Pertussis Vaccination in Every Pregnancy: Is it Safe and Effective?

I’m now 37 weeks pregnant, and it blows my mind how quickly this pregnancy has flown by. Now the days are ticking by faster than I can tick things off of my to-do list, and I can feel my body warming up for birth with increasing Braxton Hicks contractions and the baby dropping into my pelvis.

Preparing for a new baby means lots of things to me. There is the physical preparation of washing and folding tiny clothes and setting up baby’s space for changing and sleeping (in our bedroom for now). There is the arduous task of coming up with names – two of them, since we don’t know the baby’s sex. There is the mental preparation of imagining life with a new baby, trying to map out a few strategies for coping with wakeful nights and baby-filled days. There are the talks with Cee about how things will change and how they will stay the same, how she can help us with the baby, and how we’ll help her to adapt to the change in her life.

There’s also the very important aspect of making sure that we do everything we can to protect our new baby’s health, especially before the first round of immunizations at 2 months. This baby will be born during the season of flu and cold viruses, and this year is predicted to be a pretty bad one for the flu. Just south of our home in Oregon, California has so far recorded nearly 10,000 cases of pertussis, also known as whooping cough, this year, more than they’ve seen in 70 years. Cee will be exposed to a range of pathogens in preschool, and my husband will encounter them in his job in healthcare. We’ll do our best to protect our baby by leaving our shoes at the front door, changing clothes when needed, and washing our hands frequently. I also plan to breastfeed, which should confer some passive protection to the baby. However, some of the most important protection has hopefully already been given to this baby during pregnancy, because I’ve been vaccinated for both the flu (as soon as the vaccine was available this season, around 26 weeks) and pertussis around 34 weeks.

Getting vaccinated for flu and pertussis during pregnancy can protect your baby from these serious illnesses during early infancy.

Getting vaccinated for flu and pertussis during pregnancy can help protect your baby from these serious illnesses during early infancy.

The flu vaccine was first recommended for pregnant women in 1964,1 and there is a large body of research showing that the flu shot is safe in pregnancy and an effective way of preventing flu infections in expecting moms, which can pose a significant risk to the fetus. There’s also good evidence that influenza antibodies are transferred to the baby in utero,2 reducing baby’s chances of infection and hospitalization with the flu in early infancy.3,4 (Several of the above links direct you to evidence-based articles written by Tara Haelle on her blogs at Red Wine and Apple Sauce and Forbes. If you want to keep up with vaccine and other health news, Tara is an excellent blogger and science journalist to follow.)

The latest news on this year’s flu season is showing that most of the cases seen so far have been identified as being caused by seasonal influenza A H3N2, a nasty strain, and about half of these are a new subtype that isn’t well-covered by this year’s flu vaccine. If you haven’t yet gotten a flu shot this season, don’t let this news deter you. The flu vaccine will still protect you from the older strains of the flu and might decrease the severity of an infection with the newer type. The vaccine is very safe and still offers the best protection against the flu for you and your baby.

The recommendation that women be vaccinated against pertussis in every pregnancy – using the Tdap vaccine here in the U.S. – was new in 2012. It wasn’t recommended when I was pregnant with Cee in 2010, although I had recently gotten a Tdap booster for my job at the time. Several pregnant friends and readers have emailed me this fall asking if Tdap in pregnancy is safe and if they really need it, particularly if they were just vaccinated in the last couple of years. The good news is that there have been quite a few studies published on these questions in just the last year or two, and I’ll focus the rest of this post on the evidence for the Tdap shot in pregnancy.

What is the concern about pertussis in young infants?

We’ve seen big increases in pertussis recently, especially over the last decade. In 2012, there were more than 48,000 cases reported in the U.S., making it the worst year since 1955. Pertussis hits young infants the hardest. Among the 20 deaths from pertussis in the U.S. in 2012, 15 were in infants less than 3 months of age [PDF]. The first dose of pertussis vaccine is usually given with the DTaP shot at 2 months of age, and before this time, infants are particularly vulnerable to the disease. The 2012 recommendation that women be vaccinated with Tdap in the third trimester of every pregnancy came in response to these infant deaths, the hope being that maternal antibodies to pertussis could help protect infants during those first few months of life.

Previous to the recommendation to vaccinate during pregnancy, pertussis prevention strategies were focused on “cocooning” infants. That meant vaccinating women just after giving birth and also trying to vaccinate family members and others around them to decrease newborns’ exposure to pertussis. While this strategy made sense, research has shown that it isn’t particularly effective at protecting infants from pertussis. It can take several weeks for pertussis antibodies to peak in moms after vaccination, leaving mom and baby vulnerable during the first few weeks postpartum, and it can be challenging (and expensive) to get everyone in contact with the baby vaccinated. It certainly doesn’t hurt to ensure that the family is up-to-date on their pertussis vaccines, and some studies suggest that it helps a little, but overall, it’s turned out to be a pretty inefficient strategy. Tara Haelle reviewed some of the latest research on cocooning here.

Is there evidence that Tdap vaccination in pregnancy can protect babies from pertussis?

The strategy of vaccinating moms during pregnancy takes advantage of the natural transfer of mom’s antibodies to the fetus across the placenta. Several recent studies show that this is an effective way to boost baby’s immunity. Given the pertussis outbreaks in recent years and the finding that cocooning offers only minor protection, this is pretty great news.

A small randomized controlled trial led by Flora Munoz of Baylor College of Medicine, published in JAMA in May of this year, gave 33 women Tdap and 15 women a placebo at 30-32 weeks of pregnancy.5 After giving birth, the treatments were crossed over so that the women receiving the vaccine during pregnancy received the placebo postpartum and vice versa. Predictably, the moms who received the vaccine during pregnancy had higher antibody levels in their blood at the time of delivery, and this was also reflected in their infants at birth and at 2 months of age. Researchers measured antibodies to 4 different proteins produced by the Bordatella pertussis bacterium, and depending on the protein, levels were 5x-36x higher in infants whose moms were vaccinated in pregnancy compared to those who weren’t.

Although the Munoz study was small, it very convincingly demonstrated that vaccination in pregnancy confers greater anti-pertussis antibodies to infants. What it couldn’t do was tell us whether these antibody levels actually protect infants from pertussis infection in the first few months of life. To answer this question, we need much larger groups of study subjects, which means turning to epidemiological studies.

That’s where a study from the U.K., published in the Lancet in October of this year, comes in.6 As in the U.S., there was a huge pertussis outbreak in the U.K. in 2012, during which 14 infants died. In September of that year, the U.K. Department of Health recommended that pregnant women receive the acellular pertussis vaccine between 28 and 38 weeks of pregnancy. In the subsequent year, about 60% of pregnant women were vaccinated.

The Lancet study tracked confirmed pertussis cases occurring in infants younger than 3 months before and after this new recommendation and then looked back at their mothers’ vaccination records to see if vaccination in pregnancy affected their chances of infection.6 The results were impressive. Of 82 pertussis cases in young infants, most were born to women who didn’t receive the vaccine during pregnancy. Only 12 of them (15%) were born to mothers vaccinated at least one week before giving birth. The researchers calculated that the pertussis vaccine was 91% effective in preventing pertussis in young infants, so long as it was given at least 7 days before birth. If the vaccine was given less than 7 days before birth or in the immediate postpartum period, vaccine effectiveness dropped to 38%.

This last part about the timing of the vaccine is important, and it explains in part why the recommendation is to receive the vaccine during the third trimester of every pregnancy. After vaccination, it takes a couple of weeks for anti-pertussis antibodies to peak in the mom,7,8 which is why it is important to vaccinate well before your due date. However, it’s also important not to vaccinate too early. After the antibody peak, circulating pertussis antibodies seem to drop pretty quickly. When women are vaccinated before pregnancy or early in pregnancy, the pertussis antibody concentrations found in cord blood appear to be too low to provide much protection to the infant and are much lower than those found in women vaccinated in the third trimester.5,9 (This doesn’t mean that mom can’t mount an effective immune response to pertussis if exposed, just that circulating antibodies available to cross the placenta are low.) In general, maternal IgG antibodies are not transported across the placenta very efficiently until the third trimester, so to optimize placental transfer to the baby, we want mom’s antibody concentrations to peak during that time.10

Maternal vaccination during pregnancy is an elegant solution to the problem of this deadly disease in newborns. It allows us to give mom a small, controlled dose of inactivated pertussis toxoids at an optimal time in late pregnancy, and the baby gets the benefit of being born with at least temporary immunity to pertussis, enough to protect her during early infancy until she can receive her own vaccine around 2 months.

Is there evidence that Tdap vaccination in pregnancy is safe for the mom and baby?

Two studies out this year provide reassuring data on the safety of Tdap in pregnancy. Tara Haelle (again!) wrote about both of these here and here, so I’ll mention these findings only briefly. A U.K. study, published in the BMJ in July, compared pregnancy and birth outcomes in more than 20,000 women who received the pertussis vaccine in the third trimester to a matched group of unvaccinated pregnant women.11 There were no differences between the vaccinated and unvaccinated groups when it came to risk of stillbirth, maternal or neonatal death, pre-eclampsia or eclampsia, hemorrhage, fetal distress, uterine rupture, placenta or vasa previa, cesarean birth, low birth weight, or neonatal renal failure.

A more recent study, published last month in JAMA, looked back at more than 123,000 women in California’s Kaiser health system, 21% of whom had received Tdap during pregnancy.12 In this study, there were no differences in risk of small-for-gestational age birth, preterm birth, or hypertensive disorders in pregnancy between vaccinated and unvaccinated women. Vaccinated women were slightly more likely to be diagnosed with chorioamnionitis (6.1%), a bacterial infection of the fetal membranes, compared with unvaccinated women (5.5%). Tara Haelle explained why we shouldn’t freak out about that finding in her post on the study (the association is likely due to confounding factors that weren’t considered in the study).

Finally, the randomized controlled trial conducted by Munoz et al, which included the antibody data mentioned earlier, also included a detailed assessment of reactions to the vaccine as well as birth and baby outcomes.5 This study found no difference in birth weight, gestational age, Apgar scores, neonatal exams, birth complications, or the baby’s growth and development later in infancy. Pain at the injection site of Tdap was common – occurring in about 3 out of 4 women – and more frequent than found in the placebo group, but symptoms were generally mild and resolved on their own within a few days. (This was also my experience – a sore arm for a couple of days.)

What’s the bottom line? Receiving the Tdap vaccine during the third trimester of pregnancy is our best chance at protecting young infants from pertussis, a disease that can be particularly dangerous during the first few months of life. Research shows that vaccination in late pregnancy gives newborns the gift of pertussis-specific antibodies at birth and is safe for both mother and baby.

References:

  1. Keener, A. B. Efficacy studies build up the case for prenatal immunization. Nat. Med. 20, 970–972 (2014).
  2. Steinhoff, M. C. et al. Influenza Immunization in Pregnancy — Antibody Responses in Mothers and Infants. N. Engl. J. Med. 362, 1644–1646 (2010).
  3. Zaman, K. et al. Effectiveness of Maternal Influenza Immunization in Mothers and Infants. N. Engl. J. Med. 359, 1555–1564 (2008).
  4. Benowitz, I., Esposito, D. B., Gracey, K. D., Shapiro, E. D. & Vázquez, M. Influenza Vaccine Given to Pregnant Women Reduces Hospitalization Due to Influenza in Their Infants. Clin. Infect. Dis. 51, 1355–1361 (2010).
  5. Munoz FM, Bond NH, Maccato M & et al. Safety and immunogenicity of tetanus diphtheria and acellular pertussis (tdap) immunization during pregnancy in mothers and infants: A randomized clinical trial. JAMA 311, 1760–1769 (2014).
  6. Amirthalingam, G. et al. Effectiveness of maternal pertussis vaccination in England: an observational study. The Lancet 384, 1521–1528 (2014).
  7. Kirkland, K. B., Talbot, E. A., Decker, M. D. & Edwards, K. M. Kinetics of Pertussis Immune Responses to Tetanus-Diphtheria-Acellular Pertussis Vaccine in Health Care Personnel: Implications for Outbreak Control. Clin. Infect. Dis. 49, 584–587 (2009).
  8. Halperin, B. A. et al. Kinetics of the Antibody Response to Tetanus-Diphtheria-Acellular Pertussis Vaccine in Women of Childbearing Age and Postpartum Women. Clin. Infect. Dis. 53, 885–892 (2011).
  9. Healy, C. M., Rench, M. A. & Baker, C. J. Importance of timing of maternal combined tetanus, diphtheria, and acellular pertussis (Tdap) immunization and protection of young infants. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 56, 539–544 (2013).
  10. Glezen, W. P. & Alpers, M. Maternal immunization. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 28, 219–224 (1999).
  11. Donegan, K., King, B. & Bryan, P. Safety of pertussis vaccination in pregnant women in UK: observational study. BMJ 349, g4219–g4219 (2014).
  12. Kharbanda EO, Vazquez-Benitez G, Lipkind HS & et al. Evaluation of the association of maternal pertussis vaccination with obstetric events and birth outcomes. JAMA 312, 1897–1904 (2014).

 

Can Fetal Movements Predict a Baby’s Sex or Temperament?

I’m now 31 weeks pregnant. The weeks are flying by, and for the most part, I’m relishing all the physical changes in my body and the preparations for this baby. We waited a long time for this pregnancy, and it will probably be my last. I curl around my belly at night and think about the baby growing inside me. I wonder about the person that he or she will become and how our little family will adapt to welcome a second child. (We’ve chosen not to learn the sex of this baby until its birth.)

When I was pregnant with Cee and about to become a mom for the first time, I thought a lot about what kind of mother I would be and how this big life transition might alter my identity, my career path, my marriage, and my daily life. The baby-to-be was kind of a vague amalgamation of all the babies I’d known.

This time around, having been around many more babies, I recognize the individuals that babies are from the first days of life – and even in utero – and I spend a lot more time wondering about this baby’s temperament and personality. Introverted and contemplative, like Cee? Or totally different?

Filling me with wonder, this baby moves around in utero a lot, and this feels very different from my experience carrying Cee. I didn’t feel movement from Cee until around 23 weeks, but I began to feel this baby move at 16 weeks. And this baby continues to be very active, more than I remember with Cee, especially making big, dramatic movements in the evening hours but also having significant activity bouts throughout the day (and sometimes in the middle of the night, of course).

Because we don’t know the sex of this baby, I’m often asked if I have any predictions on that front. How would I know, I think? I don’t feel like I have any kind of gut instinct for this kind of thing, and I don’t buy into any of the old wives tails. But if I’m pushed to make a guess, I guess that this baby is a boy. And when I ask myself why that is, it comes down to this observation about more fetal movements. This baby feels different from Cee, and my brain makes a jump to sex as a possible explanation. And then I stop, remind myself that I’m perpetuating a total gender stereotype, and feel embarrassed.

One day, I repeated all of this to a friend as we walked together (complete with an apology for the gender stereotype), with Cee riding her bike within hearing distance. A couple of weeks later, my mom was talking to Cee on the phone and asked her if she thought the baby would be a boy or a girl. Cee answered in what seemed like a verbatim copy of my own explanation: “Well, Mom thinks that it’s a boy, because the baby moves around a lot inside of her, and I didn’t move very much.” Yikes. From now on, I’m keeping my mouth shut. And for the record, Cee is really hoping for a little sister.

All of this left me wondering if fetal movements can actually predict anything about the baby, whether sex or temperament, in postnatal life. I happened to be corresponding with Jena Pincott, author of Do Chocolate Lovers Have Sweeter Babies?, a few weeks ago, and I asked her if she knew of any research on this. She wrote back, “As for ‘in utero’ forecasts, my prediction is that your 2015 is going to be very, very busy!” and sent me a few research articles. I dug around and found quite a few more studies of this question. Finally, I could stop speculating and start talking science! Here’s what I found:

How is this question studied?

Most studies use ultrasound or a Doppler transducer placed on the mother’s belly to us baby profile croppedmeasure fetal movements. Most are conducted over a period of about an hour, during which the moms are asked to rest, and the best studies take several of these measurements over the course of the pregnancy. Studies of postnatal temperament then use standardized behavioral observations or questionnaires to describe aspects of the baby’s behavior.

Is it true that some fetuses are more active than others?

I wondered if my perception that I was carrying a more active fetus is this pregnancy was really true or if it was influenced by other factors? Continue reading

Zero to Five: A Book Review and Giveaway

I received a review copy of a really cool book over the summer: Zero to Five: 70 Essential Parenting Tips Based on Science (and What I’ve Learned So Far) by Tracy Cutchlow. I loved the book and wanted to review it on my blog, and the publisher offered to give away 5 copies to Science of Mom readers! (If you’re curious about my policy on reviews and giveaways, check my About Me page.)

Author Tracy Cuthlow with her daughter, Geneva.

Author Tracy Cuthlow with her daughter, Geneva.

Zero to Five is a book of parenting advice starting with pregnancy and going up through age 5. Author Tracy Cutchlow is a former journalist at the Seattle Times and edited John Medina’s books Brain Rules and Brain Rules for Baby. Then she had a daughter, now 2, and was inspired to create a book that would bring together relevant, evidence-based parenting advice into an enjoyable and accessible format. I’d say she succeeded.

Each of the 70 parenting tips are explained in 2-4 page spreads summarizing the research in the area and accompanied by gorgeous candid photographs of children and parents. The tips are practical, and they’re explained simply, but they’re rooted in science.

ZTF-guard-babys-sleep

The book is divided into 9 topics headings, listed below with examples of some of my favorite tips in parentheses:

  • Prepare (Bolster your friendships; Expect conflict as a couple)
  • Love (Create a feeling of safety; Comfort newborn with the familiar)
  • Talk (Talk to your baby a ton; Read together; Teach sign language)
  • Sleep, eat, and potty (Guard your sleep; Guard baby’s sleep, too; Let baby decide how much to eat)
  • Play (Let baby touch that; Save the box; Make music with baby)
  • Connect (Choose empathy first; Allow mistakes, discomfort, boredom)
  • Discipline (Be firm but warm; Label intense emotions; Teach instead of punish)
  • Move (Rock, jiggle, and swing; Keep moving)
  • Slow down (Be still; Don’t bother to compare)

Some of these tips are obvious, like talking to your baby. But they’re also really important, and that’s one of the things I love about this book. Continue reading

Caffeine and Breastfeeding

If anyone needs a little caffeine, it’s a new mom. My labor with Cee took me through two mostly sleepless nights, and when she finally arrived, we took a little time to nurse and get to know one another, and then our whole little family took a long nap. When we woke up, the first thing I did was send my husband to get me a latte. The second thing I did was breastfeed my new baby again. That dose of caffeine felt like good therapy to me, but what about for Cee? Was it good for her?

caffeine structure

Source: Wikimedia Commons

A few weeks ago, I wrote about the safety of caffeine in pregnancy, and several readers wanted to know about the postnatal effects of caffeine – how mom’s caffeine intake might affect her breastfed baby. I promised to take a look at the literature and report back, and so here we are.

 

When you drink a cup of coffee, how much caffeine ends up in your breast milk?

Several studies have examined this question, and although they are small, they give us a general idea of the transfer of caffeine from mom’s blood to her milk. After a cup of coffee, caffeine is rapidly absorbed into mom’s blood and then passively diffuses across the epithelial layers of the mammary gland. Caffeine appears in milk within 15 minutes of consumption and peaks within an hour. The concentration of caffeine in breast milk ends up being about 80-90% of that in mom’s plasma. However, taking into account the amount of breast milk consumed and adjusting for body weight, studies have estimated that the infant receives no more than 10% of the maternal dose of caffeine, and likely much less (see here, here, and here).

Is this amount of caffeine safe for a baby?

Just because levels of caffeine in breast milk are low relative to what adults normally consume doesn’t mean that these amounts are necessarily safe to a baby. Another important factor is how efficiently a baby can metabolize caffeine, and it turns out that newborn caffeine metabolism is really slow. Whereas the half-life of caffeine in adults is around 2-6 hours, it is an average of 3-4 days in newborns and can be even slower in premature babies. In other words, a morning cup of coffee for mom will easily clear her blood by bedtime, but caffeine may linger in her breastfed newborn for much longer. Metabolism gradually ramps up as the baby matures and the necessary enzyme levels come on board, and most babies can metabolize caffeine at rates similar to adults by 5-6 months of age. Continue reading

Caffeine Safety in Pregnancy

My first trimester of pregnancy coincided exactly with the last three months before my book deadline. I was lucky to have only mild nausea during this time, but I was really, really tired, especially in the afternoon. I tried hard to get enough sleep at night, but my body also seemed to want a 2-hour nap after lunch, when I just couldn’t stay awake, much less think and write. Pre-pregnancy, I responded to a post-lunch slump by pouring myself a cup of coffee or, even better, spending the afternoon at my favorite coffee shop, where a latte and the people around me helped keep me focused for a productive afternoon. A cup of herbal tea in the same atmosphere just made me want to curl up in one of the comfy chairs and take a nap, even as my caffeine-fueled coffee shop friends typed energetically around me.

But now I was pregnant, after 18 month of trying and several miscarriages, and I wanted to do all I could to minimize the risks of losing this pregnancy. In previous pregnancies I’d just given up most caffeine, and that wasn’t that hard to do. In this one, I was more afraid than ever of a miscarriage, but I also needed the caffeine boost more than ever to finish my book. I wanted to know what the research says about the safety of caffeine in pregnancy so that I could make an informed decision about whether to consume caffeine, and if so, how much.

Photo by Kevin Tuck

In her book, Expecting Better, Emily Oster includes an excellent discussion of caffeine in pregnancy. I consulted this for a quick answer to my question, and her analysis of the research on this topic helped me feel comfortable strategically drinking a little coffee in the afternoon. However, as much as I respect and highly recommend Oster’s book, I’ve also found that my approach to risk in pregnancy is a bit more conservative, and as soon as I had the chance, I wanted to look at the studies myself. Continue reading

Emerging: A Book, a Pregnancy, and Summertime

I’m back. In so many ways, I feel like I’m coming up for air after a long, long time.

I finished my book, or at least the first draft. I submitted it to the publisher a few weeks ago, and it’s now at the mercy of peer-reviewers. Like any big project, this is a huge weight off of my shoulders. It has commanded so much of my attention and energy over the last 18 months that I feel an almost unsettling freedom in each block of free time that comes my way. Where do I put my energy next? Between traveling, a much-reduced childcare schedule, and a sick Cee, I haven’t had much free time. However, since finishing my book, I’ve suddenly noticed cobwebs in the corners of our house, that our living room was still full of toddler toys that Cee never plays with, and that she had commandeered the lower shelf of the pantry for now-forgotten objects like band-aids, old catalogs, puzzle pieces, bottle caps, and pieces of gravel from the driveway. For a couple of days, all I wanted to do was clean and organize.

Another weight has lifted, too. I’m pregnant! Finally. It turned out that it took me longer to make a baby than to make a book. I’m now 15 weeks pregnant, and everything looks healthy so far. This experience – of trying to conceive, infertility, and pregnancy loss – has been more difficult than I imagined. When I tackled writing the book, I knew that the final product would be a result of how much time, effort, thought, and desire I put into it. Not so with getting and staying pregnant. This has been a lesson in relinquishing control and in patience. Having made it through the anxious first trimester, I’m now trying to adjust my attitude from one of bracing myself for something to go wrong to enjoying the pregnancy and letting myself think ahead to a new baby in December.

And now, it really feels like summer. I’m not teaching at all this summer, the first term I’ve had off in nearly two years. We’ve cut Cee’s childcare schedule way back to just a few mornings per week – just enough to give me a little time to write and edit the book as needed. We’re taking a few trips, catching up on appointments for our whole family, and sharing good meals made from our CSA produce. Best of all, we’re spending time together.

Cee and I especially need this. Over the last few months, my husband and I were doing a lot of baton parenting – both of us working long hours and then taking turns with Cee so that the three of us were rarely all together. I was starting to feel like my limited time with Cee was spent in too many battles and limit-setting and not enough connection and cooperation. Over the past couple of weeks, I’ve been thinking about and putting into action a sort of parenting reset – trying to think clearly for the first time in a while at what is working and what isn’t and being intentional about how to change it. Happily, I already feel like we’re back in a better place, and I’m looking forward to lots of time with her this summer.

I’m also setting my intention to getting back to regular blogging this summer. I plan to post at least once per week, maybe a bit more. I’ll be blogging about pregnancy, miscarriage, infertility, babies (of course!), and some of my current parenting journey. I have a long list of topics accumulated over the last year or so, but I’m always open to new questions; if you have topic ideas, send them my way!

I’m really looking forward to blogging and engaging with you all again. Thanks for all of your kind notes over the last few months and for bearing with me. It’s good to be back!

Hopeful for the New Year

I, for one, am not sad to see 2013 go. It’s been a rough year for me. I haven’t been blogging about it – haven’t been blogging about much of anything, actually – and I think it is time for an update.IMG_5374 2013 started with a miscarriage in progress, finally ending with a D&C on January 4. I grieved that lost pregnancy openly on this blog. It was therapeutic for me to blog about it and to feel support from women who had had similar experiences, or at least had empathy for the magnitude of love and hope that comes with a pregnancy. I started to feel better. I was confident that I would be pregnant again soon, and that was the obvious way to fill the gaping hole in my heart.

In the spring, I watched seedlings poke through wet dirt. Our neighborhood burst with color and new life, and I felt hopeful. But as the days grew longer and hotter, I felt sadder and sadder.  I still wasn’t pregnant. My previous due date came and went, now just another day, but such a heavy one for me. Cee and I sorted through newborn clothes in our hot attic, not for a new baby for our family, but to lend to a friend. Cee asked to keep a few onesies for her baby doll. I showed her how to fasten the snaps and then sent her downstairs so I could cry.

In August, I had another miscarriage, this time very early. Then, another one in October, early again (and thankfully spontaneous) but far enough out that I let myself think ahead to another summer due date. That one really crushed me. I know miscarriage is common, and it’s easy to chalk the first up to bad luck. But by the third time around, I had really lost faith in my body. It has failed, repeatedly, to do one of the things I feel it was always meant to do. I’ve always wanted children, and the family that I have, for which I am exceedingly grateful every day, doesn’t feel complete. There’s still a gaping hole here, and it’s only gotten bigger.

Meanwhile, Cee turned three in November. I know my sadness has affected her, and it’s affected my parenting, because my emotional reserve is just plain depleted. I am working hard at being enough for her and at assuring her that she is enough for me. (And she is. She really is. I’ve come to terms with that, most days anyway.) Continue reading

The Magic and the Mystery of Skin-to-Skin

I meant to do skin-to-skin with Cee after her birth, I swear. It was in my birth plan. But after a long labor, Cee was born blue and limp, and the understandable concern about her health trumped any ideas I’d had about optimizing our postpartum experience. Cee was whisked away to a warmer on the other side of the room and encircled by the NICU team. Thankfully, I heard her cry within a few moments, and she was in my arms soon after. But by then, she was wrapped in a pink and blue flannel blanket, and I was too overwhelmed and taken with her to think of unwrapping her. Instead, I held her, and we gazed into each other’s eyes. She started rooting and was nursing within a couple of minutes. It was a magical first meeting, and it wasn’t until later that I realized that I’d screwed up and forgotten to do skin-to-skin.

IMG_3113

What’s wrong with this picture? (besides the fact that I hadn’t slept or brushed my hair in 48 hours)

I’ve been researching this topic for a chapter in my book about the postpartum period. I’m writing about what we know and don’t know about getting to know our newborns, establishing breastfeeding, rooming in, and yes, skin-to-skin. When I started working on this chapter, I thought the skin-to-skin thing was a slam-dunk, maybe even too obvious to be of much interest to my readers.

Modern-day interest in skin-to-skin, also called kangaroo care, began in 1978 in the NICU at San Juan de Dios hospital in Bogotá, Columbia. For every 10 premature babies born there, only 3 survived. There weren’t enough incubators or nurses. Babies were tucked two to three at a time in incubators, and infections were rampant. Parents weren’t encouraged to be involved in the babies’ care, and having little emotional connection to them, many abandoned their sickly babies at the hospital. Kangaroo care was a desperate attempt to care for these vulnerable babies. Mothers were essentially asked to be their babies’ incubators, holding them skin-to-skin 24 hours per day and breastfeeding on demand.

The results were astounding. The kangaroo care babies in Bogotá grew well, were more likely to be breastfed, and were less likely to get severe infections or be abandoned. The power of kangaroo care for low birth weight babies has since been confirmed in multiple studies. A 2011 Cochrane review concluded that skin-to-skin helps stabilize premature newborns, reduces mortality, infections, hypothermia, and length of stay in the hospital. These benefits are particularly clear in developing countries, but many hold in industrialized nations as well.

With the impressive success of skin-to-skin care for preemies, it seemed natural to assume that full term babies would benefit from it as well. But the research in this area is disappointing. Continue reading

Recovery

I wrote my last blog post before going in for a D&C last Friday. The procedure itself was simple and quick. I “fell asleep” with the warm hand of my OB holding mine and woke up from general anesthesia feeling an inevitable emptiness but some degree of peace. At home, I ate a piece of toast, crawled into my own bed and woke up four hours later. What greeted me were your comments and emails of sympathy, empathy, and heart. There were a lot of them, some from people I have known for decades and some from readers that I had never heard from before, but I read every single one before I got up to face the afternoon.

The resounding message was this: You are not alone.

I was nervous about writing about miscarriage, but once it was out there, I felt nothing but support. It made me wonder why we hesitate to share this kind of hurt. It is personal, and it does seem strange to tell the whole world that I’m grieving. But the world is full of hurt. What’s wonderful is that so many people are willing to share a bit of mine – even the smallest bit – and enough people doing that really does make me feel better. I didn’t anticipate that writing about miscarriage here would be so therapeutic. The writing itself is actually sort of painful, in a good way I guess, but sharing the experience has been healing. Continue reading

Pregnancy Lost

It has been a hard couple of weeks for me, even with all the warmth and joy of the holidays. On December 21, 10 weeks into pregnancy (as yet unannounced here), we watched as my OB scanned my uterus. We saw the dark gestational sac and a small clump of embryonic tissue. There was no heartbeat, and the embryo measured at about 5 weeks. It hadn’t developed beyond that. This pregnancy would not be ending with a baby.

I’m a very cautious person when it comes to celebrating pregnancy. I didn’t really relax into my pregnancy with Cee until I saw the normal fetus at our 20-week ultrasound. I have had several close friends suffer the loss of miscarriage (and go on to have beautiful, healthy babies, I will add). I know that among clinically recognizable pregnancies (not counting the 30-50% of conceptions that never implant), about 15-20% will not survive. Even as I shared our pregnancy news with our close family and friends, I reminded them of this fact.

Although a part of me was prepared for this outcome, there was really no way that I could prepare myself for how it would feel. I have a profound sense of losing something important. Tiny as it may have been, it was part of me and part of Husband, and it was growing inside of me, if only for a short time. The wonder of pregnancy has been replaced with the vision of that ultrasound: the gestational sac a gaping dark hole, what remains of the embryo little more than a smear. Empty, dead, inevitably transient.

This is the grief of pregnancy loss, something so many of us must face as we try to build our families. What it speaks to, more than anything, is the power of a parent’s love, even for an embryo whose heart never beats. For many parents, it is the struggle to conceive, and after that, it is the fragility of human life. And even as our healthy babies become children and our love grows beyond the bounds of what we thought was possible, we know we are vulnerable to loss. It is the reason that it felt unbearable to be a mother on the day of the Newtown school shooting. This is family. This miscarriage, it is a small loss, but it still sure hurts. Continue reading