any other country in the world.
- Peripartum hemorrhage is the leading cause of maternal mortality. Misoprostol is critical to stop post partum hemorrhage and is in short supply to developing nations.
- The US ranks 50th in maternal mortality in the world. (This is the stat presented in the TV piece. “The US rank is 41st in maternal mortality” is what’s printed in the ABC News Press release.)
- Georgia has one of the highest rates if maternal mortality in the US.
- 2 women die in childbirth daily in the US. Rates are 4x higher for African American women in the US.
As one expert (sorry, I didn’t catch his name) said so eloquently,
“We have what it takes to save lives. The Question is will we decide to do it?”
I just had a similar conversation with , LM, CPM, founder and Executive Director of Common Sense Childbirth, The Birth Place, Easy Access Prenatal Clinics and creator of prenatal care “The JJ Way”. Jennie has put together an effective early access prenatal care program and is working tirelessly to bring it to women throughout central Florida, across the United States and globally where ever needed. As we talked about the issues affecting maternity care in the United States, we reached a similar conclusion; That low cost, low intervention, effective methods of delivering prenatal care are available. We have to decide as women and as a nation whether or not we are going to make the choice to make safe, accessible maternity care available to ALL women.
It really is a choice. While watching the 20/20 special, they showed a young obstetrician who had traveled to Sierra Leon and was desperately trying to help women in a nationally funded hospital that was so poorly equipped and so poorly staffed that she literally watched as a woman hemorrhaged post partum because there were so few tools available for her to intervene. Yet, there was a clinic staffed and supported by the women of Sierra Leon and there, women received supportive care and the outcomes at this locally supported clinic were far better than the outcomes for the nationally funded hospital.
In Bangladesh, maternal mortality was spiraling out of control. When skilled maternity workers realized that women were not coming to the hospitals and clinics erected, they started taking maternity services to women in their homes-the method used for centuries and the method of childbearing most familiar to the women. As a result, Bangladesh has dropped is maternal mortality rate 43%. In addition, birth workers in Bangladesh are using cell phones and an increasing rate and as a result, they are able to communicate with physicians and other workers as needed while still serving women in their most comfortable environment.
In Mexico, the government started a national campaign for contraception when birth rates and maternal and infant mortality were skyrocketing. Since implementing a contraceptive campaign and extolling the benefits of smaller families and fewer conceptions for women, Mexico has seen 76% of women using contraception. It must be noted that for all its benefit, contraception is still not widely accepted amongst men, and many still hold onto old notions of “Machismo” where the more children a man sires, the more manly he is! As a result, many women access contraception secretly in an effort to improve their opportunities in life, to have reproductive choice and to improve their overall health.
So what’s it going to be? Are we going to continue to wring our hands and lament the abysmal maternal and infant mortality numbers in this country or are we going to do something about it? Jennie Joseph is doing it. Shafia Monroe is doing it with her International Center for Traditional Childbearing.DONA International is doing it. Centering Healthcare is doing it. We can do it. Million Moms Challenge showed what can be done when we work collectively. When Johnson & Johnson pledged to donate $100,000 if the Million Moms Challenge gathered 100,000 supporters, they went to work, gathered the supporters and recouped the money. In fact, Million Moms raised more than $1.5 million dollars to support work that improves health of women, infants, children and communities.
It has been stated and shown, “We have what it takes to save lives.” The question now is, “Will we do it?”
Photo is courtesy of yfrog and printed with permission.
What will you do to improve maternal mortality in the US and abroad? What would you like to see done? Share your vision with us here, or send an e-mail to firstname.lastname@example.org. We’re talking about it on Twitter, @mamasonbedrest, and will also take your comments on Facebook. To stay in the loop, be sure to subscribe to our blog via the RSS feed on the upper right hand corner of our pages.