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tag:theconversation.com,2011:/us/topics/pregnancy/articles Pregnancy – Articles – The Conversation 2015-03-25T03:47:48Z tag:theconversation.com,2011:article/38500 2015-03-25T03:47:48Z 2015-03-25T03:47:48Z The 2015 flu vaccine – what's new, who should get it and why

For certain members of the community, catching flu can lead to severe illness or death. Piotr Marcinski

It's that time of year again when scientists and doctors make predictions about the impending influenza (flu) season and we must decide whether to go out and get the flu vaccine.

The government-funded flu vaccine will be available from 20 April, a month later than most years, as the vaccine has been reformulated to cover a new strain. But some GPs may offer the vaccine privately before then.

So, who should consider getting the vaccine and who gets it for free? And are we really in for a bad flu season in Australia?

How does the vaccine work?

The flu vaccine helps prevent us from getting the flu each season. It contains dead, broken-up bits of flu viruses that are expected to circulate during the upcoming season.

Once injected into our arms, the pieces of dead virus stimulate our body's immune response to produce antibodies, which act as a defence that can rapidly swing into action when a live flu virus infects our nose and throat.

Because the viruses in the vaccine are dead, they can't give us flu.

What's new about flu vaccines in 2015?

For the first time, Indigenous children are able to access free flu vaccine in Australia.

This is important because Aboriginal and Torres Strait Islander children are five times more likely to be hospitalised with flu and pneumonia than non-Indigenous children. Indigenous children are also 17 times more likely to die from flu or pneumonia than non-Indigenous children.

 Australia's vaccine has been updated to protect against the harmful new A(H3N2) viruses. El Alvi/Flickr, CC BY

This year a new flu vaccine, known as "quadrivalent", will be available. This type of vaccine contains four flu viruses compared with three in the normal trivalent vaccine. The additional flu strain provides extra insurance that may be useful if unexpected viruses begin to circulate.

However, it's likely that the standard trivalent vaccine will cover the great majority of the flu A and B strains expected to circulate in Australia this winter.

The quadrivalent vaccine won't be available via the government's free flu vaccine program and will be more expensive than the standard trivalent vaccine if purchasing it privately.

Who should get the flu vaccine?

For certain members of the community, catching flu can lead to severe illness or death. It is these "high-risk" groups (listed below) that should actively avoid catching it. Getting the flu vaccine is a major step towards achieving protection from flu.

Certain groups of individuals at high risk of developing severe illness or complications if infected with flu are eligible for free flu vaccine via the federal government. These are:

Anyone aged 65 years or over

Aboriginal and Torres Strait Islander people aged 15 years or over

Aboriginal and Torres Strait Islander children aged between six months and five years

Pregnant women

Anyone with with medical conditions that can lead to severe influenza, including people with heart disease, severe asthma and diabetes. A full list of eligible medical conditions can be found here.

Within the over-65 age group, a high proportion of people are vaccinated (more than 70%).

But although the flu vaccine is provided free of charge to vulnerable people, many still don't get it. Less than 30% of pregnant women and Indigenous people receive the flu vaccine. Only half of those with medical conditions that can lead to severe influenza get vaccinated.

 Fit, healthy children can't always fight off a flu. Chaikom/Flickr

Although not included in the government's free flu vaccine program, children under the age of two years are also highly susceptible to flu.

Once infected with flu, young kids are more likely to be hospitalised with severe illness than those in the over 65 age group. About half of young children who die from the flu are otherwise healthy with no underlying medical conditions or known risk factors.

Most children who die from flu are not vaccinated. Therefore the idea that fit, healthy infants can simply "fight off" a flu infection without any problem is not always true.

Another benefit of preventing flu in children is that it reduces the spread of infections to other vulnerable family members such as grandparents.

What's in store for us this winter?

The one predictable thing about flu, is that it is unpredictable! However, we often look to the northern hemipshere's winter flu season to give some insights into what might be expected here.

The recent flu season in the United States and most of Europe was dominated by the A(H3N2) strain of flu. This virus has historically been associated with increased severity in the elderly.

There has been a lot of media coverage about bad vaccine match in the northern hemisphere. This is because most of the serious influenza was caused by the A(H3N2) viruses which had changed over the five to six months when the vaccine producers were manufacturing the vaccine. But the other components of the vaccine were well matched.

Our vaccine has been updated to protect Australians against the new A(H3N2) viruses.

So, if you or a loved one fall within the high-risk groups described above, getting the vaccine remains the most effective way to avoid the inconvenience and potentially severe health risks of the flu – and passing it on.

Aeron Hurt is a Senior Scientist at the WHO Collaborating Centre for Reference and Research on Influenza, VIDRL based at the Peter Doherty Institute, Parkville, Melbourne. Aeron is also an honorary Principal Fellow at the University of Melbourne within the Melbourne School of Population and Global Healths The Melbourne WHO Collaborating Centre for Reference and Research on Influenza is supported by the Australian Government Department of Health and also receives funding from the IFPMA (International Federation of Pharmaceutical Manufacturers & Associations) and Novartis Vaccines under cooperative research agreements. AH holds shares in CSL Limited, a manufacturer of influenza vaccines.
 Aeron Hurt, Senior Research Scientist & Head of Antiviral Sensitivity Analysis at WHO Collaborating Centre for Reference and Research on Influenza Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/34273 2014-12-19T10:53:14Z 2014-12-19T10:53:14Z Babies in your 30s? Don't worry, your great-grandma did it too

Freeze your eggs or free your career? Woman via g-stockstudio/Shutterstock

The shift towards late motherhood – commonly defined as motherhood after 35 – is often presented as a story of progress and technological liberation from the biological clock.

The narrative goes something like this: Before the widespread availability of the Pill women had no choice but to have children in their teens and early twenties. But the introduction of effective contraception meant that women could trade babies for briefcases. And technologies such as IVF, egg donation and egg freezing allow women to beat the biological clock, freeing them from the tyranny of their own biology. A recent Newsweek headline, for example, announced that women can now "freeze" their biological clocks, while the cover of Businessweek urged women to "Freeze Your Eggs, Free Your Career."

While this triumphal narrative contains a few grains of truth, it is as simplistic as it is satisfying. History shows us that the "best age" to have a child is very much a product of the cultural and economic moment, not a just dictate of biology that we need to escape.

Changes throughout the 20th century

In motherhood manuals published in the early 20th century, eugenicists warned women to wait until they were at least 24 to have children, lest their offspring suffer from both their biological and emotional immaturity. But the manuals cautioned women from waiting too long, however, as postponing childbirth also increased the likelihood of sterility.

In the late 1920s, one sociologist recalled that couples who had children soon after marriage were the targets of gossip and severe judgment. The Great Depression also added to the popularity of postponing pregnancy, as economic anxiety dampened the desire to procreate and American birthrates dropped.

In 1942, physician and editor of the Journal of the American Medical Association Morris Fishbein complained of the selfishness of young couples who preferred consumer comforts to the demands of child rearing.

In fact, it was only after second world war that early parenthood became a cultural norm. A strong economy and widespread embrace of domesticity encouraged both early marriage and childbearing, resulting in a "baby boom" that lasted almost two decades. In 1957, birthrates among American teenagers hit an all-time high, at 96.3 births per 1000 adolescents aged 15-19. To compare, the current birth rate for teenage girls aged 15-19 sits at 26.6 births per 1000 women. The postwar tendency towards early childbearing, which we now imagine to be the product of some kind of biological inevitability, was actually a cultural aberration.

 The 'best age' to have a child is very much a product of the cultural and economic moment. Leonardo D'Amico, CC BY-NC-ND

Economic necessity

The roots of our modern discussion on delayed parenthood lie in the 1970s, when the average age at first birth began to increase dramatically. The number of women having their first child between the ages of 30 and 34 almost doubled, from 7.3 births per 1000 women in 1970 to 12.8 per 1000 in 1980. But the 1980 figures mirror those recorded between 1920 and 1940, where the number of first births among women aged 30 to 34 averaged 12.1 births per 1000 women. By 1986, the first time pregnancy rate for women between 30 and 34 hit 17.5 per 1000 births, an increase of 140% over 1970 levels. By the late 1980s, post-30 motherhood was becoming the middle-class norm. And the trend has only intensified: in 2013, the first time pregnancy rate for women between 30 and 34 hit 29.5 per 1000 births.

This shift towards midlife pregnancy that started in the 1970s was, of course, connected to both the widespread availability of new contraceptive technologies, as well the successes of second-wave feminism. But there is a third, often overlooked, catalyst in this story: the flagging economy.

The 1970s saw the combination of runaway inflation with stagnating growth. The real value of wages fell dramatically. In this environment, the movement of middle-class women into the workplace was not just liberating – it was an economic necessity. Two working parents were now required to achieve the middle-class status that a single income used to support.

The return to delayed childbearing was not a dramatic break with the past, but a continuation of a trend that began before the second world war. Delaying parenthood to invest more time in education and career development became a favored strategy for surviving in an increasingly competitive marketplace.

This move back to later parenthood produced its fair share of cultural anxiety. In 1978, a columnist in the Washington Post coined the expression "biological clock" to describe the dilemma of women who had delayed childbearing. The media had a heyday after a study published in the New England Journal of Medicine in 1982 warned that female fertility dropped off sharply after the age of 30. A self-help industry of pregnancy guidebooks, courses on tape, and magazine features tackled the challenges of "Pregnancy Over 30."

Using technology to escape biology

Reproductive technologies are often cast as the heroes of this story. Women who waited too long to have children were "saved" by the ingenuity of these technologies, tricking their own biology to have children later and later in life.

This narrative has two problems. First, it implies that women who have children in their 30s or even their 40s always need reproductive technologies to conceive – they don't. Fertility is highly individual, influenced by both members of the couple hoping to conceive. Surprisingly little is known about the exact decline of fertility with age. There is no magic age limit for pregnancy that applies to all women.

Second, it implies that using fertility technologies to delay pregnancy is a story of progress, of technology trumping biological limitation. Carl Djressai, father of the birth control pill, recently predicted that by 2050 all women would use egg freezing and IVF to reproduce. The resulting "Manana" generation will be able to delay pregnancy indefinitely and without consequence. This is not inevitable. In fact, this vision of the future may be less about triumphing over biology, and more a statement of how our society and corporate culture treats working mothers.

If we continue to treat childbearing as an impediment to economic productivity (see Facebook and Apple's egg freezing programs, for example), we may be closer to Djressai's vision of the future than we think.

Jenna Healey does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Jenna Healey, PhD Candidate at Yale University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/35119 2014-12-05T14:16:10Z 2014-12-05T14:16:10Z Drinking can harm a foetus, but court finds girl born with disorder wasn't victim of crime

A foetus is not 'a person', court rules.  Scan by Shutterstock

A young girl born with Foetal Alcohol Spectrum Disorder is not entitled to criminal injuries compensation from her mother drinking excessively while pregnant, the Court of Appeal has decided.

It was alleged that the child (called "CP" in proceedings) was born with the disorder from her mother's drinking, which included a half-bottle of vodka and eight cans of strong lager a day, in circumstances where the mother was aware of the danger of harm to her unborn child. As such, it was argued, the child should be entitled to compensation from the government-funded Criminal Injuries Compensation Authority (CICA) as an "innocent victim of crime".

The story behind the case, brought on her behalf by the local authority funding her care, has stirred up considerable public and media debate and raises issues about the role of the criminal law and the burden of risk-taking behaviour during pregnancy.

Compensation for criminal injury

The rules under which the CICA administers the scheme were amended to exclude people with Foetal Alcohol Spectrum Disorder, but CP's claim was considered under an earlier 2008 version of the rules. It was not disputed that CP had suffered injury. The central issue was whether she was a "victim of crime," and if so, whether it was a crime of violence. There was also a further issue about whether the mother had the necessary "guilty mind" and whether this issue had been satisfactorily addressed by an earlier tribunal decision.

The mother was never prosecuted or convicted of a crime. However, CP alleged that her mother had committed a crime under section 23 of the Offences Against the Person Act 1861; namely that she had unlawfully administered to "any other person any poison or other destructive or noxious thing" and as a result had inflicted grievous bodily harm. There was no dispute that the mother had administered the relevant "thing" as a result of her excessive alcohol consumption or that CP had sustained the necessary degree of harm – what was in issue was whether CP was "any other person."

The court's decision

The Court of Appeal determined that CP was not "any other person". Applying an earlier decision of the House of Lords that had concluded that a foetus was not to be regarded as "another person" despite finding that it was a "separate organism from the mother".

The court also ruled against CP's alternative argument that equated her situation with the offence of manslaughter. This argument relied on the premise that a foetus becomes a person when it is born. The problem for CP was that the conduct element of the section 23 offence required the administration and the infliction of harm to be on "a person". Infliction of harm on a foetus would not suffice.

Crucially, then, CP's attempt to argue that some harm was caused after birth was also rejected: the foetal alcohol spectrum disorder was caused before her birth. Any post-birth suffering was regarded as a consequence of the harm suffered in the womb. As a result of these conclusions, the court did not find it necessary to reach any definite conclusion on the crime of violence issue. The court also accepted that the earlier tribunal had made sufficient findings and given sufficient reasons in relation to the mental element of the section 23 offence.

Legal protection for the foetus

Does this mean that the foetus has no protection under the criminal law in England and Wales? The court was keen to highlight the legal protection that was available. Sections 58 and 59 of the 1861 act provide criminal offences where there is an intention to kill the foetus prior to birth. So a mother who uses poison with intent to procure her own miscarriage is committing an offence.

Further, Section 1 of the Infant Life (Preservation) Act 1929 provides that it is an offence to destroy the life of a child capable of being born alive. Again the offender must have a certain guilty mind: intent to destroy the life.

A woman who drinks excessive alcohol during pregnancy may foresee risks to or for the unborn child as result of her conduct but foresight of some risk is not sufficient to show that she had the necessary "guilty mind" for these offences. It should also be highlighted that a doctor who complies with the requirements of the Abortion Act 1967 does not commit these offences even if there is an intention to procure the miscarriage or death of the foetus.

The court also highlighted that a pregnant woman does not owe a civil duty of care to her unborn child and the child when born cannot bring a civil claim against her for harm caused during the pregnancy (except where the harm had been caused by her driving a motor vehicle). The court suggested that the law would be incoherent if a child was denied civil compensation but allowed criminal injuries compensation on the basis that her mother was criminally liable.

The state of things

Because CP's claim was made by a local authority, it set up a situation where one organ of the state was claiming compensation against another. This raises a question about the role of the state in circumstances where conscious risk taking results in harm. Master of the rolls, Lord Dyson – the third most senior judge in England and Wales – made it clear in his judgement that:

The role of the state in these circumstances should be to provide care and support for the child who has suffered harm to the extent that this is necessary. It should not be to pay compensation on the basis that the child is the victim of a crime by her mother.

Much can be said about the awareness of the risks of excessive alcohol consumption during pregnancy and the extent to which these risks can be foreseen in circumstances like this case. However, it is legitimate to consider where and how the burden of conscious risk taking should fall in society. Given that a large number of similar claims for compensation by children allegedly harmed by alcohol in the womb were reportedly awaiting the outcome of CP's appeal, this case makes clear, for now, that the criminal law (and the criminal injuries compensation scheme) is not the appropriate vehicle to address these issues.

Jeffrey Wale does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Jeffrey Wale, Lecturer in Law at Bournemouth University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33989 2014-11-11T05:51:56Z 2014-11-11T05:51:56Z How taking drugs while pregnant harms unborn babies

Can cause behavioural problems in children later on.  Injection by Shutterstock

Women smoking while pregnant has been an uncomfortable reality for decades. Whatever the reason – whether a lack of concern about the risk, belief it's too hard to quit or even reports that a resultant smaller baby will make for an "easier" birth – the reality is that a small baby that was meant to be bigger is at risk of stillbirth, cot death, future heart disease and shortened life span.

Substance misuse has affected all strata of society for millennia. And for several decades, researchers have been studying the effects of recreational drug use in pregnancy. An annual survey of more than 65,000 women in the US found that one in 20 pregnant women said they had used illegal substances, while one in 10 of the general population did so. These relatively stable rates appear lower than those identified in smaller UK studies, but what is clear is that rates are highest among pregnant teenagers and lowest in the highest maternal age groups.

Cigarette smoking was the first to receive attention, and this was followed by alcohol in the 1980s and subsequently given to other drugs such as marijuana, opiates, cocaine and methamphetamine. But although we have a wealth of knowledge about the risks, illegal drugs – unlike cigarettes or alcohol – don't come with a warning label that says "using this substance while pregnant may harm your baby."

One recent study from University College London suggested that using recreational drugs while pregnant put babies at risk of brain abnormalities. The study found that babies born with brain defects were twice as likely to have a mother who used illegal drugs in pregnancy than babies with normal brains. Of the 517 women studies, one in six had used recreational drugs – predominantly cannabis and cocaine – around conception or during pregnancy, which was confirmed by testing hair samples.

Crossing the placenta

 Crossing through the barrier. Sean Dreilinger, CC BY-NC-SA

Different substances might do different things and carry varied risks, but virtually all commonly used recreational drugs cross the placenta, where they are exposed to a developing foetus. Studies assessing these risks have been limited by both willingness of women to agree to testing (for example through urine or hair samples) or reliability of self-reporting. However, both animal and human studies strongly suggest that recreational drug use in pregnancy leads to problems from those that are visibly apparent at birth, such as cleft lips, to those manifesting in behavioural problems which may have consequences throughout adulthood.

Drugs may harm a developing foetus via multiple mechanisms and can vary depending on the stage of pregnancy. Direct effects on organ development are possible with drug use in very early stages of pregnancy, but evidence of this link beyond cigarette smoking is very limited, making the recent study from UCL a particularly welcome contribution. In later stages of pregnancy, more subtle effects include impaired delivery of nutrients that affects foetal growth and altered signalling within its brain.

Nicotine in cigarette smoke has been linked to development of cleft lip and palate, while heavy alcohol puts the baby at risk of foetal alcohol syndrome which disrupts development, with early signs including drowsy newborns and later problems including attention deficit and disrupted schooling.

Many pregnancy problems attributed to recreational drug use are common to multiple drugs, with the obvious example being poor foetal growth. This occurs commonly with cigarette smoking, heavy alcohol use and cocaine use, which has also been linked to smaller head size at birth. The effects are particularly prominent with alcohol as the effects are seen throughout childhood. These effects are likely to arise from restricted blood flow from the placenta. This also puts an unborn baby at risk of placental separation, which often results in vaginal bleeding, preterm birth and/or stillbirth.

Babies born to opiate-dependent mothers often suffer the effects of withdrawal syndrome following birth. This may include an unsettled baby with feeding problems, diarrhoea and seizures. The seriousness can be such that many such babies require an infusion of opiates to stabilise them before gradually reducing the dose until weaned entirely, which may take several weeks.

A mothers' illegal drug use may also indirectly expose unborn foetuses to additional dangers – poor nutrition, for example, or exposure to violent situations, avoidance of healthcare and an increased likelihood of mental health problems.

Behavioural problems

Behavioural consequences of maternal substance abuse – the best known result from foetal alcohol syndrome – arguably gives rise to the greatest social burden, but tend to receive less public attention.

The behavioural effects of cigarette smoking and opiates appear to extend into childhood, with impulsive behaviour and attention problems particularly problematic (one study on cocaine suggested environmental factors also play a key role). Tobacco and alcohol have also been linked to delinquent and criminal behaviour, in addition to substance misuse in later life. Maternal use of cannabis appears to cause attention problems and impulsive behaviour about the age of ten, while metamphetamine also leads to drowsy or stressed babies.

In parallel with behavioural problems are those affecting thought processes, with recreational drug use in pregnancy resulting in impaired ability to memorise, analyse and problem solve, with or without a lower level of intelligence as measured by IQ. These problems are particularly apparent with heavy alcohol use, while cannabis appears to cause difficulty with problem-solving skills that require sustained attention. Cigarette smoking may impair language development resulting in poor language and reading abilities in children aged nine to 12.

Happens to normal people

 Drug use casts a wide net. Prensa420, CC BY-NC

Many of the risks described above can be mitigated by reducing or stopping drug-use in pregnancy. However, identifying who needs help isn't straightforward because it is often a hidden activity. These women are not always in the heroine addicted, petty crime-associated circles of popular imagination, but may be part of outwardly thriving families, where boredom, loneliness or domestic abuse may lead to hidden substance abuse.

There has been a consistent fall in the number of pregnant women who class themselves as smokers in the UK (in England, the number of women who smoked in the 12 months before or during their pregnancy fell from around 15% in 2006-7 to 13% in 2011-12) and in the US.

 % of maternities smoking at time of delivery in England. Guardian/HSCIC

This still leaves a significant number still but gives reason for optimism. But any possibility of this occurring in illegal drug use seems unlikely – these drugs aren't used as publicly and so aren't exposed to the same level of everyday scrutiny. These behaviours are also not subject to large-scale public health campaigns.

The mainstay of current treatment of recreational drug use in pregnancy is advice, support and detox, or replacement therapy. Alcohol detoxification is offered to those heavily dependent on alcohol, where risk of foetal alcohol syndrome is high. Opiate-replacement programmes, traditionally involving methadone, have enabled women to adopt more stable lifestyles and to regularly access healthcare.

This somewhat supportive and tolerant approach in the UK is in stark contrast to elements of policy in the US (though a recent UK test case of a mother accused of attempted manslaughter after heavily drinking while pregnant is currently in the courts). A rise in popularity of "crack" cocaine in the 1980s prompted some US states to legislate the reporting of any women known to use drugs in pregnancy for alleged child abuse or possible homicide.

The risk of this approach clearly include fewer women who are likely to come clean with their healthcare providers. Legislation was recently extended that obliges physicians to report all cases of newborn babies who show signs of drug addiction. But the impact of such legislature on actual drug-use in pregnancy or adverse consequences of the practice has yet to be seen.

The effects of using recreational drugs in pregnancy are wide-ranging. While many women who have used recreational drugs in pregnancy go on to deliver apparently healthy infants, severe problems may manifest in later years, whether encountering difficulties with education or displaying behavioural problems. Yet the enormity of the social burden on family dealing with such consequences may never be attributed to what happened during pregnancy.

Mairead Black does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Mairead Black, Clinical Lecturer and Research Fellow at University of Aberdeen Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33910 2014-11-07T06:13:01Z 2014-11-07T06:13:01Z Giving a foetus 'personhood' will have serious consequences for women

Not recommended. But criminal? Lars Kristian Flem, CC BY-SA

A story of a woman who drank a half-bottle of vodka and eight cans of strong lager daily during pregnancy and gave birth to a disabled child that ended up in foster care, was certain to stir up emotion and interest. Many will feel that "something must be done" to address behaviour that sounds unnatural, selfish and morally wrong. Based on what we know, heavy consumption of alcohol is clearly not giving the foetus the best chance. Nevertheless, how we respond to such a situation is critical.

The case which has just been heard by the Court of Appeal brings the question of how we should respond keenly into view. Judges are considering their decision after a day-long hearing on a case brought by a local council seeking criminal injuries compensation on behalf of a six-year old child, "CP", now in foster care.

CP was diagnosed at birth with Foetal Alcohol Spectrum Disorder (FASD) allegedly caused by her mother as a result of consuming excessive quantities of alcohol during pregnancy. The council claims, as was accepted by an initial tribunal, that this consumption of alcohol meant that the child had been a "victim of violence" by virtue of the mother having maliciously administered poison so as to endanger life or inflict grievous bodily harm as defined under Section 23 of the Offences Against the Person Act 1861. The upper tribunal, however, found that the child did not constitute a victim of violence because at the relevant time, the child was "not a person" in legal terms, but a foetus. As such, no crime had actually been committed to underpin a compensation claim. It is this decision that the Council appealed.

All about compensation?

At face value, the council's objective looks pragmatic. The aim is not to encourage the prosecution or conviction of CP's mother. It seeks an indemnity for costs incurred in providing for disabled children in its care. If successful, the "personal injury" it is claimed CP has suffered, of FASD (as opposed to Foetal Alcohol Syndrome) could lead to many compensation claims, given that a significant proportion of children may have been removed from environments where parental neglect or abuse emerges as a result of substance abuse.

But to tap into the Criminal Injuries Compensation Scheme in the absence of an actual conviction, it needs to be determined whether a relevant crime has actually been committed. And this is why the case raises far broader issues than the health of the council's finances. Though only involving a theoretical assessment that a crime has been committed, the ramifications for women will be very real, potentially inviting a whole host of legal measures with foetal protection at their heart.

Such fears are justified. In the United States, many states now prosecute women for committing criminal offences against their foetuses. Substance abuse by pregnant women has been a popular target with some States going to extraordinary lengths to protect foetal life. Some have passed legislation declaring the foetus to be a legal person, affording it a right to life from the moment of fertilisation. This makes applicable a wide range of offences, including that of child abuse or homicide that wouldn't otherwise apply to the foetus. Short of recognising foetal personhood, some courts have stretched child abuse laws to include the foetus; in one case, a court prosecuted a woman under drug trafficking laws for passing drugs to her "child" during the 60-second gap between birth and cutting the umbilical cord.

UK position

Such approaches stand in stark contrast to English law where the foetus lacks legal personhood until born and holding a separate existence from its mother. The broad position is that a woman's autonomy and right to bodily integrity trumps any interests a foetus might be said to possess. A pregnant woman can refuse medical treatment even when this may result in the death of a viable foetus. The priority afforded to women's interests is also reflected by the Abortion Act 1967 which applies to England, Wales and Scotland; providing an abortion is performed in accordance with the 1967 Act, there is no offence.

It seems unlikely that the judiciary would risk unsettling a position so firmly embedded within English law, by suggesting that a woman could even theoretically have commissioned an act of violence against her foetus. Much is risked by so doing. Those most opposed to abortion and keen to limit women's access to it, however, will see a successful appeal as a critical step in encouraging a legal regime which offers ever stronger foetal protection.

Nevertheless, the urge to extend the criminal law may emerge for completely different reason – those who see this as a truly exceptional and hard case demanding an exceptional response.

Criminal law and extreme cases

Hard cases, typically involving extreme situations, can generate powerful debate around our moral responsibility to prevent harm-causing behaviour – "something must be done!" The danger is that if not tempered by a full evaluation of broader concerns and a critical look at the criminal law as a vehicle for behavioural change, we can end up believing that criminalising conduct is justified.

The criminal law is a very blunt instrument. Even if we could be certain that the law would only be directed at those exceptional cases involving pregnant women engaging in heavy substance abuse (rather other kinds of risky activities), it's unclear what benefits this could deliver, or for whom. The idea that criminal measures may be powerful in deterring women from engaging in such behaviour would seem to be founded upon some fallacy of choice and rational risk-benefit: that pregnant women who engage in such risky practices will weigh the risk of imprisonment and change their behaviour as a result.

More likely is that the threat of criminalisation will push those women who are most in need away from any help on offer for fear of criminalisation. As Emma Cave suggests: "pregnant addicts would shun health care to avoid detection. It would constitute a step backwards'.

Game of consequences

A recognition of stronger foetal interests would have far-reaching consequences for women's rights and bodily integrity and risk constructing all women as potential threats to foetal life.

So too would this sit at odds with abortion policy given the incoherence of criminalising women who it is alleged have caused serious or even lethal harm to their foetuses through alleged substance abuse or other "risky" practices, yet accepting as lawful the intentional demise of foetal life through abortion. When sat side-by-side it would create a perverse incentive for those engaged in risky behaviour to terminate.

Critically however, as US scholars have noted, women are being punished in these cases for "risky" behaviour that would not, absent of pregnancy be subject to criminal punishment. As such, what makes substance abuse, alcohol consumption, even sex or attempted suicide the subject of the criminal law is not the behaviour itself, but the fact of pregnancy. Pregnant women – and indeed women – are being unfairly targeted.

Nicky Priaulx does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Nicky Priaulx, Reader in Law at Cardiff University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/32476 2014-11-03T05:30:30Z 2014-11-03T05:30:30Z Pregnant women must be studied too

Pills ok during pregnancy? We can't know if we don't study them. Medications image via www.shutterstock.com

Imagine being pregnant while having a chronic health condition such as diabetes, hypertension, depression or asthma, or being diagnosed with an illness while pregnant. Amazingly, your doctor may not know exactly what treatments or drugs, or what dose, will work best for you. This is a reality faced by millions of American women every day.

The simple fact is, pregnant women get sick and sick women get pregnant. Meanwhile, rates of chronic disease are rising and women are having children at an older age. Stopping medication or avoiding new treatments is not always the optimal approach. Significant knowledge gaps exist because pregnant women have historically been excluded from medical research, mainly due to concerns about the effect on the fetus. But even a normal pregnancy has risks.

Medication conundrum

There is a common belief that medication during pregnancy is unhealthy and unwise. Past tragedies – such as the limb-reduction birth defects related to first trimester thalidomide exposure – serve to support careful consideration of the risks and benefits of drug treatment. But avoiding all medication use is not a realistic possibility.

Failing to take medication, taking inappropriate doses or not being prescribed a needed treatment can be harmful or fatal for a mother or her unborn child. Today, an American woman will take at least one and on average four medications during her pregnancy. Health care professionals, though, often have inadequate information about how a drug works during pregnancy because most medications have not been evaluated in pregnant women.

Confronted with this lack of data, a woman who is pregnant or nursing may stop taking drugs or breastfeeding, even though that may not be the best course of action. With more information about both the benefits and risks of drug expsoure, she might choose to continue medications that improve her short-term and long-term health and quality of life while minimizing harm to herself or her baby.

 Without the data, pregnant women are left guessing. Woman image via www.shutterstock.com

Moreover, newer medications shown to be effective in non-pregnant patients have the potential to improve disease outcomes in pregnancy, but have not yet been tested in pregnant women. For example, newer treatments for hepatitis C may help prevent the mother-to-child transmission of hepatitis C, but they need to be studied in pregnancy.

Unfortunately, this lack of new scientific information leads to uncertainty for health care professionals about how to prescribe needed medications and sometimes results in no treatment at all for pregnant or breastfeeding patients with an illness. Worse, in the search for answers, many pregnant women turn to the internet and social media, which often results in conflicting, confusing and just plain wrong advice.

Rx: collect more data

Our nation must do better. Currently women – pregnant or not – are vastly underrepresented in clinical trials. Pregnant women should determine what level of risk they are willing to take. A robust, transparent informed consent process can help them make this decision. Though pregnant women have participated in some studies, most research protocols continue to exclude pregnant or breastfeeding women, and this just has to change.

Additionally, we need to improve data collection related to drugs and pregnancy, which is currently inadequate to make informed decisions. For example, the US Food and Drug Administration keeps a list of what are called Pregnancy Exposure Registries that collect health information, mostly on birth defects and infant health, from researchers and drug companies about women who take medicines or vaccines while pregnant.

Existing data from these registries should be standardized and easily accessible to support sound decision-making by providers and patients. Pregnancy registries should be required for new drugs, and registries must capture not just adverse events but healthy outcomes to create a baseline of both positive and negative medical data.

Also the US Office of Management and Budget should finalize the long-pending FDA Pregnancy and Lactation Labeling Rule, which would provide patients and prescribers detailed, updated information about fetal risk, clinical considerations and the quality of studies available for each drug.

Federal policymakers and the medical community must re-evaluate the near-exclusion of pregnant women from medical research and strengthen requirements to collect as much data as possible, including follow-up with women who become pregnant and drop out of a study.

Incentives, such as longer exclusivity clauses or fast track designation for an unmet need, must be created for pharmaceutical companies to perform lab research and clinical trials focusing on pregnancy when seeking approval for new drugs that may be used by pregnant women.

By taking these actions, pregnant women will be better served by medical research. With 62 million women in the United States of childbearing age and 4 million births each year, getting the best possible health care is vitally important now and for generations to come.

This piece was co-authored by Martha Nolan, JD, Vice President of Public Policy at the Society for Women's Health Research.

Katherine Wisner has received funding from NIMH, NICHD, and the Department of Psychiatry at Northwestern receives Consultation Fees from Dr. Wisner's work with Quinn-Emanuel Law firm, which represents pharmaceutical companies.

Vincenzo Berghella does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Katherine Wisner, Professor in Psychiatry and Behavioral Sciences and Obstetrics and Gynecology at Northwestern University Vincenzo Berghella, Professor of Obstetrics and Gynecology at Thomas Jefferson University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/32353 2014-10-29T09:34:19Z 2014-10-29T09:34:19Z Mom's prenatal hardship turns baby's genes on and off

Icy times for mom-to-be meant bad news for baby-on-board. Shaun Best/Reuters

In January 1998 five days of freezing rain collapsed the electrical grid of the Canadian province of Québec. The storm left more than 3 million people without electricity for anywhere from a few hours to 45 days – one of the worst natural disasters in Canadian history.

As devastating as the ice storm and its effects were, these challenging conditions also provided an unusual research opportunity.

As a professor of psychiatry, I've long been interested in stress during pregnancy. Usually we're forced to study prenatal stress retrospectively. Researchers have relied on databases of birth, death, and health information to conclude that exposure to major events during pregnancy, like war or death of a relative, increases health risks in the unborn child. Interviewing mothers many years later about stressful events that might have occurred during their pregnancies is another retrospective way to examine the question. But it still doesn't get at what it was about the stressful event that influenced the fetus's development.

 How would the ice storm affect unborn babies? Pregnancy image via www.shutterstock.com

The challenging conditions left in the ice storm's wake provided the unusual opportunity to study prenatal stress prospectively. Living without electricity in the middle of the Canadian winter would stress plenty of pregnant women. Instead of looking backwards, we could track effects of stress going forward in time.

So in June 1998 we recruited nearly 200 women who were pregnant during the ice storm. We sent them questionnaires to measure the objective severity of the hardship they experienced (days without electricity, financial loss, injuries, moving house and so on), and also how much subjective distress they were still feeling from the disaster.

Since then, we have seen that a mother's level of objective hardship predicts many outcomes: the more days she was without electricity, for example, the lower the child's IQ, the greater the child's risk of becoming obese, and the more insulin the child secreted in a glucose tolerance test, which might set him up to develop diabetes later in life.

The big surprise was that the mother's subjective experience of distress had no effect on any of these outcomes. The theory had been that prenatal maternal distress could affect the fetus' development via the mother's stress. Distress would trigger a cascade of stress hormones in her body that would then pass through the placenta to disrupt normal development of the baby. There was no room in that theory for objective hardship to have an effect on the baby without going through the mother's level of distress and her resulting stress hormones.

We were perplexed: how is it that a child whose mother stayed calm and collected during the ice storm despite losing power for weeks could have worse outcomes than one whose mother was clearly distraught by the ice storm but never lost power? Our study showed it was happening, but how could objective maternal hardship – independent of subjective stress – affect these biological mechanisms? To investigate, my colleague Dr. Moshe Szyf and I started to look at the epigenetics of the ice storm kids.

To understand epigenetics, imagine that your genetic makeup is a printed sheet of music, the product of the DNA from your mother and father. Every human being has a different song printed on their score, and no one can change what has been printed.

 How fast or slow is the song in your DNA played? Rebecca Jasso

On the other hand, any song can be played in different ways: a little faster here, a little slower there; a little louder here, but softer there. These nuances may be written on the printed score. And so it is with our DNA, which cannot be changed, but can take on different forms according to markings made on it by the environment.

Methylation is one way those markings are made on the score of DNA. Imagine that your DNA has thousands of little switches, like dimmers on lights, which slide up and down to increase or decrease the expression of those genes. The process of adding biochemicals called methyl groups to those little switches is methylation. Where these methyl groups are attached to your DNA helps determine which genes in your genome are actually expressed.

We wanted to know if mothers' objective hardship or subjective distress from the ice storm changed the way in which the babies' DNA was methylated. In 2011, 34 of the children, then 12 or 13 years old, gave blood samples. Our post-doctoral fellow Dr. Lei Cao found that the women's objective level of hardship from the ice storm predicted the children's epigenetic profile, while their level of distress from the storm didn't predict any effect. For instance, the more times the family changed house during the crisis predicted more methylation in certain genes – regardless of the mom's subjective feeling of stress during the ice storm. As in our earlier work, the changes in the kids weren't due to their mothers' degree of emotional distress following the ice storm, but rather to factors outside of the moms' control, such as the number of days without electricity.

Though small, our study showed the 1998 ice storm created sufficient hardship for pregnant women that it caused epigenetic changes in their unborn children that have lasted at least 13 years – that's pretty permanent! No other study had previously shown epigenetic effects linked to objective hardship rather than subjective distress.

The objective severity of the mothers' hardship most affected the methylation of two kinds of genes in the ice storm kids: immune system genes, which might increase risk for asthma and allergies, and metabolism genes, which might affect risk of obesity or diabetes. Our next challenge is to figure out how these epigenetic changes actually affect the children's health. And a remaining big question is how did the mothers' experiences produce these altered patterns of gene expression?

Suzanne King, Ph.D. receives funding from The Canadian Institutes of Health Research (CIHR).
 Suzanne King, Full Professor of Psychiatry at McGill University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/30356 2014-10-20T03:33:21Z 2014-10-20T03:33:21Z Health Check: what to eat and avoid during pregnancy

Many women find it difficult to strike the right balance between nutrition and safety. Sean McGrath/Flickr, CC BY

As soon as women announce "I'm having a baby!", the congratulations are quickly followed by long lists of dos and don'ts about food. Try ginger for morning sickness. Avoid soft cheese because of listeria. Eat more meat to boost your iron. Eat this fish – but not that one, because of mercury.

Pregnant women are understandably confused. So, how do you strike the balance between nutrition and safety, when so many things are off the menu?

During pregnancy, women need to consume a variety of different foods and need more of the main pregnancy nutrients: protein, folate, calcium, iron, zinc, iodine, and fibre. Here's a quick guide to the best sources.

Protein: lean meat, chicken, seafood, dairy products, legumes, nuts, eggs

Folate: fortified bread and breakfast cereal, green leafy vegetables, legumes, seeds, chicken, eggs, oranges

Calcium: dairy foods, fortified soy milks, green leafy vegetables, nuts, seeds, canned fish with bones

Iron: red meat, fortified cereals, egg yolks, green leafy vegetables, legumes, nuts

Zinc: meat, eggs, seafood, nuts, tofu, miso, legumes, wheat germ, wholegrain foods

Iodine: canned salmon and tuna, other fish, oysters, bread fortified with iodine

Fibre: wholemeal and wholegrain breads and high fibre cereals, oats, vegetables and fruit with the skin on.

 National dietary guidelines recommend pregnant women consume five serves of vegetables and legumes per day. Ginny/Flickr, CC BY-SA

We have recently shown that a moderate intake of protein (18-20% of a total energy intake) allows pregnant women to eat the best range of foods across all the healthy core groups in the Australian Guide to Healthy Eating, while optimising vitamin and mineral intakes.

Interestingly, the protein to carbohydrate ratio was related to the amount of muscle and fat tissue in the developing baby. While more research is needed, it may contribute to the risk of developing diabetes in the future.

How much?

The Australian dietary guidelines advise pregnant women to consume the following number of servings from the five core food groups each day.

Vegetables and legumes/beans: five servings. One serve = 75g or 100-350kJ, for example, half a cup cooked green or orange vegetables, one cup of raw salad vegetables, half a medium potato, one tomato.

Fruit: two servings. One serve = 150g or 350kJ, for example, one medium piece (apple, banana, orange), two small pieces (apricots, kiwi fruit), one cup diced or canned fruit.

Grain (cereal) foods, mostly wholegrain or high-fibre varieties: eight-and-a-half servings. One serve = 500kJ, for example, one slice of bread, half a cup of cooked rice, pasta or porridge, one-quarter of a cup muesli, three crispbreads.

Lean meats and poultry, fish, eggs, tofu, nuts and seeds, legumes and beans: three-and-a-half servings. One serve = 500-600kJ, for example, 65g cooked lean meat, 80g cooked lean poultry, 100g cooked fish, two eggs, 170g tofu, 30g nuts, one cup of cooked beans.

Milk, yoghurt, cheese or alternatives, mostly reduced fat: two-and-a-half servings. One serve = 500-600kJ, for example, 250ml milk, 200g yoghurt, two slices (40g) of cheese.

Morning (noon and night) sickness

Nausea and vomiting affects about three in four pregnancies. While the data on fetal risks associated with drug treatment are controversial, non-drug approaches are a good place to start.

 Eating small snacks rather than big meals can help alleviate morning sickness. Michael Pettigrew/Shutterstock

Limit exposure to food odours by having foods that do not smell as much during cooking or by reducing cooking time, with stir-frys or a BBQ cooked outdoors.

Nausea can be worse in the presence of hunger, so avoid an empty stomach by having small, frequent meals and snacks comprised of foods that you can tolerate and don't have much smell, such as fruit or nuts, or raisin bread or sandwiches, or yoghurt. Very cold drinks can help with the nausea and prevent dehydration.

You could try ginger as a ginger tablet, cold ginger beer or ginger cordial. While only some evidence supports the use of ginger and/or vitamin B6 supplements to relieve nausea of pregnancy, they're unlikely to cause harm.

Mercury and fish

Fish and seafood are important sources of protein and minerals. They are low in saturated fat and are a major source of omega-3 fatty acids.

During pregnancy, omega-3s play an important role in the baby's developing central nervous system, the brain and retina in eyes. Research shows that maternal omega-3 fatty acid consumption during pregnancy reduces the risk of preterm birth, and increases the length of gestation and therefore birth weight.*

Deficiency of omega-3s is associated with irreversible visual and behaviours deficits in children, as well as an increased risk of depression, pre-eclampsia and pregnancy hypertension in the mother.

 Pregnant women eat less fish than is recommended. Shaiith/Shutterstock

Population surveys in the United Kingdom and United States show that pregnant women don't eat enough fish and therefore omega-3s, partly due to fears about adverse effects of mercury and other toxins (such as polychlorinated biphenyls).

We have shown that pregnant women in Australia also eat less fish than is recommended. But when we estimated what their weekly exposure to mercury would be from eating two to three serves a week, it was well below the targets. Pregnant women in Australia can safely eat fish.

Listeria risk

Due to changes in the immune system during pregnancy, women are more susceptible to food poisoning. But by avoiding all foods that carry a risk for harbouring listeria, women are consuming fewer nutrients.

You don't have to go without. For every item on the "no" list, there are a number of alternatives:

Avoid pre-packaged cold meats. This includes deli meats and sandwich bars. Instead, choose freshly cooked seafood one to two times per week and/or canned fish up to four times a week. Choose home-cooked meat instead and make it into homemade sandwiches.

Avoid ready-to-eat pre-cooked chicken pieces, especially if cold. Instead, choose home-cooked chicken or hot take-away whole chicken or large pieces – but eat it immediately.

Avoid raw and chilled seafood including oysters, sashimi or sushi, smoked salmon, ready-to-eat peeled prawns, prawn cocktails, sandwich fillings, and prawn salads. Don't eat shark (flake) or billfish (swordfish, broadbill and marlin). Limit orange roughy (deep sea perch) or catfish to once per week. Instead choose other fish species, including canned salmon and tuna two to three times a week.

Avoid salads (fruit and vegetables) that are pre-prepared or pre-packaged or from salad bars or smorgasbords. Instead, choose freshly prepared homemade salads (with leafy greens or other salad vegetables), fresh fruit, or canned or frozen fruits and vegetables.

Avoid soft, semi-soft and surface-ripened cheeses such as brie, Camembert, ricotta, feta and blue cheese. Instead, choose hard cheeses such as Cheddar or tasty, processed cheese, cheese spreads, or plain cottage cheese if packaged by the manufacturer.

 Opt for hard cheeses to reduce the risk of listeria food poisoning. Markus Mainka/Shutterstock

Avoid soft serve ice cream and unpasteurised dairy products such as raw goat's milk. Instead choose packaged frozen ice cream and pasteurised dairy products such as milk, yoghurt, custard and dairy desserts.

Listeria can live in lower temperatures, so take extra care with foods served cold, and avoid buffets and smorgasbords altogether. Cooking, however, kills listeria but the food needs to be heated until steam rises. And remember to always wash your hands before handling food or starting to prepare foods.

Constipation

Up to 40% of pregnant women develop constipation. This is caused by rising levels of progesterone and oestrogen, and the relaxation of muscles of the bowel. Low fluid and fibre intakes can also play a role.

Mild constipation can be self-treated by increasing high-fibre foods, including soluble (oats, lentils, dried peas and beans, psyllium) and insoluble (wholemeal and wholegrain breads and cereals, wheat bran, vegetables and fruit) fibres. To counter constipation in pregnancy aim for 25 to 28 grams of fibre per day, drink plenty of water (1.5 to two litres per day) and exercise regularly.

Some oral iron supplements can cause constipation. If medication is required, only use what your doctor prescribes as not all laxatives are safe during pregnancy.

Multivitamins

Women planning or in early pregnancy are likely to need a folic acid supplement to reduce the risk of the baby having a neural-tube defect, and iodine for the developing brain and nervous system.

Multivitamin supplements may be recommended when there is a fairly high chance of not meeting nutrient needs from food. This is more likely for pregnant adolescents, vegetarians, those on pre-existing special diets, individuals with drug, tobacco and alcohol addictions, or obese pregnant women on medically restricted diets to limit weight gain.

Pregnancy is an important time to focus on what you eat. The food-based recommendations in the Australian Dietary Guidelines will help you enjoy a variety of foods while getting the best mix of nutrients important at this time.

* This article originally said omega-3 fatty acid consumption during pregnancy was associated with increased birth weight and improve brain development in the child. This has been updated to better reflect the evidence.

Clare Collins receives or has received funding from NHMRC, ARC, Hunter Medical researcg Institute, The University of Newcastle, Meat and Livestock Australia.

Michelle Blumfield does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Clare Collins, Professor in Nutrition and Dietetics at University of Newcastle Michelle Blumfield, Postdoctoral researcher, Priority Research Centre in Physical Activity and Nutrition at University of Newcastle Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/31574 2014-10-02T05:59:34Z 2014-10-02T05:59:34Z 'I didn't know who I was anymore' – myths vs realities of early parenthood

Most parents we interviewed described having "unrealistic" expectations about baby behaviour. Robyn Lee/Flickr, CC BY-NC-ND

Becoming a parent is commonly imagined to be a joyful and "natural" life event. The reality is often very different. In the early weeks and months of life with a first baby, parents must master new skills including nappy changing, breast or bottle feeding, and "settling" a crying baby, usually while experiencing considerable sleep deprivation.

New mothers have to recover from labour, childbirth and/or caesarean delivery. Primary carer parents find they need to re-orient their lives around their baby, at least in the short term. And partnered parents confront a changed dynamic in their relationship and the need to accommodate a third family member.

For many people, these challenges are unexpected, either in nature or magnitude.

Australians today are having fewer children than past generations and are often starting their families later. This reduces the opportunity to learn informally about infant care through raising younger relatives or being around friends with babies.

New parents are also burdened by the way our society romanticises early parenthood, especially motherhood. Played out in media imagery, this contributes to perceptions of instant bonding, instinctive breastfeeding and "perfect babies" being cared for by "perfect mothers".

Overly optimistic expectations and a lack of preparation can cause significant distress at a time when new parents already feel vulnerable. For some parents, this may impede bonding with their baby, shade over into postnatal depression – which affects up to 16% of new mothers and 5% of new fathers – or strain the relationship with their partner.

Expectations and experiences

 Settling a newborn takes patience. Stacy Benton/Flickr, CC BY-NC-ND

We recently interviewed 45 parents in Australia about their expectations and experiences of early parenthood. The parents came from varied socioeconomic and cultural backgrounds. They included single parents, adoptive parents, parents through surrogacy, same-sex attracted parents, parents in blended or step families and parents who had experienced IVF.

Most parents we interviewed described having "unrealistic" expectations about baby behaviour, particularly in relation to crying, sleep patterns and feeding.

As Susanne, a mother in a same-sex relationship, said:

… I thought my baby would come with me to the café and I'd sit there and stare lovingly into her eyes and people would say, "Oh, she's gorgeous," and I'd be like, "Motherhood's wonderful" … And yeah, she'd cry a bit at night and I might be a bit tired but my life would essentially be the same with a baby. No. The reality was I didn't know who I was anymore.

Some parents talked about self-imposing standards that were "too high". And a few mothers believed this contributed to their experiences of postnatal depression. Melanie, a mother of one who experienced postnatal depression, said trying to "do everything perfectly" had exhausted her and made bonding with her baby difficult.

Parents were often surprised to discover a new baby placed their relationship with their partner under strain. Tina, a migrant mother from Iran, said bridging the unexpected and "very deep gap" between her and her husband in early parenthood took time and effort. While most couples' relationships recovered after an initial period of difficult adjustment, a few ended.

Many parents were distressed by the difference between their expectations and experiences of early parenthood. Some described feelings of anger, anxiety, resentment towards their babies, guilt, or a sense of failure. Those for whom becoming a parent held few "surprises" described less distress, though they still found early parenthood challenging.

Many felt that, as a parent-to-be, they had been too focused on pregnancy and childbirth and this was reinforced by their antenatal classes. Sara, a parent of two children, questioned whether "half an hour with the crocheted breast and the doll" was adequate preparation for breastfeeding.

 Shorter hospitals stays mean less time to get used to feeding, bathing and settling while help is on hand. Amy Bundy/Flickr, CC BY-NC

The trend towards shorter hospital stays after birth was also considered unhelpful. A few women who were able to stay in hospital up to five days appreciated being able to gain infant care skills and establish breastfeeding before going home, where often they had very little formal or informal support.

Bridging the gap

Based on our research and previous studies, we suggest the following three avenues to prepare expectant mothers and fathers for early parenthood:

better antenatal education

a greater willingness by parents of older babies or children to be open about their experiences with expecting parents

the development of credible online resources to share experiences of early parenthood.

Antenatal education provided through maternity hospitals is an obvious opportunity for assisting parents to prepare better. Past research has identified a number of shortcomings with antenatal education, including relevance to expecting parents' needs, reach, teaching style and cost-effectiveness.

Classes could be re-designed to include greater balance between labour and birth and early parenting, and could also involve more peer-to-peer learning, including through inviting new parents to talk about their experiences.

In an attempt to recreate the informal learning about early parenting that is no longer as available through family networks, experienced parents can help counter some of the myths of early parenthood by sharing their experiences with expecting parents or those with younger children.

Many concerns can hold parents back from speaking openly with one another. These include a desire to not scare expecting parents with "horror stories", or a fear of being judged a "bad" parent if they share feelings of doubt and ambivalence. In fact, greater openness can help expecting parents be better prepared for what lies ahead.

 Sharing your own experiences of parenting can help expecting parents prepare. James Laing/Flickr, CC BY-NC-ND

Finally, the internet is an increasingly important source of information about pregnancy, labour and birth, and early parenting for expecting and new parents. Hearing other people's experiences online is particularly valuable.

Maternity hospitals should offer expecting and new parents a guide to useful, reliable online resources on these subjects to counter the sense of "information overload" and the desire for credible information.

If you're a new or expecting parent, you can watch the interviews from the Emotional Experiences of Early Parenthood project here. The site contains a rich array of experiences of every step on the journey to parenthood, from people from a wide range of backgrounds and circumstances.

Kate Johnston-Ataata was employed to work on the Emotional Experiences of Early Parenthood project funded by Healthdirect Australia. She is a member of the The Australian Sociological Association.

Renata Kokanovic receives funding for her research from ARC LP and NHMRC and beyondblue: the national depression initiative. Parenting project has been funded by Healthdirect Australia.
 Renata Kokanovic, A/Professor of Sociology of Health and Illness at Monash University Kate Johnston-Ataata, Research Associate, Health in Society Research Network at Monash University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/31881 2014-09-25T13:18:44Z 2014-09-25T13:18:44Z Couvade syndrome: why some men develop signs of pregnancy

Sympathetic or jealous? Belly by Shutterstock

Harry Ashby, the 29-year-old security guard who was signed off work with morning sickness, cravings, a growing stomach and breasts during his girlfriend's pregnancy, was told he had Couvade syndrome.

Couvade is an involuntary manifestation of pregnancy in men with a partner who is expecting a baby – sometimes called "sympathetic pregnancy". It isn't a medically recognised physical or mental disorder, and it isn't explained by injury or illness.

A range of "pregnancy-related" physical and psychological symptoms include abdominal pain and bloating, back pain, pseudocyesis (euphemistically known as "phantom pregnancy"), lethargy, morning sickness, toothache, food cravings and aversions – many of which were confirmed in a study we carried out at St George's hospital, in London. Prominent psychological symptoms include ante-natal depression and mood swings, early morning waking, anxiety, poor concentration, distraction and memory loss.

Collectively, these symptoms may signify an empathic identification with a pregnant partner and to the man's unborn child, but the could also be a resolution of unconscious thoughts that might threaten both.

Couvade symptoms follow a chronological pattern, beginning in the first trimester of pregnancy, before temporarily disappearing in the second and then re-appearing in the final trimester. They can even extend into the period after the baby is born.

While the syndrome primarily occurs in developed countries all over the world, the number of new cases in those countries varies. Several studies have found an incidence of between 25-52% of all men with a pregnant partner in the US; 20% in Sweden, and an estimated 61% in Thailand, though this includes mild to extreme symptoms such as the physical ones above. The incidence in the UK is unknown, but estimates in the 1970s put it between 11%-50%.

A range of theories that have been proposed to explain Couvade syndrome. Along with psychoanalytical and psychosocial explanations, they also include emotional attachment to both the unborn child and partner, and hormonal influences.

Psychoanalysis

 Oedipus: mixed feelings. Henri Fuseli via Daderot

Psychoanalytical theory proposes that the syndrome evolves from the man's envy of the woman's procreative ability. The theory also proposes that for the male partner, the pregnancy acts as a catalyst for the emergence of ambivalence and the resurgence of oedipal conflicts. The event may cause regression – the man's retreat to childhood feelings and conflicts triggered by his partner's pregnancy, such as rejection, exclusion, ambivalence and anxiety – with a sense of passivity and dependency that is intensified by the developing foetus and which conflicts with the man's need for autonomy.

A second psychoanalytical theory proposes that expectant fathers may sometimes view the unborn child as a rival for maternal attention. Some have explained this as the expectant father's interpretation of the unborn baby as a rival from whom attention is diverted. But this is expressed through a more socially acceptable outlet such as the syndrome. This interpretation would suggest that the syndrome has a protective function for the man because it enables him to identify with his pregnant partner and strengthens his protective instincts towards her and the baby.

Psychosocial

Psychosocial theory, which takes in social circumstances, instead focuses on a marginalisation of men during the woman's gestation and childbirth, especially among men who are having their first child. While motherhood is an important defining feature for women, the same may not be true for fatherhood and men; expectant women have their maternity careers endorsed commercially, socially and medically in contrast to the careers of prospective fathers. Since the 1970s men have become familiar figures in the delivery room and their attendance is now almost obligatory.

 Left out. Delivery room by Shutterstock

The fact that men can't actually give birth or experience delivery directly can relegate men to an ancillary role where they feel marginal and sometimes useless. To resolve this ancillary status during gestation and childbirth the man inadvertently diverts attention from the woman to himself through a display of the Couvade syndrome. However, this implies that the syndrome is a conscious entity, which I and others, such as Arthur Klein reject.

Transition and crisis

Paternal transitional theory proposes that the transition to fatherhood is potentially pathological, involving disruptive interpersonal struggles that are highly stressful.

According to Klein the transition from dyad – two tied entities such as man-wife – to a triad – group of three – constitutes one of the most cataclysmic periods for the expectant man. This may be compounded by the fact that men usually accept pregnancy but without any concomitant physical changes that reinforce its reality. They lack the biological markers of the transition to parenthood and these "disembodied" experiences of pregnancy are very different from the woman's experiences. This in turn causes multiple conflicts during transition, including jealousy and rivalry with the unborn baby, an intensified ambivalence toward their own parents and sexuality conflicts. With all of this going on, it wouldn't be surprising to see some psychological fallout.

Attachment

Yet paradoxically, men who have had preparation for their parental role – ante-natal classes, for example – show a higher susceptibility to being afflicted the syndrome. Attachment theory proposes that the man's closeness to the foetus gives rise to the syndrome. In a seminal study published in 1983, a sample of white middle-class, first-time expectant men found a modest correlation between more paternal-foetal involvement and attachment (feeling and hearing the unborn child kicking, confirmation through the woman's pregnancy symptoms and the ultrasound scan) with the incidence of six physical symptoms of the syndrome. These included feeling more tired (34%), sleeping difficulties (33%), indigestion (14%), stomach upsets (12%), appetite changes (8%) and constipation (6%). The investigators concluded men's symptoms were a reflection of their level of attachment to the unborn child and involvement in the pregnancy.

Attack of the hormones

Couvade syndrome also appears to show a relationship with hormones, but there is a dearth of research investigating such an association. To date only two studies have supported a hormonal basis for the syndrome, one published in 2000 and another in 2001. The findings of both indicated a significant increase in men's levels of the hormones of prolactin and oestrogen in the first and third trimesters of pregnancy, but lower levels of testosterone and the stress hormone cortisol. These hormonal changes were associated with the display of paternal behaviours as well as Couvade symptoms of fatigue, appetite changes and weight gain.

So a plethora of different theories have offered accounts for the origins of the syndrome. However, some of these, such as the hormonal explanation, have not been investigated sufficiently. And those that have, psychosocial reasons for example, clearly show disparate findings, which weakens a definitive conclusion that the syndrome has roots in this. Suggested directions for future research in the area might focus more hormonal associations with the syndrome.

Arthur Brennan does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Arthur Brennan, Senior Lecturer in Psychology, Research Methods and Statistics at St George's, University of London Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/30529 2014-09-01T04:18:34Z 2014-09-01T04:18:34Z Health Check: how to get pregnant

Timing matters. Stacey Newman/Shutterstock

For couples trying to conceive, the chance of this happening within a year depends on their age. The monthly chance of pregnancy for couples where the woman is 35 years or younger is about 20% and 80-90% become pregnant within 12 months.

By age 40, the monthly chance has dropped to 5% and half of couples conceive within 12 months.

The age of the father-to-be matters too. Women with partners aged 45 or older are almost five times as likely to take more than a year to conceive compared to those with partners in their 20s.

While there is little we can do about our age, timing sex to coincide with the most fertile days of the month can reduce the time it takes to conceive and could even save you a trip to the fertility clinic.

Finding your fertile window

At ovulation, an egg is released from the ovary and if there is sperm waiting around at that time, there is a good chance it will be fertilised and grow into a baby.

Conception is only possible from about five days before ovulation through to the day of ovulation. These six days are the "fertile window" in a woman's cycle and reflect the lifespan of sperm (five days) and the lifespan of the egg (24 hours). But the likelihood of conceiving is dramatically increased if sex occurs in the three days leading up to and including ovulation.

The fertile window varies depending on the length of a woman's cycle. The time from ovulation to the next period is approximately 14 days, irrespective of cycle length, but the time before ovulation varies between women.

In a 28-day cycle, ovulation typically occurs around day 14 and the chance of conceiving is greatest between days 11 and 14. In longer cycles, say 35 days between periods, ovulation happens around day 21 and days 18 to 21 are the most fertile days. In a 24-day cycle, ovulation happens around day ten and the most fertile days are days seven to ten.

 Women are more likely to conceive in the three days leading up to and including ovulation. Dafne Cholet/Flickr, CC BY

If a woman has sex six or more days before she ovulates, the chance she will get pregnant is virtually zero. Then, the probability of pregnancy rises steadily. If she has sex in the three days leading up to and including ovulation, she has a 27-33% chance of becoming pregnant.

From that point, the probability of pregnancy declines rapidly. Twelve to 24 hours after she ovulates, a woman is no longer able to get pregnant during that cycle.

Knowing your body and how it changes when ovulation approaches is also important. A few days before ovulation, the vaginal mucus changes and becomes clear and slippery (the consistency of egg white), which is perfect for sperm to swim along. Mucus changes provide an early and useful cue that ovulation is approaching.

If you want to reassure yourself about getting your timing right, you can use ovulation predictor kits which are available at pharmacies and supermarkets. A few days before you think you will be ovulating you start testing your urine each day. You can expect to ovulate 24 to 36 hours after the test turns positive.

If all this seems too complicated, an alternative is to have sex every two to three days. That way all bases are covered without getting too technical about when the chance of conceiving is greatest.

For more information about the factors that affect fertility, visit www.yourfertility.org.au.

Karin Hammarberg does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Karin Hammarberg, Senior Research Fellow, Jean Hailes Research Unit, School of Public Health & Preventive Medicine at Monash University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/29954 2014-08-19T20:20:50Z 2014-08-19T20:20:50Z Lizards help us find out which came first: the baby or the egg?

Australia's southern grass skink gives birth to live young and a valuable species for understanding placenta evolution. Jacquie Herbert, Author provided

Have you ever wondered why we give birth to live young rather than lay eggs? Scientists have pondered this for a long time and answers have come from an unlikely source: some of Australia's lizards and snakes!

In research published this month in the American Naturalist, my colleagues and I at the University of Sydney studied reptile pregnancy to identify the factors necessary for a placenta to evolve.

Although most reptiles lay eggs, live birth has evolved many times in the group of reptiles that includes lizards and snakes.

Some of Australia's most iconic species, such as the blue-tongue lizards and red-bellied black snakes, have discarded egg-laying and instead hang onto their babies for the duration of pregnancy and give birth to fully developed young.

First came the egg

Evolution is a slow process, which means that many adaptations we see in animals today arose a long time ago. Pregnancy in mammals is no exception.

The earliest mammals laid eggs. A couple of these egg-laying ancestors are still around today – the platypus and echidna – and both are found in Australia.

From fossil evidence we know that today's live-bearing mammals had a live-bearing ancestor that roamed the earth 160 million years ago, so live birth in mammals must have evolved before this.

Understanding why evolutionary transitions that happened so long ago occurred can be difficult to infer. So researchers have to rely on systems where evolutionary transitions have occurred more recently.

Some lizards do it both ways – but why?

Live birth has evolved more recently in reptiles than in mammals. One Australian species, Bougainville's skink, has a live-bearing form on Kangaroo Island, off South Australia, but had an egg-laying form found on the mainland in South Australia, Victoria and New South Wales.

In cases where a single species has both egg-laying and live-bearing populations, we can infer live birth has evolved very recently. In these recent origins of live birth it is much easier to study why and how pregnancy evolves.

 Developing lizard embryo inside the placenta. Oliver Griffith

We know from reptile studies that live birth has several advantages over pregnancy.

In cold environments, eggs can have low survival rates because embryos are too cold to complete development. Meanwhile, pregnant mothers can either produce their own body heat (as in mammals) or can bask in the sun to warm themselves (as in reptiles), which keeps embryos warm enough to grow.

Pregnancy does offer one major disadvantage – mothers are burdened with the cost of carrying around their offspring for a long time. The mammal with the longest pregnancy is the African elephant, which can be pregnant for nearly two years.

In contrast, mothers that lay eggs get the advantage of their embryos developing in a nest. For most reptiles, this means that once the eggs are laid, they will leave them to fend for themselves.

What's needed for a placenta to evolve

Reptile live birth is very similar to mammalian live birth. After the eggs are fertilised, they are held inside the mother's uterus. As the embryo begins to develop, a placenta forms.

The placenta is the support organ for pregnancy. It allows mother and embryo to communicate and it allows the mother to provide nutrients to the embryo as it is developing.

Some reptiles have a placenta that provides all of the nutrients embryos receive before birth, just like most mammals. Some species have a placenta that is very simple and transfers very few nutrients, and only provides embryos with oxygen necessary for respiration.

But other species of lizard transfer an intermediate amount between these two extremes, and one such species is the Australian southern grass skink, found in some of Australia's coldest regions including the Blue Mountains, Snowy Mountains and Tasmania.

 An Australian southern grass skink. Jacquie Herbert , Author provided

Studying this intermediate amount of nutrient transport allowed us to see how maternal diet during pregnancy might favour the evolution of a mammalian-like placenta. We found that mothers that ate more through pregnancy gave birth to larger offspring.

Some mothers ate their offspring

We also found that when food is limited, the mothers turned to a more sinister strategy to maintain their own body condition. They aborted and cannibalised their own offspring.

Although eating your offspring sounds like a terrible idea, it can be beneficial for mothers.

In environments where there is insufficient food, instead of giving birth to small offspring that have a low chance of surviving, the mother can regain nutrients by eating their offspring. Nutrients gained from cannibalising their offspring can then be used to produce more offspring in the next breeding season.

Because low food abundance resulted in unsuccessful pregnancies, we were led to conclude that nutrient provisioning by the placenta is only viable when mothers have predictable access to food throughout pregnancy.

What about birth in human ancestors?

This research allows us to tell a story about our own evolutionary history.

The first mammals laid eggs, then due to predation on eggs or perhaps cold temperatures, mothers held onto their eggs in the uterus until development was complete. They were much more successful.

 Live birth in humans. Flickr/Bies, CC BY-NC-SA

In these first live-bearing mammals, the embryos required adequate access to oxygen and this induced the evolution of a placenta.

In an environment where food availability was predictable, females evolved to provide developing embryos with nutrients using the placenta, as occurs during pregnancy in humans.

Without studies on pregnancy in lizards and snakes it would not be possible to understand these evolutionary steps.

Next time you ponder why some particular trait has evolved, it might be worth considering if reptiles could shed some light on the answer.

Oliver Griffith has received funding from the Australian Society of Herpetologists.
 Oliver Griffith, PhD Candidate Evolutionary Biology at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/29696 2014-07-27T20:22:35Z 2014-07-27T20:22:35Z We must do better to curb discrimination against working parents

One in two Australian women report discrimination, despite existing protection laws. Flickr/Ryan, CC BY

A landmark study by the Australian Human Rights Commission reporting that one in two mothers has experienced work discrimination shows employers clearly believe they have legitimate reasons to discriminate against women raising families, and their partners.

But with a solid legislative framework in place clearly mandating how employers must behave towards pregnant women and their partners, is this sort of behaviour really excusable?

The Supporting Working Parents: Pregnancy and Return to Work National Review surveyed 2000 mothers and 1000 fathers and partners on their experiences of discrimination.

One in five (18%) mothers told the AHRC they were made redundant, their jobs were restructured, they were dismissed or their contract was not renewed because of their pregnancy, taking parental leave, or family responsibilities that included the need to breastfeed or express milk at work.

There was significant negative impact of this discrimination on women's health, finances, career and their family. An alarming 72% reported that the discrimination impacted on their mental health. Some 42% reported that the discrimination had a financial impact on them, while 32% of mothers went to look for another job or resigned.

The report found fathers and partners also experienced discrimination in the form of negative attitudes through to dismissal. This group also reported similar impacts on mental health, finances, career and their family.

"Nothing will change"

Strikingly, their responses to the discrimination also did not vary. The survey found 91% of mothers and 95% of fathers and partners did not make a formal complaint either within their organisation or to a government agency.

Primarily mothers did not complain because they "perceived that the discrimination was not serious enough, that it was too hard, stressful or embarrassing to take action, or that they would not be believed or nothing would change."

Researchers Byron and Roscigno in their analysis of US pregnancy based employment discrimination claims stated that what "explains the relative infrequency at which pregnant women win favorable judgments…" is that when women do contest employer actions, "the structural and cultural playing fields … are quite uneven."

The AHRC's findings showed that employers are confused about their own legal obligations, and about employee rights related to pregnancy, parental leave and return to work issues. It recommends assistance for employers and employees to understand the legislative framework.

Australian laws

Australia already has a suite of federal laws that protect pregnant women and new parents from workplace discrimination in Australia, including the Sex Discrimination Act 1984, the Fair Work Act 2009, and Work Health and Safety laws.

The Sex Discrimination Act 1984 for example, specifically prohibits discrimination on the grounds of pregnancy, potential pregnancy, breastfeeding and pregnancy/return to work discrimination. So to claim confusion and uncertainty about workplace legal obligations is difficult to understand.

Although the report cites that there are many employers who support and retain pregnant employees and working parents, other employers identified challenges managing the uncertainty around pregnancy, parental leave and return to work issues.

In response, the report advises that workplaces need a solid foundation of the right policies and practices which are effectively communicated and supported by leaders.

Effectively implementing the strategies and practices requires developing a plan from the time an employee announces her pregnancy; through to preparing for an employee's parental leave; staying connected during parental leave; reintegrating after parental leave; and career acceleration upon their return.

Financial bottom line

It is clear that financial interests are also a concern for employers. One of the challenges identified by employers in managing pregnancy/return to work issues was "limiting the direct costs associated with training a temporary replacement employee." Seeing pregnant women as "economic liabilities" could be one of the motivations perpetuating pregnancy-based discrimination.

However there are more primal reasons underlying the "hidden, insidious, and often intentionally carefully concealed" discrimination.

The report found "harmful stereotypes and attitudes in the workplace about "the pregnant employee" and "the employee with family or caring responsibilities", "the flexible worker", as well as stereotypes about "the ideal worker", are pervasive in Australian workplaces."

What is clear is that pregnancy continues to be associated with gender stereotypes and organisations are continually recreating gender inequalities related to working parents.

Pregnant presenteeism

Patriarchal stereotypes that "women cannot be good mothers and good workers" persist. There is even evidence that challenges the "common belief" that pregnant employees are prone to take sick leave. The term "pregnant presenteeism" was coined to describe pregnant employees who resist taking sick leave.

Given that increasing women's workforce participation in Australia by 6% could increase the national GDP by A$25 billion, there is a compelling reason to curb pervasive discrimination that has changed little in the 15 years since the first Inquiry by the AHRC.

The report concludes that we are all implicated in ensuring that this form of discrimination against working parents is curbed:

"It is up to all of us – government, employers, unions, peak bodies, community organisations and men and women in workplaces around Australia – to play a role in addressing such discrimination and preventing its continuation."

Diann Rodgers-Healey does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Diann Rodgers-Healey, Adjunct Professor at James Cook University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/29050 2014-07-14T05:04:35Z 2014-07-14T05:04:35Z Health Check: eating for two during pregnancy

Energy requirements don't rise much but nutrient requirements do, so women need to be mindful of the quality of their diet.  Shutterstock

Women are often encouraged to "eat for two" during pregnancy. While this is right in terms of eating to meet both mum's and baby's needs, it doesn't mean doubling her total food and energy intake.

The amount of weight you should gain during pregnancy depends on your pre-pregnancy body mass index (BMI). If you're a healthy weight, with a BMI of 18.5 to 24.9, you should gain 11.3 to 15.9 kilograms. If you're underweight, with a BMI of less than 18.5, you'll need to gain a couple more: 12.7 to 18.1kg.

If you're overweight, with a BMI of 25 to 29.9, you should gain a little less: 6.8 to 11.3kg. For obese women with a BMI of 30 or above, the recommended weight gain is between five and nine kilograms.

These amounts increase for twin and triplet pregnancies. A woman of a healthy weight carrying twins, for example, should aim to gain around 16.8 to 24.5kg.

If this weight gain sounds excessive, keep in mind that the baby at term makes up only about one-third of this weight. The rest may be made up of other tissues and fluids, including an extra 2kg of blood, 1.5kg of breast tissue, 0.5kg placenta and 1kg amniotic fluid. All of this weight is quickly lost after birth.

It's only the 2.5 to 3.5kg of extra fat mass gained that women need to lose. This can happen quite quickly if she chooses to breastfeed. Milk production, and hence lactation and breastfeeding, uses a lot of energy.

If a woman gains closer to 20 to 25kg during her pregnancy, however, more of that will be fat and it will be much harder to lose. It could also put her at higher risk of developing gestational diabetes and other complications during the pregnancy.

Not gaining any weight during pregnancy, or not enough, can also be dangerous.

Energy requirements vary over the pregnancy. A woman's energy requirements increase only slightly in the first trimester, so no additional energy (in terms of calories or kilojoules) is required. And only about 500g to 2kg of weight should be gained during this time.

But nutrient requirements are higher, so women need to be mindful of the quality of their diet.

In the second trimester, the energy requirements increase by about 1,400 kilojoules per day (or 300 calories). That's the equivalent of a small tub of yoghurt and a banana.

For the final trimester, the energy requirements increase again, by a total of 1,900kJ a day above pre-pregnancy requirements. So add another piece of fruit to the yoghurt and banana and you're meeting your additional energy needs.

While all nutrients are important during pregnancy, three stand out for those of us living in the western world: folate, iodine and iron.

Adequate folate levels are critical for the healthy formation of the neural tube in the developing foetus. Folate is found in green leafy vegetables and is added to commercial breads. On top of these dietary sources, antenatal guidelines recommend supplementation with 500 micrograms per day of folic acid, from 12 weeks before conception and throughout the first 12 weeks of pregnancy.

Iodine is important for hormone development and is found in dairy products, seafood, seaweed, eggs and bread. But diet alone may not deliver enough of this nutrient during pregnancy. Antenatal guidelines therefore recommend healthy pregnant women take an iodine supplement of 150 micrograms each day.

Iron helps the body manufacture red blood cells that carry oxygen around the body and can be found in red meat, fish, chicken, legumes and other plants. Unless pregnant women have a severe clinical iron deficiency, routine supplementation is not recommended. Instead, make sure you're consuming enough iron-rich foods along with foods high in vitamin C to aid absorption.

Women with clinical deficiencies or health conditions should consult their doctor prior to taking and stopping supplements.

The bottom line is that pregnant women do need to eat enough nutrients to meet both their needs and the needs of their growing baby, but the increases in energy requirements during pregnancy do not equate to "eating for two" in terms of volume.

Women need to have a sensible increase in their total energy intake to avoid excessive weight gain during pregnancy and have optimal outcomes for them and their babies.

Regina Belski does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Regina Belski, Senior Lecturer in Dietetics and Human Nutrition at La Trobe University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/28753 2014-07-04T04:57:09Z 2014-07-04T04:57:09Z Birthing pools recalled after case of Legionnaires – so, should you be worried?

Home or away? Jason Lander, CC BY

The recall of hired home-birthing pools after a baby contracted Legionnaires' disease will inevitably lead some women to worry about having a water birth at home. While the incidence is rare, it is worth keeping in mind some clear guidelines about how to best use a water pool.

Home birth is an option for women who are at low risk of complications, but it is certainly not widespread. In the UK, the percentage of women who have their baby at home is very low – only 2.3% in 2012 (included in this figure are many home births that are unplanned). Others who plan home births initially labour at home using water, but then transfer to hospital for additional pain relief.

But about half of women who planned home births use water birth pools, as immersion in water helps relieve pain.

In the case of the baby with Legionnaires', it was born in a pool that was pre-filled and kept heated for several days before. The recommended water temperature for water birth pools is 36-37°C so that during labour the baby is not overheated or shocked by cold water. But this is also an ideal temperature for many bacteria to flourish in, including the Legionnelle bacteria, which cause a severe lung infection. So the recommendation is that home birth pools should never be pre-filled and kept warm. This is the reason that hot tubs that aren't cleaned and looked after have also been implicated in cases of Legionnaires' disease.

Some women may be tempted to pre-fill the pool when they know they could go into labour so that they don't have to wait while it fills up when labour starts, or to try it out beforehand. But a good idea is to fill it with cold water to see how long it takes to fill – most only take 10-20 minutes – before emptying, cleaning and drying the pool until it's actually needed, which will also give you an idea of when to start the process. This would prevent the unusual Legionnaire bacteria but also more common bacteria.

Hiring a pool

Not all women buy pools because they are for a one-off use or because buying one may be too expensive. Some NHS Trusts provide a rigid shell and women can then purchase a disposable liner, although many are hired privately. These hired pools come in a variety of types, usually free standing, and can have inflatable or rigid frames with disposable liners. Most come with pumps and pipes to aid filling and draining and most companies provide advice about safety and hygiene which should be read and adhered to. Even so, it's ideal to discuss the pool, how and when to fill it and ensure it's clean and safe with a midwife.

While an investigation into how the baby contracted Legionnaires' is carried out, certain types of birthing pool have been banned by the NHS and Public Health England (PHE) until further notice. Heated pools from the particular supplier in this case have been recalled and a further six companies that hire out pools are being questioned over whether they carry out the right risk assessments.

Concerns about infection are not new. But a Cochrane review I lead that looked at the evidence to date showed no difference in the incidence of infection in mothers or babies using a variety of pools, both plumbed in and free-standing. Importantly, however, all were filled at the time of use, were carefully maintained, with strict cleaning regimes, or with one time use only liners.

The concept of a pool that is pre-filled and kept warm is a new phenomenon but not one that is recommended in any NHS facility. The risk of infection is well recognised and all NHS facilities have policies and processes that include birth pools being filled at the time they are needed, are thoroughly cleaned and dried after every use and monitored for potential infections. Most good companies would recommend similar precautions.

All midwives are also very aware of the risk of infection and any woman considering birth at home or using water during birth should speak to her midwife about her plans. Advice in local waterbirth workshops for expectant parents also now explicitly includes not using pre-filled/heated pools because of the rare but possible infection risk.

There are important advantages for women giving birth at home, such as a sense of well-being from being in their own environment. The use of water during labour and birth is likely to be a contributing factor to this, so it is vital that women have all the information they need to safely birth at home and use water immersion during labour if they wish.

So the key message must be that any infection is unusual – and legionnaires extremely rare – but good practice when it comes to birthing pools, and under the guidance of a midwife, will contribute to a positive birth experience for all.

Elizabeth Cluett was lead reviewer on the Cochrane review into outcomes from immersion in water during labour and birth
 Elizabeth Cluett, Director of Programs for Family, Child and Psychosocial Health. Lead Midwife for Education. at University of Southampton Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/27659 2014-06-06T13:36:15Z 2014-06-06T13:36:15Z 3D imaging and robotics device could transform surgery inside the womb

A delicate world. Kambodza, CC BY

Performing surgery on foetuses while still in the womb is a risky business. Although pioneering work in this field began in the 1980s, it remains very challenging, with only a few highly trained teams scattered around the world treating a handful of conditions. But new technology could transform the treatment of congenital problems in the womb.

In spina bifida, for example, part of the spinal cord and nerves may come through the spine of the foetus. This may cause both nerve and brain damage as it may block proper fluid drainage between the brain and the spinal cord. Having no prenatal surgery runs the risk of potentially serious neurological problems in the developing baby but surgery, which currently involves making a large opening incision in the mother's abdomen and uterus, can lead to premature birth.

It is one of the most common birth defects but also one of the most complex procedures to carry out. Open prenatal repair is rare and has never been performed in the UK, for example.

Three-fingered device

Our goal is to make foetal surgery safer and more accessible to a broader set of surgeons. To do this, we're working to develop a device, part of a £10m project bringing together world-renowned experts in foetal surgery, robotics, physics, optics and medical image computing.

The device will enable surgeons to operate from outside the womb using an extended flexible roboticised arm fed in through a small incision in the abdomen of the mother. Three fingers will give the surgeon even more dexterity and better vision at the surgery site. While two of the fingers can carry out procedures – in the case of spina bifida, patching up the source of the protrusion from the spine – the third may carry an innovative endoscopic imaging device to create 3D images of the womb to assist the surgeon. The images will appear on a screen visible to the surgeon and will help surgeons actively work in a difficult environment where the foetus might move for example. The images will also serve as a feedback for guiding the roboticised arm.

 Robot probe. Wellcome Trust/EPSRC

Some foetal surgery already involves passing surgical tools through a smaller incision in the abdomen and uterus. This minimises the risks of complications for the mother and foetus, notably preterm labour.

 A fetoscopy. Denise Pedreira, CC-BY-SA 3.0

Minimal access with laser coagulation, for example, is the current standard of care for treating twin-to-twin transfusion syndrome (TTTS), a condition where two identical twins share blood through the same placenta. While the donor twin is deprived of blood and can develop growth defects, the other twin is overloaded with blood and can suffer from heart failure. To operate, surgeons currently use a foetoscope that acts like a long stick-shaped camera with a laser coagulator attached to it to cauterise the blood vessels that link the blood circulation between the twins, but this tool lacks flexibility and this kind of surgery is still quite complex and has limited access possibilities.

Minimally invasive surgery can also be used to stimulate lung growth in another condition called congenital diaphragmatic hernia. However a subsequent more invasive procedure called ex utero intrapartum treatment procedure, or "EXIT surgery", might then be required at the time of the baby's delivery.

 Picture of an exit procedure, a type of foetal surgery performed at the time of delivery. Francois Luks, MD, Public Domain

While minimally invasive repair of spina bifida is possible, it remains inaccurate, has a high failure rate and requires multiple small incisions, which increases the risks associated with the procedure.

Our flexible robotised arm project has been designed to allow surgeons to perform minimally invasive surgery in all these scenarios with improved safety and efficacy compared to the options we currently have today.

Latest developments in robotics

We will build on the latest developments in robotics, for example using fluid hydraulic systems to create movement with motors that have a much smaller footprint than the standard ones. Although we do not intend to make the robotic arm fully automated, image guidance will be used to intelligently assist the surgeon. The design will, for example, help lessen tremors in the surgeon's hand and allow for bigger or more fine-grained manipulation by scaling down the surgeon's gestures.

The 3D imaging that will be used is based on photo acoustics. Photo-acoustic imaging is a hybrid technique that employs harmless laser pulses that enter deep into the tissue and convert into sound waves that can be detected by ultrasound. Combining this with conventional ultrasound technology will give a unique visualisation of both structural and functional information of the foetus in its environment.

Surgeons will be able to use external 3D ultrasonography as well as MRI, when available, to construct a plan for the operation based on the specific anatomy and pathology of the foetus to be operated on. Computer modelling embedded with biomechanical information will be able to compute and predict deformations that may occur during surgery. Both the pre-operative data and the feedback from the "live" 3D imaging will be fed into the model and processed to give surgeons ongoing context, much like a GPS might tell us where we are on a predefined map.

By combining these elements, we will provide surgeons with instrumentation that will help them make the surgery much safer and much more efficient. The surgeon will still be at the centre of the operation but will be able to rely on additional guidance, like you might get power steering, collision detection and rear cameras in a modern car.

Severe congenital defects account for many baby deaths each year but many more could survive if help could be given in the womb. Instead of carrying out neonatal surgery when it may be too late, pioneering new technology could transform this field of surgery.

Tom Vercauteren receives no direct funding for his involvement in the project.

Sebastien Ourselin is principal investigator on this project and receives funding from the Wellcome Trust and the Engineering and Physical Science Research Council.
 Sebastien Ourselin, Head of the Translational Imaging Group at UCL Tom Vercauteren, Senior Lecturer in the Translational Imaging Group at UCL Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/24817 2014-04-28T09:44:30Z 2014-04-28T09:44:30Z Late-stage unborn babies can learn and remember nursery rhymes

Repeat after me: Humpty Dumpty sat on a wall ... Pregnant woman via Shutterstock

As technology advances so does our ability to monitor unborn babies. Now it's even possible to track how a very young fetus, still in its mother's womb, learns and remembers basic speech.

As a labour and delivery nurse in the 1980s, the limits and potential value of monitoring a fetus always intrigued me. The research of Anthony DeCasper a decade later really caught my interest – demonstrating early learning and memory capabilities.

In a recent piece of research, my team and I decided to use a fetal monitor similar to those used in traditional labour and delivery units to record a fetus's heart rate in response to a recording of a passage of speech. We did this to help us understand more about how early a fetus could learn a passage of speech and, if learned, whether the passage could be remembered as long as four weeks later.

Because the fetus cannot speak to us, we used a small change in heart rate called the "cardiac orienting response" to determine when and for how long the fetus could remember. The conventional interpretation of this kind of response is that it shows the heart-rate decelerating because of a stimulus. Researchers have used this response for decades in newborns and some hypothesise that it indicates familiarity with a stimulus or learning.

Poetry recital

In our study, from 28 to 34 weeks of pregnancy, mothers spoke a passage or nursery rhyme out loud twice a day and then came in for testing at 28, 32, 33, and 34 weeks gestational age. The nursery rhyme was untitled and it was therefore unlikely for mothers to have heard it before.

During testing, we decided to make things a bit more difficult for the fetus. Rather than play back a recording of the mother speaking the rhyme, instead, we played a recording of a female stranger speaking the same rhyme. We believed this would help us determine whether the fetus was responding simply to its mother's voice or to a familiar pattern of speech – a more difficult task.

At 34 weeks gestational age, we asked mothers to stop speaking the passage out loud so that we could then see how long the fetus could remember the pattern of speech.

Interestingly, the fetus' heart rate began to respond by 34 weeks gestational age – or once the mother had spoken the rhyme out loud for six weeks. The fetuses in this study continued to respond in the same way for as long as four more weeks after the mother had stopped saying the rhyme, or until 38 weeks gestational age – just before birth.

This should not be entirely surprising, because a mother's voice is a predominant source of sensory stimulation for her developing fetus and, while speaking, not only does her fetus hear but, it also feels her vertebral column and diaphragm gently vibrate and move in sync with her speech.

So our findings should not be used to suggest alterations in the typical ways mothers interact with their unborn baby. But they do highlight just how sophisticated the third trimester fetus really is and suggest that a mother's voice can be involved in the development of early learning and memory capabilities.

Charlene Ann Krueger receives funding from the National Science Foundation. She is affiliated with the University of Florida.
 Charlene Ann Krueger, Associate professor, College of Nursing at University of Florida Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/23578 2014-02-26T05:59:52Z 2014-02-26T05:59:52Z Newly infected mothers are more likely to pass HIV on to babies

Not out of the woods yet.  US Army Africa, CC BY

Women are twice as likely than men to contract HIV during intercourse and according to the authors of a new US study, women who contract HIV while pregnant may be especially vulnerable and more likely to pass on the virus to their child than women who already had the virus.

Published in PLOS Medicine, the researchers analysed the results of 19 studies (all carried out in sub-Saharan Africa) that had estimated the rate of new, or "incident", HIV infections in pregnant women or those who had given birth in the preceding 12 months. They then calculated a "pooled" rate of new HIV infections during pregnancy.

The pooled rate suggested women were at high risk of contracting HIV while pregnant. This rate was similar to other high risk groups, such as female sex workers and discordant couples (where one partner is HIV-positive and the other HIV-negative).

Newly infected

All people who are newly infected with HIV have extremely high levels of virus in their bodies during the first few months after becoming infected, but are usually unaware they are infected. This puts them at higher risk of transmitting the virus – either to their sexual partners or, in the case of pregnant or breastfeeding women, to their babies. This is clearly important in countries like Swaziland, the country most affected by HIV/AIDS and where a quarter of the adult population lives with HIV. It also has the highest rates of new HIV infections in pregnancy.

In general, women are both biologically and behaviourally more vulnerable to HIV infection and around twice as likely as male partners to become infected during sex. But it is still uncertain whether pregnant women are more vulnerable to HIV than they would be if they were not pregnant. The study was a systematic review, meaning it looked at existing studies and was limited by the number of studies that included relevant information on pregnant and non-pregnant women.

In two of five studies that could address the specific question of risk (one carried out across seven African countries and the other in South Africa), pregnant women were around twice as likely to become HIV infected than non-pregnant women. But when the researchers combined the findings of all five, they didn't find a higher risk of becoming infected with HIV in pregnant women compared with non-pregnant women. So while pregnant women can be deemed high risk, the evidence of whether they are at more risk than non-pregnant women is still inconclusive.

One potential explanation for an increased vulnerability to HIV in pregnancy may be biological, including changes in hormonal levels and in the immune system. However, behavioural factors are also likely to be important. The increased risk of HIV infection during pregnancy identified in some studies may be partly explained by more women having unprotected sex because they are no longer using condoms while pregnant. Other factors may include behavioural changes in male partners, for example, who may initiate or increase sexual activity outside the relationship while their partner is pregnant or breastfeeding.

Transmission

One important finding from the study is that babies were more likely to be infected if their mothers became HIV-infected during pregnancy or while breastfeeding compared with babies whose mothers had longer-established or "chronic" HIV infection.

Transmission between mother and child can take place in the womb, during delivery and through breastfeeding. But only once an HIV-positive pregnant woman is identified can she be offered effective interventions like anti-HIV drugs to reduce the risk of transmission.

Antenatal HIV testing is the cornerstone of WHO and UNAIDS strategies to prevent HIV-positive mothers from passing on the virus to their babies and to eliminate new HIV infections in children. In the UK and Ireland, mother to child HIV transmission is at an all time low, according to a study in journal AIDS, thanks to a combination of factors including the very high uptake of antenatal HIV screening and early antenatal combination antiretroviral therapy. This shows how important intervention is.

The findings from the PLOS Medicine study draw attention to the fact that women are at high risk of becoming HIV infected during pregnancy and the period after birth in countries where HIV is common. The authors recommend that in these settings, repeat HIV testing should be offered to women in late pregnancy and to women who have delivered babies but haven't received antenatal care. Although international guidelines recommend that repeat testing should be happening, in practice this has usually not been the case.

Repeat HIV testing could identify more women with new HIV infections who could then receive anti-HIV drugs to reduce the chance of them passing the infection on to their child. It would also give more opportunity for HIV care and treatment, and testing for their partners.

The most effective approach to preventing new infant HIV infections is to prevent women of childbearing age from becoming HIV infected in the first place. The authors also suggest that efforts to prevent HIV infection among pregnant and new mothers should be strengthened, for example, with additional counselling on the benefits of condom use while pregnant or breastfeeding.

Claire Thorne receives funding from the European Union (FP7), Public Health England, Janssen and AbbVie.
 Claire Thorne, Lecturer in Population Health Sciences at UCL Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/22544 2014-02-04T19:40:35Z 2014-02-04T19:40:35Z Call the Midwife: playing catch up with Australia's maternity care

Only a handful of Australian hospitals offer continuity of care and midwives on call. Image from shutterstock.com

In the much-loved British TV drama Call the Midwife, women are offered care from dedicated midwives through pregnancy, labour and birth. The midwives are therefore able to get to know the women and practice their skills with confidence, independence and pride. The show is set in 1950s London but could this also be the future for mainstream maternity care in Australia?

In a recent study, my colleagues and I at the University of Sydney found that pregnant women who see the same midwife throughout pregnancy, birth and the postnatal period are much less likely to experience interventions during birth and cost the public hospital system less.

The study, published last week in BMC Pregnancy and Childbirth, examined the outcomes of a group of first-time mothers who were at low risk of complications during their pregnancies.

Over one financial year (2009-2010), there was an average saving of more than A$1,000 per woman who chose continuity of midwifery care compared to routine public hospital care – where the woman is cared for by the midwife of duty – or private obstetric care in the public hospital system.

Our close neighbour, New Zealand, gives all women the option of a lead midwife care provider and around 80% choose this option. But to date, Australia's effort has been half-hearted: only a handful of hospitals run a midwifery group practice, offering continuity of care and midwives on call.

Better for women

Caseload midwifery care works on the assumption that women will labour more effectively, have a shorter stay in hospital and feel a stronger sense of satisfaction and personal control if they have the opportunity to get to know their midwife at the beginning of pregnancy.

The BMC Pregnancy and Childbirth study found that those who received continuity of care through a midwifery group practice were significantly more likely to spontaneously go into labour (rather than taking drugs to induce labour) and were less likely to have a cesarean birth. Most women prefer to avoid major intervention in birth, have better outcomes and are more satisfied if they have a normal birth.

There were also no differences in serious outcomes for the babies in this study.

 Studies show caseload midwifery delivers better outcomes for women and their babies. dolanh/Flickr

The findings come on the heels of our randomised controlled trial of caseload midwifery published last year in the Lancet medical journal, which found caseload midwifery delivers improvements in outcomes and cost. Women were more likely to start their labour spontaneously, required less pain relief, had short postnatal stays and fewer babies were admitted to neonatal intensive care.

It also follows a 2013 Cochrane Systematic Review which examined 13 randomised controlled trials (over 16,000 women) and showed that compared with a variety of other models, continuity of midwifery led to reduced interventions in birth and, most stunningly, a 23% reduction in babies being born preterm. There were also fewer babies dying before 24 weeks gestation.

The new study is the first to calculate the average cost, per woman, of receiving caseload midwifery compared with private obstetric care in the public system and showed around a A$1,400 cost saving.

Making it a reality

Hospitals are large immovable systems that are very difficult to change – even when the evidence points to the advantages of having a restructured workforce. Managers find it difficult to trust midwives with the flexibility this work requires to enable them to respond to the needs of women in their care.

There is also some resistance among the medical profession. In Australia, around 25% of women will have private obstetric care, which means an obstetrician is the lead care provider during the antenatal period and for the birth. Midwives provide the labour care and postnatal care.

While this gives women continuity of care with an obstetrician, we recently published a paper showing the rates of intervention during birth are much higher under private obstetric care than in the public sector and even higher than when women have continuity of midwifery.

 Around 25% of Australian women opt for private obstetric care. Tyler Olson/Shutterstock.com

Continuity of midwifery care can no longer be overlooked because it is perceived to be too expensive. With nearly 300,000 births a year in this country, caseload midwifery could potentially save around A$4.5 million dollars per year by reducing medical intervention and reducing hospital stays.

Following the release of the Productivity Commission's Report, Health Minister Peter Dutton last month called for an overhaul in health spending to cut "waste". With a finite health budget we can no longer afford to be complacent.

Women should be able to choose an obstetrician; these medical specialists provide an indispensable service in maternity care. But based on the evidence of better outcomes and lower cost, women should have the option of calling the midwife.

Sally Tracy receives funding from The National Health and Medical Research Council of Australia

Hannah Dahlen receives funding from the NHMRC and ARC. She is affiliated with the Australian College of Midwives.
 Hannah Dahlen, Professor of Midwifery at University of Western Sydney Sally Tracy, Professor in Midwifery at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/20996 2013-12-02T14:55:33Z 2013-12-02T14:55:33Z Overweight women shouldn't panic about contraception

Weighing up the options. Puuikibeach

The warning made by HRA Pharma, the French manufacturer behind Norvelo emergency contraceptive pills, that the product is ineffective in women who weigh more than 80kg (12st 7lb) and has reduced effectiveness in women over 75kg is a major one, especially given the relatively small amount of data on which it appears to be based.

The decision was based on a 2011 meta-analysis that combined data from two studies comparing levonorgestrel, the active ingredient in the Norvelo contraceptive, to another emergency contraceptive called ulipristal acetate (UPA). A total of 1731 women took levonorgestrel pills, 38 of whom became pregnant, while 1714 women took UPA, 22 of whom became pregnant. Obese women accounted for 13.6% of the total study population, and overweight women accounted for 21.6%.

The move has also raised alarm in the US over Plan B emergency pills, which have an identical formula to Norvelo. The FDA in the US said it was reviewing the research.

While the study that sparked these concerns raises important concerns about the efficacy of levonorgestrel emergency contraception in overweight and obese women, the relatively small number of these women in the study and low number of pregnancies means we should be cautious in applying the results too broadly. Two important questions remain to be answered: how might obesity affect levonorgestrel emergency contraception, and what are the risks of changing the labelling on these pills based on the current evidence?

You are generally considered to be overweight if you have a BMI (your weight in kilogrammes divided by your height in metres) of around 25 to 29 and obese between 30 to 40. It is estimated that around 15-20% of pregnant women in the UK are overweight or obese, rising to more than a half in the US.

And there are numerous ways that obesity can affect how a drug interacts with the body. Obese individuals may absorb a drug faster through the gut, have a different metabolism and serum concentrations of a drug, and can eliminate a drug either faster or slower from the body. This all depends on the various characteristics of a drug.

One study that investigated the pharmacokinetics of an oral contraceptive pill containing levonorgestrel found that the maximum serum concentration in the body and time taken to achieve it were not different in normal weight and obese women. It was noted that obese women had a larger area under the concentration-time curve and that levonorgestrel had a longer half-life – this means that it took a greater overall exposure and a longer time to reach a steady state of concentration. The findings were in women who had taken a daily pill for 21 days, and it is unclear how these findings relate to a one-time dose of levonorgestrel as in an emergency contraception pill.

Without a clearer understanding of the pharmacokinetics of levonorgestrel as an emergency contraception in normal weight and obese women, it remains difficult to interpret the available data. For instance, it is unclear whether giving a larger dose of levonorgestrel to obese women would counteract the apparent decreased efficacy of a current recommended dose.

Ultimately, the decision of whether to allow overweight and obese women to continue using levonorgestrel as an emergency contraception must balance benefit and risk. While the meta-analysis that underpinned the decision does indicate reduced efficacy in women with a BMI greater than 25 kg/m2, what are the risks to obese women taking this regimen?

There are no medical dangers associated with levonorgestrel as an emergency pill and the risks of obesity during pregnancy are well known – these can include developing gestational diabetes or more complications during childbirth.

Until there are additional data to support the conclusion that these pills are ineffective in overweight and obese women, it seems most prudent to encourage the use of more effective emergency contraceptives, such as the copper IUD or UPA, but this doesn't mean taking away levonorgestrel as an option.

Jenny Robinson does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Jenny Robinson, Fellow in Clinical Pharmacology at Johns Hopkins Medicine Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/19985 2013-11-17T20:26:51Z 2013-11-17T20:26:51Z Why losing my daughter means I don't support Zoe's law

Mothers are best placed to make decisions about what to do with the life within them. Flickr/Peej's photos

A bill currently before the NSW Parliament attempts to criminalise harm to late-term foetuses that die due to injuries inflicted on their mother. But is foetal legal personhood the best way to recognise the particular harm of losing a much-wanted pregnancy due to someone else's violent or careless act?

As a feminist legal academic, I have professional insight into the prospective law; I also have personal insight as a mother who lost her unborn child in a car accident.

It reads like a macabre riddle – someone died within my body, and yet I live. It's one that I've puzzled (and wept) over many times since a 4WD hit our station wagon when I was eight months pregnant in December 2009, causing our baby daughter to die before she could be born.

The current law's attempt to answer this riddle is a clumsy one. It characterises our daughter's death as one of my "injuries", because she died in utero, and was not a legal "person" with a separate existence from me at the time she died.

It is exactly this riddle which Zoe's law (No 2) attempts to resolve.

What the bill does

The bill defines a foetus over 20 weeks or weighing more than 400 grams as a legal "person", for the purposes of dangerous driving causing grievous bodily harm and a number of other criminal offences.

Zoe's law is named after Brodie Donegan's daughter, Zoe, who also died in utero due to dangerous driving in December 2009.

For Zoe's parents, this bill seeks to close what they see as a gap in the law:

We have never felt that Zoe's loss of life was acknowledged or taken into account …I couldn't reconcile that the child I'd applied for a stillbirth certificate for, held a funeral for, received the baby bonus for, received paid parental leave from work for; wasn't recognised separately to me.

The law's response touches a raw nerve because so much of the grieving process is about developing an understanding of who you are mourning – a process already complicated when your child dies before (or around the time of) birth.

Calling our loss an "injury" fails to acknowledge the depth of sorrow involved in grieving a child. But is foetal legal personhood the best way for the law to recognise our loss?

Legal personhood

A key difficulty here is that legal personhood has been interpreted as the definition of human life and worth. Legal personhood is a technical category that sometimes includes non-humans, such as corporations. Its purpose is not to define human life but to enable an autonomous interaction with the law.

Legal personhood doesn't make sense for a baby in utero. The physical reality of pregnancy means that the baby is the opposite of autonomous – it depends completely on the mother and is completely contained within her body until birth.

While inside the mother, a baby is covered by her legal personhood. Birth is the moment of separation when the baby is no longer contained within the mother and her legal personhood.

I have no doubt that my daughter was a person - but I am comfortable with the idea that, at the time she died, she was protected by my legal personhood rather than her own.

Once the foetus is defined as a legal person, the law has a direct relationship with it, and the mother's consent becomes irrelevant. She becomes invisible in the eyes of the law, despite the physical realities of pregnancy meaning that any interaction with the foetus necessarily involves her.

Zoe's bill is drafted to create exceptions for anything done to the foetus by the mother, with her consent or by a medical professional. But this creates a situation where it is legal to take the life of some legal persons, but not others, depending on the consent of a third party (the mother).

And it opens up the prospect of human rights claims being brought on behalf of a foetus. With that comes the prospect of challenges to the pro-choice exceptions built into Zoe's law.

Reproductive autonomy

My own view is that the foetus is a life. But because it is a life completely contained within a legal person (the mother), any interests or rights it could have can only be advanced through the consent of the mother.

As a pregnant woman, what you choose to do with the life within you is a huge moral decision. But because that decision is completely contained within your body, and because you are already the mother to any child that might potentially be born, you are the best person to make that decision.

You are the most qualified person, the most concerned person, the person most at risk, and the most interested person.

For anyone to take that decision out of your hands, whether to insist that you continue with a pregnancy or to terminate a pregnancy against your will, is a violation. It goes beyond pain and physical injuries – it violates the mother's decision for her own body and for any potential child.

It is this violation that I would suggest would be a much more effective base for a law recognising the harm Brodie Donegan and I experienced.

This could involve, for example, a specific offence addressing conduct that ends the life of a foetus without the mother's consent.

Our current laws misconstrue forced pregnancy loss as just another type of bodily injury, rather than recognising it as a violation of reproductive autonomy. Like rape, forced pregnancy loss deserves its own offence centred on the notion of violation, rather than injury.

A law that frames forced pregnancy loss as a specific offence could acknowledge the family's suffering in cases like mine and Brodie's – and protect reproductive autonomy.

It doesn't resolve the heart-breaking riddle of losing a child, but I'm not sure that any law could.

Hannah Robert does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Hannah Robert, Law Lecturer at La Trobe University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/18512 2013-10-29T03:34:44Z 2013-10-29T03:34:44Z Not for profit: the case against commercial surrogacy

Safeguards to protect women and children should not be eroded. Image from shutterstock.com

For singles and couples who can't naturally conceive and carry a baby to term, surrogacy is sometimes considered an option to have a child. Current laws across Australia permit "altruistic" surrogacy which prohibit the exchange of funds for surrogacy, beyond reasonable expenses, in order to protect the woman and child involved.

Some commentators argue these restrictions should be lifted to allow commercial surrogacy. This would involve a transaction between a commissioning person or couple and a woman, either directly or via a broker. So the woman carries and bears a child, and then permanently relinquishes it to the commissioning person or couple, in exchange for a fee.

But while advocates for commercial surrogacy in Australia present it as a workable solution to issues of global exploitation of women and children, if you look a little deeper it emerges as an ethically and legally fraught process. Australia should not join the ranks of Guatemala, India, Thailand, Russia, Georgia, the Ukraine and some US states which permit commercial surrogacy.

The market mentality

Commercial surrogacy advocates focus on payment for the surrogate's "services", using strong market-based language. Such market mentality preys on people's vulnerabilities, and detracts from the realities involved.

Commissioning couples are sold the idea that commercial surrogacy is simply a business transaction that can be performed with ease. They are told they will achieve emotional fulfilment and a family of their own using commercial surrogates who are really giving, altruistic women, who want to help (for a fee or compensation).

The reality of commercial surrogacy paints a different picture. Concerns for women and children are minimised or ignored by brokers, lawyers, and others who stand to profit.

Sociological studies of surrogates suggest that commercial surrogates are susceptible to financial inducement and are vulnerable to exploitation because of their financial status. As US legal researcher Katherine Drabiak points out:

rhetoric that portrays the surrogate as a reasonably well-educated, financially stable woman motivated by altruism stands in contrast to reality.

This is so in both developing and developed countries.

 Commissioning couples are sold the idea that commercial surrogacy is simply a business transaction that can be performed with ease. Image from shutterstock.com

Some proponents of commercial surrogacy argue that in order to prevent exploitation, surrogates should be paid a minimum amount to compensate them for the risk and burden they take. Allegedly the minimum payment will serve to avoid "unfair inducements".

But who would act as a surrogate in such circumstances? It's most likely to be women who are vulnerable or financially needy: low-income single mothers, migrants, unemployed women, or mothers unable to work and care for her children at the same time – enticed (or induced) by the minimum payment.

Perhaps what will follow is that we will be asked to believe that accepting low payments for commercial surrogacy reflects that surrogates are not really doing it for the money after all. Of course, such rhetoric keeps the price of commercial surrogacy down.

Note, while advocates of commercial surrogacy equate carrying a child with labour (work), they do not suggest that anywhere near the minimum wage be paid (24 hours a day for nine months at A$16/per hour = approximately A$107,000).

Finally, we can't forget that the "marketisation" of birth involves a child. That child will perhaps one day be aware of the commercial transaction that surrounded his or her birth. The consequences of being handed over for "minimum" compensation are unknown.

Global commercial surrogacy

There is no doubt that in the global commercial surrogacy market, poor and vulnerable women have been trafficked for use as surrogates for the profit of agents or brokers.

Even in more "routine" cases, in both the developing and developed world, there are concerns about the extent to which women engaged as surrogates are influenced by social, cultural, and economic inequities.

This is not reason to bring commercial surrogacy to Australia. In fact, it should be reason not to do so.

Back in Australia, those who commission surrogates in commercial arrangements abroad must apply for legal parentage of these children. This is not always guaranteed. In such instances, our concern should lie with the welfare and best interests of the child, but this does not mean that legal parentage should be assured. Courts must scrutinise each individual case.

The law should not be changed because of people who have chosen to enter into, or facilitate, commercial surrogacy arrangements abroad – sometimes in contravention of Australian laws.

Protecting women and children

Australian states and territories need to preserve their current laws that serve to protect women and children by prohibiting commercial surrogacy, while permitting "altruistic" surrogacy in some circumstances. Everyone should be treated equally under such laws.

Australia also has an obligation to work to reduce the international commercial surrogacy trade. One option is to prohibit Australians from engaging in such arrangements abroad. But in doing so we must be careful to recognise the vulnerabilities of commissioning parents too. As such, we need also consider the actions of lawyers and other agencies who make a business (and handsome profit) out of giving "advice" to people about commercial surrogacy abroad, and who are pushing for its inception here.

Most importantly, Australia needs also to facilitate and support different family formations via other means, such as co-parenting arrangements, or foster-care and adoption when there is a child in need. We must recognise the desire some people feel to have children but commercial surrogacy should not be sold to them as a way to achieve such desire.

Sonia Allan does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Sonia Allan, Senior Lecturer, Law at Macquarie University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/18961 2013-10-11T05:25:06Z 2013-10-11T05:25:06Z New fertility treatment brings hope, but not for all

Way before the birds and the bees. Jpogi

It's Nobel season and who could forget IVF pioneer Sir Robert Edwards who won the accolade for medicine in 2010? More than ever before, reproductive medicine is throwing up new treatments and answers to women's infertility. In-vitro activation, or IVA, is the latest to make waves after scientists were able to help a woman give birth through a process that involved finding minute follicles in her ovaries.

In women's ovaries the follicles are responsible for producing the eggs and most of the female hormone oestrogen needed for pregnancy. Women are already born with these follicles and the eggs they contain. But the overwhelming majority of these are at an immature primordial stage which means they aren't capable of either oestrogen or egg production. To do this they must first develop to a more advanced stage, which happens during ovulation every month.

However, because women already have a set reservoir of follicles when they are born, the follicles - and the eggs within them - succumb to the adverse effects of aging, one notable one being progressive damage to the eggs' genetic material or DNA as women get older. Another important biological process that comes from this limit is the menopause.

Remarkably, for the vast majority of women the age of the menopause is relatively constant at around the age of 51, indicating that the ovary maintains a tight system of checks and balances on its follicular bank.

And exciting new research is unveiling a complex system of signalling pathways through which the ovary maintains this tight leash on how many primordial follicles are allowed to begin development at any one time in order to ensure a supply of oestrogen and egg sand that the finite supply of follicles aren't used up too early in adult life.

For some women however, this ordinarily tightly controlled mechanism goes awry and any visible signs of oestrogen and egg production disappear a decade or more earlier than expected. Women with premature ovarian insufficiency (POI or premature menopause as some commonly call it) are unable to produce eggs either naturally or with conventional ovary-stimulating drugs such as used with IVF.

IVA - a new breakthrough?

Until now women with POI could still become pregnant but most needed donated eggs to do so. But a team of American and Japanese researchers have reported the birth of a baby to a patient with POI using her own eggs and a technique called in vitro activation (IVA).

The study involved 27 women whose ovaries were both removed and dissected into tiny fragments. In 13 of these women, primordial follicles were found when examined under the microscope. The significance of this was that POI wasn't caused by the absence of eggs and follicles but because follicles were not being coaxed into developing into more advanced stages.

Once "activated", ovarian tissue was then transplanted back into the patients and a further eight of these women showed signs of follicular development. And after being treated with IVF drugs to stimulate the ovary, mature eggs were successfully harvested in five cases and resulted in one live birth - the source of the news story.

It's a landmark paper that successfully translated knowledge about IVA from previous lab-based research into practice. And these results undoubtedly bring fresh optimism when hope previously seemed lost.

But as with all ground-breaking research, these findings also bring new challenges and raise important questions about wider applicability. The papers' authors have been very measured in considering the potential implications of their findings and alluded to many of the points that the findings raise in my mind.

Working out the maths

IVA was not possible for 14 of the 27 patients in the study, who showed no viable follicles under the microscope. Also, up to the time of the study report, among the remaining 13 women who had ovarian tissue transplanted, eight showed signs of follicle development, five had mature eggs obtained and went on to produce embryos (the earliest pregnancy stage) and one had the live-birth.

So while it is a major advance that proves that IVA can work, it also illustrates that many POI patients may not benefit from IVA. This probably reflects a number of causes of POI. An important challenge for the future will therefore be devising a method that can be used in clinics to identify suitable candidates and avoid invasive surgery for women unlikely to benefit. Also, women with POI account for a relatively small proportion when compared with the wider infertile population.

A needle in a haystack

Can IVA be used to help a wider cross-section of infertile couples? An increasing number of women who seek IVF treatment are well into their forties, when ovarian follicular reserve is known to be very low. One challenge here is actually finding the follicles as they are likely to be few and far between, akin to finding a needle in a haystack.

It also means that IVA is very unlikely to be applicable to post-menopausal women as follicles have all but disappeared by that stage. For older women, IVA will not circumvent genetic and other cellular damage that accumulate in eggs with advancing age and which reduces pregnancy success rates.

A group who could potentially benefit from burgeoning technologies like IVA are young women diagnosed with cancer whose fertility would be jeopardised by the irreversible toxic effects that many cancer treatments have on ovarian follicles. Frozen ovarian tissue biopsies containing primordial follicles obtained from such women before their treatment could theoretically be subjected to IVA and transplanted later in order to obtain eggs.

Notwithstanding these issues, the research is a triumph for translational reproductive research and opens new avenues that brighten the outlook for many whose fertility prospects looked bleak. However, a contracting budget for fertility treatment in the NHS means that even if further evaluation of technologies like IVA validates their use, making them accessible to infertility patients will present an altogether different challenge.

Hayden Homer does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Hayden Homer, Clinical Senior Lecturer and Consultant in Reproductive Medicine at UCL Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/16332 2013-08-06T13:40:07Z 2013-08-06T13:40:07Z Effects of prenatal stress can affect children into adulthood

Stressful times for mum increase the risk of later problems for her baby. Flickr/Roberto Carlos Pecino

If we want to understand child development, we need to start before birth. We have known for decades that health depends on an interaction between our genes and our environment. But we've also come to realise that a key part of that environment is in the womb before we're born.

There is now considerable evidence that the mother's emotional state during pregnancy can affect the development of her baby's brain.

This is because of "foetal programming", where a changing environment in the womb through different sensitive periods can alter the development of the foetus. This then goes on to affect the child in the longer term and into adulthood.

This is clearly important in physical health; if a baby grows less well than it should in the womb, he or she will be at greater risk of coronary heart disease or diabetes in later life. But there is now considerable evidence that foetal programming is also important for neurodevelopment in the brain.

Prenatal stress has been associated with the risk of a wide range of outcomes. These include both neurodevelopmental and physical problems, with the likes of anxiety, ADHD and lower cognitive development on one hand and diseases such as asthma on the other.

What kind of stress?

"Stress" is a generic term, which includes a number of different types of exposure. Many exposures, varying from mild to very severe, have been shown to affect outcomes for the child. They can include symptoms of maternal anxiety and depression, pregnancy specific anxiety, daily hassles, bereavement, life events, bad relationships and exposure to acute disasters.

Our research showed that a child's risk of developing emotional or behavioural problems doubles from 6% to 12% if its mother is stressed, anxious or depressed. Although this means that most children will not be affected, this increased risk is of clinical significance.

One important question is whether or not these associations between prenatal stress and altered outcomes are causal, ie directly linked, or whether the associations are due to other factors. For example, mothers who are anxious, depressed or stressed prenatally can continue to suffer these issues after the baby is born. This can also affect their parenting. Factors such as smoking, drinking alcohol and hereditary genetic defects may also play a role.

There are various ways of addressing the question of causality. Studies using animals have been conducted, where offspring were cross-fostered to eliminate parenting problems as a cause. This model also showed that prenatal stress causes behavioural alterations in offspring.

Imperial College's Fetal and Neonatal Stress Research Group have conducted large population studies using the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort from Bristol. Our research accounted for a wide range of external factors which could influence the findings, including the father's mood, to control for genetics. The associations with child emotional and behavioural outcomes remain strong, providing good evidence for a causal link.

How stress reaches the womb

Our group wants to discover the underlying mechanism that causes this association. One possibility is that the foetus is exposed to increased amounts of the stress hormone, cortisol.

This has been shown in animal studies. And our research found that exposure to raised cortisol levels in the amniotic fluid is associated with lower cognitive function in the child later on.

We also recently proved that the function of the placenta changes in association with maternal anxiety. Essentially, we noticed a decrease in the enzyme that breaks down cortisol, potentially allowing more cortisol to pass through the placenta and affect the baby's development.

We're only just starting to understand these possible mechanisms. Many other systems are likely to be involved, for example the role of serotonin, a neurotransmitter that transmits signals in the brain and which is known to affect foetal neurodevelopment.

Most anxiety, depression and emotional and physical abuse experienced by pregnant women remains undetected by health professionals. Even when the symptoms are recognised, it can be difficult to get help. To counter the harmful effects that stress has on a developing baby, we need to be more aware and provide more emotional support.

Vivette Glover has received recent funding from the Medical Resarch Council , the Wellcome Trust and the National Institutes of Health, USA.
 Vivette Glover, Professor of Perinatal Psychobiology at Imperial College London Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/16208 2013-07-19T05:45:17Z 2013-07-19T05:45:17Z Drunken midwives and snooty surgeons: a short history of giving birth

BBC's The White Queen set to feature 15th Century birth scene, when female midwives were the norm. BBC

The history of childbirth and midwifery has seen some dramatic changes, not only in new medical discoveries that vastly improved the safety of both mother and baby but also in social trends and the way we view giving birth.

The 18th century witnessed the rise of medical intervention and a more professionalised class of midwife - and of accoucheurs or men-midwives. But developments haven't always been welcomed, straightforward or accepted. The story of maternity care has been (and remains) complex and often contradictory.

Today, the internet has enabled the exchange of more information than ever before and a new debate over whether childbirth has become too medicalised and subject to the power and authority of doctors.

Rise of the accoucheur

Before the 18th century, women in labour were traditionally attended by other women. These might be friends and relatives with experience or women who made it their profession. Women became midwives through an informal apprenticeship by attending labours, particularly in the company of another midwife.

At the beginning of the 18th century, the employment of medical men in the conduct of normal as well as abnormal labourers was rare. But by the end of the century, many women of all social classes would engage a medical practitioner rather than a midwife to attend them in their labours and virtually all the surgeon-apothecaries were also men-midwives or accoucheurs.

 Sarah Gamp: not exactly a shining example of midwifery. Wikimedia Commons/Fred Barnard

Accoucheurs characterised themselves as the carriers of rational, scientific expertise to an area hitherto dominated by allegedly backward and dangerous practices. This view of the "incompetent midwife" was popularised in Charles Dickens' Sarah Gamp, an alcoholic midwife, sick nurse and layer-out of the dead in Martin Chuzzlewit.

Lying-in hospitals

This growth in male-midwifery went in tandem with the development of hospitals as a place for women to give birth. From about 1740, lying-in hospitals were established in Britain, as well as outpatient maternity charities. By the 1790s between a third and a half of all deliveries in England are estimated to have been attended by medical practitioners.

It has been argued that this rise in more medicalised births through male doctors and the sudden rise of the acchoucheur undermined the female ceremony of childbirth by substituting women's customs for new medical rites masquerading as scientific practices and founded on "objective" knowledge.

But it was also an age with a new spirit of medical enquiry, especially in the fields of anatomy and physiology. Surgeon-apothecaries, an early precursor to our modern-day family doctors, also appeared during this time. They were trusted to deliver your babies, but also to attend your children's complaints, treat your fevers and indigestion, set your fractures, dress your wounds and ulcers, and draw your teeth.

 Members of the Royal Academy including William Hunter: physician, anatomist and man-midwife. Wikimedia Commons/Richard Earlom

The rapid adoption by the surgeon-apothecary of the role of man-midwife could have taken place only if it were actively sought by women and their husbands. Despite this shift, the majority of women throughout the 19th century continued to be delivered in their own homes by locally-based midwives.

There were sporadic attempts to develop midwifery training and regulation during the century but most midwives remained untrained until the first Midwives' Act introduced in 1902 to regulate training and practice.

Caesarean sections

In the 1900s, caesarean section deliveries increased. Before the 1890s it had been so dangerous that they were scarcely ever performed. But the widespread introduction of maternal welfare clinics and antenatal care, and obstetric specialists and maternity beds meant they became a more tenable option.

Yet, in spite of all these supposed advances, maternal mortality remained on a high plateau from 1850 to the mid-1930s - the risk of a mother dying in childbirth was as high in 1934 as it was in the 1860s.

 Caesareans became more common in the 1900s. Today you can book yourself in for one. Wikimedia Commons/Mediajet

Anti-bacterials and antibiotics

The introduction of anti-bacterial sulphonamide drugs in 1936-7 cut deaths from puerperal fever, a bacterial infection contracted by women during childbirth or miscarriage. Between 1937 and 1945, about 70% of the steep decline was due to this factor alone.

Other drugs that cut the mortality rate were the introduction of ergometrine, which narrows blood vessels and can be used to help deliver the placenta and prevent bleeding. The discovery of penicillin by Alexander Flemming in 1928, also cut infection.

Blood transfusions also became widely available. An early pioneer was Dr James Blundell, a British obstetrician who in the early 19th Century used animal experiments to treat hemorrhages. In 1818 he performed the first successful human transfusion to treat a hemorrhage after a birth.

Home to hospital

The greatest transformation in the postwar period was the acceleration of the move from home to hospital as the usual place of birth. This trend had been gaining momentum throughout the 20th century. Nationally, the proportion of deliveries in hospital was about 64% percent in 1954 and only slightly more in 1960. But between 1963 and 1972 the rate rose from about 68% to 91%. From 1975 onwards it has never fallen below 95%.

Ultrasound

New technologies within hospitals have marked a further evolution in antenatal care in the latter decades of the 20th century. New antenatal testing and monitoring became widely available - most notably the introduction of ultrasound. By the 1980s ultrasound was the accepted way of viewing the foetus and used to routinely screen for gestational age.

 4D sonogram of foetus at 20 weeks. Wikimedia Commons/Madcapslaugh

Originally used as a diagnostic aid in high risk pregnancies, ultrasound scans are now widely accepted as a rite of passage in pregnancy; 12-week scans today are when we start to see the foetus as a "real baby" and announce the news. We now have 3D colour ultrasound scans and 4D in real time.

Intervention also became a feature of birth itself with an increased use of oxytocic drugs, to induce labours, episiotomies, or surgical incisions, and more caesarean sections.

At the turn of the 21st century the language of choice, control and consent were increasingly used in maternity care, with midwives recasting their role as the lead professional, but as Tania McIntosh argues it's really the language of science, technology and risk that has come to define childbirth at the start of this new era.

This article is part of a collaboration between BBC Learning and The Conversation. You can read more on the BBC History page

Angela Davis receives funding from the British Academy.
 Angela Davis, Postdoctoral Fellow at University of Warwick Licenced as Creative Commons – attribution, no derivatives.