Thursday, June 02, 2005

The Lesser of Two Evils

When I was pregnant with my second child, I was surprised to learn that a group B strep screen had been added to the standard prenatal test menu.

Group B streptococcus bacteria (GBS) can kill newborns. The problem is, at any given time 10-30% of women are colonized with it. It comes and goes from the vagina and usually causes the carrier no problem. If the newborn develops an infection from GBS passed during delivery, which happens in 0.5-1% of the cases, the baby has one in twenty odds of dying and higher odds of permanent disability from GBS-caused meningitis. (Data source: Centers for Disease Control)

The midwives handed me a pamphlet with this data in it and I tried to do the math while I was sitting on the bus: worst-case scenario, there’s a 30% chance I am a carrier. If I’m a carrier, there is a 1% chance of my passing GBS to my baby. 1% of 30% is 0.3%. And if my baby gets GBS, there is a 5% chance it will die. 5% of 0.3% is? 0.015%

I, sitting there on the bus holding my group B strep pamphlet, not knowing what bacteria were growing inside me, had a hundredth of a percent chance of having my baby die of GBS. Put another way, out of 100,000 pregnant women – nearly enough to fill the football stadium near my house, only 15 would lose their baby to this bacterial infection.

Until ACOG adopted the CDC recommendation for routine GBS screening, obstetricians and midwives determined whether a mother would receive antibiotic treatment based on certain risk factors (prolonged rupture, maternal fever, etc). Research demonstrated that it was far more effective to use prenatal screening as the means for identifying babies at risk, than using signs during labor.

The dilemma for natural birth proponents is that if your GBS test comes back positive, you have to have IV antibiotics during labor. In many hospitals an IV means no hydrotherapy. Not only that, but to ensure enough time for the medication to be effective, you need to have it in your system several hours before the baby is born. With one fell swoop, women lose the option of laboring at home until very late in labor, the chance to avoid an IV and the possibility of using a tub or shower in the hospital.

As always, this is a small price to pay for protecting your child from death. On the other hand, it’s completely unnecessary for the 199 babies out of 200 that never contract GBS from their GBS-positive mothers. Many women who use a doula are looking to avoid hospital interventions wherever possible. What do they do about the GBS screen?

One option is declining the test in the first place. If the hospital doesn’t know you are GBS positive, it doesn’t have grounds for the IV antibiotics protocol.

Another option is to get the screening and pray you’re negative. Though, interestingly, about 10% of women who test negative will have GBS at the time of delivery and 30% of the women who test positive for GBS will have cleared the bacteria by the time they deliver.

A final option, it seems to me, though I have never asked whether this is an option or not, would be to have the baby get the course of antibiotics after it is born, rather than giving them to the mother during labor. After all, this is what they do when a GBS-positive woman delivers before she’s had the antibiotic in her system long enough. And they do this with babies who, regardless of their mother’s GBS status, are born after labors with a lengthy rupture and/or maternal fever. So why not omit maternal antibiotics in the first place (in those instances where the mother prefers to labor without an IV) and treat the baby? Other than the needle stick to the baby, is there a reason to space her and not the mother? I am asking this in seriousness, since I honestly do not know.

I often get asked by families what my thoughts are on this. I tell them it is a frustrating situation to be in, but a situation (when they’re debating declining the test) they have to come to terms with nevertheless. If they get the test, they have a 10-30% chance of testing positive and receiving the treatment that comes with it. If they don’t get tested, their child is 99.7% likely to be untouched by GBS anyway.

The odds are in your favor, I point out.

Then I tell them that when I rode the bus and did the math and looked at that pamphlet detailing what could happen to my child IF…I decided to get screened.


Blogger Pink Lady said...

I was told I was GBS positive around 30 weeks or so. I had an emergency c-section at 34 weeks, but was OB/GYN never gave me any antibiotics for it. Either they forgot or didn't care. Judging by my doctors lack of...doctoring after my c-section and during my subsequent infection, I've decided she just didn't care.

9:49 AM  
Blogger Suburban Turmoil said...

Having had a baby a little more than a year ago without a doula (but with an incredible nurse who along with my husband was frankly all I needed), with real actual doctors and with an epidural (at the last possible moment, but still...), I just don't understand this push for natural birth and no doctors. We all hope for a perfect birth experience, but if something goes wrong, don't you want a neonatal unit and lots of doctors around? And why would anyone choose not to have a Group B strep test???!!! I have a friend whose baby was born with Group B strep and nearly died, all because her doctor didn't even tell her the Group B strep test was available. And you're telling me some women are choosing not to have this test run? You'd have to be an idiot. The birth experience is not about you and your fantasies (and I mean "you" universally, not you Doulicia)- It's about delivering a healthy baby. In the end, that's all that matters. So I don't understand why something like this would even be optional to a pregnant woman. And don't even get me started over women who had an emergency c-section and are "grieving" over missing out on the natural birth process. Another mother in my play group came out with that one the other day. Try having your baby die in childbirth or end up with serious complications and you'll know the true meaning of grief.

9:53 AM  
Anonymous Anonymous said...

Suburban Turmoil, the answers to your questions are fairly easy for me. I understand why, from your surface view, you would think a woman an "idiot" for choosing to not hospital birth or even for not testing for GBS... but I assure you, there are good reasons. First, I'd like to point out that what was good yesterday... isn't always good today. In the late 1950s, Thalidomide was given to several pregnant woman (who clearly trusted their physician's choices) for morning sickness and, as a result, they had babies with severe deformities (boneless, flipper-like feet and hands being one). This initiated a new process in testing safety of medications for pregnant women, however, let's look at some other facts. From 1938 to the late 1970s, DES was another drug given to pregnant women that, in 1971, was linked with causing miscarriage, deformities to the fetus and a rare vaginal cancer. Even after this link was established, the US continued to administer it for not just months but years. Man, isn't the money made off of pharmaceuticals (and health care) powerful?! Anyhow, it seems to me that there are a HIGH percentage of women in the US that choose to not REALLY review the risks involved in procedures and tests that our obstetrical societies deem "safe enough" every day for pregnant women... because they simply trust their physician (and sometimes, unfortunately, because they feel pressured to do what is "the norm" because it feels "safest"). The doctor IS their resource. To me, this is so sad. The fact is that US doctors, in general, give care based on liability... or based on what their practice deems best as a whole (still liability-related), NOT what, without a doubt, is best for you and your baby. Of course, I don't believe the physicians are out to harm... but I DO believe the physicians are following guidelines comprised by companies (insurance, drugs) that are thinking of one thing: MONEY. I have found that, most commonly, when an obstetrician finds a drug/procedure that APPEARS to work well for his/her patients... he/she will continue the use of it. When a woman is intelligent enough to see that she is being lead down a road of "cultural practice" rather than what is absolutely safe, she will press deeply enough to discover the horrifying risks involved in these procedures. A few examples are the oh-so-popular epidural and spinal blocks. Try reading some birth stories or speaking to a variety of other women who have had them. Any permanent pains in the back/neck/legs now? Some aren't so fortunate... they're left permanently paralyzed or with what is called "spinal headaches" which are debilitating. The procedure involved in curing THAT one is called a "blood patch".. with its OWN set of risks. Epidurals/spinal blocks DO pass through the placenta. Physicians will dismiss the amount when you press about it "oh, well, if any does, it's minor"... but compare a baby born w/out the drugs to one with... and form your own opinion. Many labors will slow with the use of medications. Many women will find their babies suddenly with dropping heartbeats. Do you KNOW the reasons for C-section? Think these narcotics could lead you to one? Anyhow... I think I've covered enough here to make my point about why I home birth: hospitals are for emergencies and OBs practice preventing problems that yet exist... and, in their practice of prevention, they more often than not, CAUSE the problems. I say that I have a better chance of having a normal, healthy baby at home than in a hospital. Of course, this is my view - shared by some, shrugged by others. WHY I would choose to not test for GBS. Well, you'll need to go read up on GBS to understand that. As our initial posting stated, you have what? a 1/100,000 chance of having a baby seriously affected by this? Here is something to think about... how do they treat women with GBS? Doses of antibiotics through IV every 4 hours through labor perhaps? Okay... How much research has gone into this practice? What statistics have been formed showing death due to antibiotic-resistance illnesses (in GBS-treated babies) to those born and who died due to GBS? New practices are on the rise constantly... and medications are being pushed out faster and faster for a growing industry. The choices involved in having a baby, for some, is easy. If a problem arises out of a procedure... it was either "a mishap" or the physician's fault. So much easier on the woman's mind, isn't it? But, for the researcher, for the thinker, for the open-eyed woman... protecting her child and herself is a complex process and any one human, regardless of *assumed* knowledge, isn't to be trusted alone.

9:22 PM  
Anonymous Anonymous said...

Suburban Turmoil...I understand where you are coming from (as I was of the same mind not that long ago) but I have to warn you that your reasoning is extrememly naive. Like annonymous mentioned most dr's practice in a way to avoid liability and will only tell you as much as you need to know to consent to their wishes. That doesn't mean they don't want what is best for you, but they literally cannot give you options that stray from ACOG recommendations because should something go wrong, you can sue them. Rarely will they inform you of all the risks of procedures that are deemed the "norm". Not because they do not care for your welfare, but because they don't want you to freak out and decline the procedure. As long as you follow the ACOG guidelines they are not liable should something go wrong. All those risks associated with "normal" procedures that are recommended by ACOG, they are not liable for because you sign a general consent form stating that you agree to follow these guidelines & are aware of the risks. But are you aware of the risks?

For you know the risks to a newborn when the mother has been given IV antibiotics to treat GBS? I did not. My dr. only told me about the horrible risks associated with NOT treating for GBS. However, there is a growing amount of research (and I mean a lot) showing the link between GBS prophylaxis and childhood eczema, hay fever, asthma, and allergies. In fact, the increase of these conditions can be traced and connected to the year that ACOG made the policy to test everyone for GBS and also to the year when they made the decision to give antibiotics to all positive women.

Also, did you know that the infant can still contract bacteria resistent strains of GBS and e. coli despite the antibiotics? In addition there is a huge increase in the occurance of yeast infection for mom, thrush, colitis and a host of other gastrointestinal complications later in life. Why? Because when a mother gives birth vaginally the baby is colonized with healthy bacteria/flora on his way out so to speak. The baby is completely sterile in your uterus, but he NEEDS certain healthy bacteria in order to kick start his immune system and certain digestive and gastro-intestinal functions. That healthy flora gets transfered to the baby from you while he is exiting your vagina. However, antibiotics kill the healthy bacteria, meaning non get to baby and totally disrupting mom's system. Did you know that? I didn't. No one bothered to tell me that at the dr's office. They didn't go over this information at my childbirth class. In fact, unless you are a med student I doubt you would ever know that this is an important part of the birth process.

Did they warn you of this before your c/s? No, because the c/s was probably more important for your child's health then telling you there is a change your child will get eczema or asthma or allergies. Obviously any mother would want to have a child ALIVE and deal with allergies then risk the child's life. Did they warn you that your child might have breathing problems due to being delivered via c/s? Because exiting via the vaginal canal suctions and establishes the proper pressure in the lungs of an infant. Probably not. Again, because having your child remain alive is more important. I'm not knocking the fact that there are complications that require a c/s, but your disregard for mother's who are adamant about delivering vaginally is not fair. They have a very good reason for this desire!

I agree that a mom must do everything possible to ensure a healthy baby, but that INCLUDES being informed and making informed decisions. Relying on your dr. doesn't cut it. Not unless that dr. is a family memeber who will give you honest advice and thorough information.

9:45 AM  
Anonymous Anonymous said...

Ok...not getting into the whole debate of hospital/homebirth or medically assisted/nautural births, I don't understand why anyone would want to turn this test down. I have had 2 children and am pregnant with the 3rd now...I opted for the GBS test with both, and with both I tested positive. So I will defiantly be getting tested with this baby too.

That being said, a girl I went to high school with, with whom I talk to every now and again through myspace, had a little girl about 6 or so months ago. She did the test for GBS, and it came back negative (good for her)..but as the blog said, 10% of women will have GBS by the time of birth after testing negative for it. This was the case with this girl, she tested negative, had the baby, and went home after the normal 1 day wait. The only problem being, her baby ended up contracting the GBS, and ended up dying at just a month old. The odds were only 0.0015%, but it still happened.

I just think that even 0.0015% is too much of a risk for my baby's life, when all it comes down to is a simple IV during labor. I will take the IV over the risk anyday thank you very much.

2:29 PM  
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5:02 AM  

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