Pelvic floor disorders linked to mode of delivery among first-time mothers

Nine-year, NIH-funded study suggests that C-sections present lower risk compared to vaginal delivery

A first-time mother’s risk of pelvic floor disorders is strongly associated with how her baby is delivered, according to a study funded by the National Institutes of Health. 

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  NIH-funded study suggests that C-sections present lower risk compared to vaginal delivery

Pelvic floor disorders are thought to result from weakening or injury of the muscles, ligaments and connective tissue in the lowest part of the pelvis. The study, funded by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development, was led by Victoria Handa, M.D., of Johns Hopkins Bayview Medical Center, Baltimore, and appears in the Journal of the American Medical Association.

Researchers enrolled more than 1,500 women into the study after their first birth; 778 of the women delivered by cesarean, 565 by spontaneous vaginal delivery, and 185 by operative vaginal birth (delivery assisted by forceps or other devices to extract the fetus). After up to nine years of observation, researchers found that women who delivered by Cesarean were at approximately half the risk of developing stress urinary incontinence (incontinence resulting after a cough, sneeze or other activity) and overactive bladder, compared to women who had a spontaneous vaginal birth. Their risk of pelvic organ prolapse (when the cervix and uterus drop into the vagina and protrude through the vaginal opening) was 70-percent lower, compared to the same group. Women who had operative vaginal delivery were almost twice as likely to experience anal incontinence and pelvic organ prolapse, compared to those who delivered by cesarean.

According to the study authors, earlier studies had linked pelvic floor disorders to childbirth, but little was known about how the mode of delivery might influence their development. Treatments for pelvic floor disorders include exercises to strengthen pelvic floor muscles, medication for bladder control problems and surgery to repair the pelvic floor and provide support for internal organs.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) conducts and supports research in the United States and throughout the world on fetal, infant and child development; maternal, child and family health; reproductive biology and population issues; and medical rehabilitation.

The nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. 

NIH scientists find that breast cancer protection from pregnancy starts decades later

Breast cancer risk remains elevated 20-30 years after childbirth.

The study suggests breast cancer protection from pregnancy may not begin until as many as 30 years after the last pregnancy.NIEHS

In general, women who have had children have a lower risk of breast cancer compared to women who have never given birth. However, new research has found that moms don’t experience this breast cancer protection until many years later and may face elevated risk for more than 20 years after their last pregnancy.

Scientists at the National Institutes of Health, along with members of the international Premenopausal Breast Cancer Collaborative Group, found breast cancer risk increases in the years after a birth, with the highest risk of developing the disease about five years later. The findings, which appeared online in the Annals of Internal Medicine, suggest breast cancer protection from pregnancy may not begin until as many as 30 years after the birth of the last child. 

According to senior author Dale Sandler, Ph.D., head of the Epidemiology Branch at the National Institute of Environmental Health Sciences (NIEHS), part of NIH, a few prior studies reported an increase in breast cancer risk after childbirth. However, most of what researchers knew about breast cancer risk factors came from studies of women who have gone through menopause. Since breast cancer is relatively uncommon in younger women, it is more difficult to study.

Researchers combined data from approximately 890,000 women from 15 long-term studies across three continents, to understand the relationship between recent childbirth and breast cancer risk in women age 55 and younger.

“We were surprised to find that an increase in breast cancer risk lasted for an average of 24 years before childbirth became protective,” said Sandler. “Before this study, most researchers believed that any increase in risk lasted less than 10 years.” 

The scientists also found that the association between recent childbirth and breast cancer risk was stronger for women who were older at first birth, had more births, or had a family history of breast cancer. Breastfeeding did not appear to have any protective effect, even though it is generally thought to reduce breast cancer risk. Many of these additional factors were not addressed in earlier studies, underscoring the statistical power of this larger project.

Sandler and first author Hazel Nichols, Ph.D., of the University of North Carolina Lineberger Comprehensive Cancer Center, started the study when Nichols was a research fellow at NIEHS. Nichols explained that childbirth is an example of a risk factor that is different for younger women than older women.

“This difference is important because it suggests that we may need to develop tools for predicting breast cancer risk that are specific to young women,” Nichols said. “Doing so would help women talk to their health care providers about when they should start mammography screening.”

Nichols and Sandler both stressed the importance of keeping these findings in perspective.  Breast cancer is uncommon in young women. An increase in the relative risk of breast cancer in women under age 55 translates to a very small number of additional cases of breast cancer per year. 

Anthony Swerdlow, D.M., D.Sc., Ph.D., and Minouk Schoemaker, Ph.D., scientists at the Institute of Cancer Research, London, co-led the study with Sandler and Nichols.

Nearly 30 million sick and premature newborns in dire need of treatment every year

Nearly 30 million babies are born too soon, too small or become sick every year and need specialized care to survive, according to a new report by a global coalition that includes UNICEF and WHO.

“When it comes to babies and their mothers, the right care at the right time in the right place can make all the difference,” said Omar Abdi, UNICEF Deputy Executive Director. “Yet millions of small and sick babies and women are dying every year because they simply do not receive the quality care that is their right and our collective responsibility.”

The report, Survive and Thrive: Transforming care for every small and sick newborn, finds that among the newborn babies most at risk of death and disability are those with complications from prematurity, brain injury during childbirth, severe bacterial infection or jaundice, and those with congenital conditions. Additionally, the financial and psychological toll on their families can have detrimental effects on their cognitive, linguistic and emotional development.

“For every mother and baby, a healthy start from pregnancy through childbirth and the first months after birth is essential,” said Dr Soumya Swaminathan, Deputy Director General for Programmes at WHO. “Universal health coverage can ensure that everyone – including newborns – has access to the health services they need, without facing financial hardship. Progress on newborn health care is a win-win situation – it saves lives and is critical for early child development thus impacting on families, society, and future generations.”

Without specialized treatment, many at-risk newborns won’t survive their first month of life, according to the report. In 2017, some 2.5 million newborns died, mostly from preventable causes. Almost two-thirds of babies who die were born premature. And even if they survive, these babies face chronic diseases or developmental delays. In addition, an estimated 1 million small and sick newborns survive with a long-term disability.

With nurturing care, these babies can live without major complications. The report shows that by 2030, in 81 countries, the lives of 2.9 million women, stillborns and newborns can be saved with smarter strategies. For example, if the same health team cares for both mother and baby through labour, birth and beyond, they can identify problems early on.  

In addition, almost 68 per cent of newborn deaths could be averted by 2030 with simple fixes such as exclusive breastfeeding; skin-to-skin contact between the mother or father and the baby; medicines and essential equipment; and access to clean, well-equipped health facilities staffed by skilled health workers. Other measures like resuscitating a baby who cannot breathe properly, giving the mother an injection to prevent bleeding, or delaying the cutting of the umbilical cord could also save millions. 

According to the report, the world will not achieve the global target to achieve health for all unless it transforms care for every newborn. Without rapid progress, some countries will not meet this target for another 11 decades. To save newborns, the report recommends:

• Providing round-the-clock inpatient care for newborns seven days a week.
• Training nurses to provide hands-on care working in partnership with families.
• Harnessing the power of parents and families by teaching them how to become expert caregivers and care for their babies, which can reduce stress, help babies gain weight and allow their brains to develop properly.
• Providing good quality of care should be a part of country policies, and a lifelong investment for those who are born small or sick.
• Counting and tracking every small and sick newborn allows managers to monitor progress and improve results.
• Allocating the necessary resources, as an additional investment of US$ 0.20 cents per person can save 2 of every 3 newborns in low- and middle-income countries by 2030.

Almost three decades ago, the Convention on the Rights of the Child guaranteed every newborn the right to the highest standard of health care, and it is time for countries around the world to make sure the legislative, medical, human and financial resources are in place to turn that right into a reality for every child, the report says.

WHO study shows drug could save thousands of women’s lives

A new formulation of a drug to prevent excessive bleeding following childbirth could save thousands of women’s lives in low- and lower-middle-income countries, according to a study led by the World Health Organization (WHO) in collaboration with MSD for Mothers and Ferring Pharmaceuticals.

Currently WHO recommends oxytocin as the first-choice drug for preventing excessive bleeding after childbirth. Oxytocin, however, must be stored and transported at 2–8 degrees Celsius, which is hard to do, in many countries, depriving many women of access to this lifesaving drug. When they can obtain it, the drug may be less effective because of heat exposure.

The study, published on 27 June 2018, in the New England Journal of Medicine, has shown an alternative drug – heat-stable carbetocin – to be as safe and effective as oxytocin in preventing postpartum haemorrhage. This new formulation of carbetocin does not require refrigeration and retains its efficacy for at least 3 years stored at 30 degrees celsius and 75% relative humidity.

“This is a truly encouraging new development that can revolutionize our ability to keep mothers and babies alive,” says Dr Tedros Adhanom Ghebreyesus, Director-General of WHO.

Approximately 70 000 women die every year because of post-partum haemorrhage – increasing the risk that their babies also die within one month.

The clinical trial, the largest of its kind, studied close to 30 000 women who gave birth vaginally in 10 countries: Argentina, Egypt, India, Kenya, Nigeria, Singapore, South Africa, Thailand, Uganda and the United Kingdom.

Each woman was randomly given a single injection of either heat-stable carbetocin or oxytocin immediately following the birth of her baby. The study found that both drugs were equally effective at preventing excessive bleeding after birth.

Since both drugs in the study were kept in at the temperatures required to ensure maximum efficacy of oxytocin, the trial may underestimate the benefit expected with heat-stable carbetocin use in real-life settings where oxytocin may have degraded due to exposure to higher temperatures.

“The development of a drug to prevent postpartum haemorrhage that continues to remain effective in hot and humid conditions is very good news for the millions of women who give birth in parts of the world without access to reliable refrigeration,” says Dr Metin Gülmezoglu, from the Department of Reproductive Health and Research at WHO.

The next step is regulatory review and approval by countries. WHO will ask its Guideline Development Group to consider whether heat-stable carbetocin should be a recommended drug for the prevention of postpartum haemorrhage.

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About the study

This WHO study, also referred to as the CHAMPION (Carbetocin HAeMorrhage PreventION) trial, was funded by MSD for Mothers. Heat-stable carbetocin was provided by Ferring Pharmaceuticals, the product innovator and oxytocin was provided by Novartis for the study. The study was conducted under a collaborative arrangement between WHO, MSD for Mothers and Ferring Pharmaceuticals. Following the positive results from the trial, the parties will now work to advance affordable access to this lifesaving drug in countries that have a high burden of maternal deaths.