Among the readers of Midwifery Today are mothers of autistic children. Many of them are seeking explanations about the current autism epidemic. Some are ready to transform themselves into amateur epidemiologists and to design their own surveys. Before supporting one of these surveys, Jan Tritten requested the point of view of Dr. Michel Odent, the founder of the Primal Health Research Centre in London, UK. Primal Health Research is a developing branch of epidemiology. It includes all studies exploring correlations between what happened during the "primal period" (fetal life, perinatal period, year following birth) and what will happen later on in life in terms of health, behavior and personality traits.
JT: Midwifery Today is considering supporting a survey of parents of autistic children to try to interpret what is leading to the current epidemic of autism (and autistic spectrum disorders). The intent of the survey is to consider possible risk factors such as prenatal pollution, exposure to ultrasounds during fetal life, obstetrical procedures during the perinatal period and vaccinations. Do you consider such a survey promising?
MO: I am skeptical about the value of such a retrospective study, which will reach too few families to accurately evaluate the risks of autism. Explore the primal health research database www.birthworks.org/primalhealth and select keywords such as "autism", "vaccination" and "ultrasound scans": You'll find dozens of huge published studies that address these issues. An accumulation of data suggests that the timing of the gene-environment interactions is different for autism than for schizophrenia. Several authoritative studies indicate the paramount importance of what happened at birth in the genesis of the autistic spectrum disorders.
Perinatal Period Risks. Among the recent large and authoritative studies of autism from a Primal Health Research perspective, the Australian one will convince anyone that the main risk factors occur in the perinatal period (Glasson, E.J., et al. 2004. Perinatal factors and the development of autism: a population study. Arch Gen Psychiatry 61(6): 618–27). The birth records of 465 subjects born in Western Australia between 1980 and 1995 and diagnosed with an autism spectrum disorder by 1999 were compared with those of 481 siblings and of 1313 controls. No differences in gestational age at birth (including the proportion of premature infants), weight for gestational age, head circumference or length were observed between cases and control subjects. Pre-eclampsia did not appear as a risk factor. These negative findings lend more importance to perinatal factors. Compared with their siblings, individuals with autism were more likely to have had induced births, to have experienced fetal distress and to have been born with low Apgar scores. Compared with control subjects, they were more likely to have been born after induction and by elective or emergency c-section.
The largest study ever published about the perinatal risk factors for autism was published in July 2002.(Hultman, C., P. Sparen and S. Cnattingius. 2002. Perinatal risk factors for infantile autism. Epidemiology 13: 417–23) The researchers had at their disposal the recorded data from the Swedish nationwide Birth Register regarding all Swedish children born during a period of 20 years (from 1974 until 1993). They also had at their disposal data regarding 408 children (321 boys and 87 girls) diagnosed as autistic after being discharged from a hospital from 1987 through 1994 (diagnosis according to ICD-9 code 299A). Five matched controls were selected for each case, resulting in a control sample of 2040 infants. The risk of autism was significantly associated with caesarean delivery and a 5-minute Apgar score below 7. Unfortunately the variable "labour induction" could not be taken into account, because it did not appear in the National Birth Register until 1991 (personal correspondence with one of the authors).
A recent report from Israel also found no prenatal differences between autistic children and controls, but the rates of birth complications were higher among the autistic population. In addition, we must consider data indicating that perinatal factors may play a lesser role in autism in "high-functioning" individuals compared with studies of autism associated with severe retardation, as well as data suggesting that anesthesia during labour is a risk factor for the development of dyskinesia among autistic children. Although the risk factors for autism seem to occur mostly in the perinatal period, we must keep in mind the association of autism with fetal valproate syndrome (a rare congenital disorder caused by exposure of the fetus to valproic acid during the first three months of pregnancy), thalidomide embryopathy (a syndrome related to in utero exposure to thalidomide) and Mobius sequence (disorder linked to first-trimester exposure to misoprostol).
Vaccinations. In regard to a link between autism and vaccinations, a study involving all children born in Denmark from January 1991 through December 1998 (more than half a million children) will convince anyone that the main negative effect of the MMR (measles, mumps, rubella vaccination) fuss has been to divert the attention (and probably money) from the study of risk factors that might explain the current autism epidemic.(Madsen, K.M. et al. 2002. A population-based study of measles, mumps, and rubella vaccination and autism. N Engl J Med 347(19): 1474–75) An accumulation of data suggests that the significant risk factors occur before the age at which babies receive MMR, which is usually given at 12 months or after.
The hypothesis that mercury associated with certain vaccines is a risk factor is not supported by a study involving all children born in Denmark from January 1990 until December 1996 (nearly half a million).(Hviid, A, et al. 2003. Association between thimerosal-containing vaccine and autism. JAMA 290(13): 1763–66) The risk of autism and other autistic-spectrum disorders was the same among children vaccinated with thimerosal-containing vaccine and children vaccinated with thimerosal-free vaccine.
Ultrasound Scans. Although prospective studies found effects of exposure to ultrasounds during fetal life on average birth weight and handedness, none of them found effects on intellectual performance and therefore (probably) on the risks of autism.
I think that many people express opinions, theories and hypotheses (that lead to small surveys) without being aware of huge valuable studies published in authoritative medical or scientific journals. These studies can be easily explored on the primal health research database (it is more time consuming to feed it!).
JT: Taking into account the studies already included in your database, can you imagine some fruitful avenues for research in the near future?
MO: We have many reasons to suspect a link between "autism epidemic" and "labour induction epidemic." The first reason is that in all studies that took into account independently the variable "labour induction," it appeared as a risk factor. Labour induction should be explicitly taken into consideration by epidemiologists, because it can be associated either with birth by the vaginal route (with or without intervention such as forceps), or with cesarean birth.
Another reason is that the epidemic of autism and the epidemic of induction seem to have developed side by side in Western countries and in China. Bai, from the Association of Rehabilitation for Children with Autism of Wuhan City, estimates that the number of children with autism is growing at an annual rate of 20 percent in that country, higher than the world average of 14 percent (http://news.xinhuanet.com/english/2004-08/11/content_1759576.htm). Let us recall that the rate of inductions is growing fast in China, since the Chinese are autonomous for synthesizing misoprostol.
A third reason is that the results of recent studies suggest that children with autistic disorder show alterations in their oxytocin system. The first clues came from a study of mid-day blood samples from 29 autistic and 30 age-matched normal children, all prepubertal.(Modahl, C., et al. Plasma oxytocin levels in autistic children. 1998. Biol Psychiatry (4): 270–77) The autistic group appeared to have significantly lower blood oxytocin levels than the normal group. Oxytocin increased with age in the normal but not in the autistic children. These results inspired an in-depth inquiry into the oxytocin system of autistic children.
In recent years oxytocin has been shown to appear in the brain in several forms. The nonapeptide oxytocin (OT) and the "C-terminal extended peptides" are described together as OT-X. The OT-X represent intermediates of oxytocin synthesis that accumulate due to an incomplete processing mechanism.
Twenty-eight male children, diagnosed with autistic disorder, were compared with 31 age-matched control children with no psychiatric disorders: A decrease in blood OT, an increase in OT-X and an increase in the ratio of OT-X/OT were seen in the autistic sample, compared with control subjects.(Green, L., et al. 2001. Oxytocin and autistic disorder: alterations in peptides forms. Biol Psychiatry 50 (8): 609–13) In other words autistic children show alterations in the oxytocin system: there are deficits in the synthesis of oxytocin.
We are learning that, among humans, the period surrounding birth is a period of dramatic reorganization of central oxytocin binding. Artificial induction of labour creates situations that undoubtedly interfere with the development and the reorganization of the oxytocin system in such a critical period. This fact alone is a reason for further epidemiological studies focusing on labour induction as a possible risk factor. It would be useful to know also how autistic children release oxytocin. Oxytocin is more effective when released rhythmically, in a succession of fast pulsations. Today it is possible to measure the rhythmicity "the pulsatility" of oxytocin release. In other words, the time has come to study autism as an "impaired capacity to love."
Editor's Note: Oxytocin is a hormone released by the posterior pituitary gland. Its mechanical effects, particularly its stimulating effects on uterine contractions during labour, have been known for a long time. Recently we learned that oxytocin also has important behavioral effects. Today we are in a position to summarize the results of dozens of studies by claiming that oxytocin is the typical hormone of love: Whichever facet of love one considers, oxytocin is involved.
— Jan Tritten
Editor in Chief, Midwifery Today
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A 1997 study of children with autism was done, with the intent to determine frequency and onset of macrocephaly (abnormal largeness of the head). Researchers measured head circumference at birth, during early childhood and later in life. They found that 14% of the children had macrocephaly. Of these children, the prevalence was 11% for the boys and 24% for the girls.
The researchers noted that macrocephaly is not usually present at birth, but growth of head circumference may be abnormally increased in early and middle childhood in 37% of children with autism. However, neither macrocephaly nor abnormal head growth were related to nonverbal IQ, verbal status, seizure disorder, some neurological signs or minor physical anomalies.
— J Am Acad Child Adolesc Psychiatry, February 1997
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The CDC reported that preliminary data for 2005 indicate that 30.2% of all live births in the US were cesareans deliveries, the highest rate ever reported. The rate of c-sections has increased by 46% since 1996. Rates vary by part of the country; they are lower in the western mountain states and upper Midwest region and higher in the Southeast and East regions.
— MMWR 56(1): 373, April 20, 2007
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- Lessons from a Homebirth Practice—by John Stevenson
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Q: I just bought a birth stool at: http://www.birthwithsol.com/birthstool1.html, and it came today. I'm really excited to start having it available to my students and clients. HOWEVER, I tried sitting on it today for quite a while and could not figure out for the life of me how I'd push a baby out on it. Do you want the sit bones on it or in the opening, for example?
Does anyone have any specific tips (from your own experience or births you've attended) about how to properly use a birth stool? Thanks!
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Q: I have just received a kidney transplant and it seems as though the positive messages I got before the transplant about pregnancy being pretty normal and fairly easy have been replaced with warnings that extend beyond the first year when the immunosuppression is most severe. I would appreciate hearing from midwives who have attended births of women with kidney (or other abdominal organ) transplants. What common problems or complications arise and what kinds of remedies/preventive intervention can be used to address them?
— Adria Armbrister
New York, New York
A: I cannot find a link to the full text of the article, but this journal article deals with the ethical considerations of pregnancy (and ART) after kidney transplant. The author explores complications and considerations.
Lockwood, G.M. 1999. Pregnancy, autonomy and paternalism. Journal of Medical Ethics, 25(6): 537–41.
— Rosa-Maria DiDonato
Responses to any Question of the Week may be sent to E-News at any time. Write to firstname.lastname@example.org. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
I am starting to find a bit trying the mass hypnotism that leads people to believe that a woman needs to give birth at 40 weeks. If she doesn't, more and more people become impatient and believe that the baby is late! Am I the only one who believes that babies come when they are ready?
At 42 weeks hospitals and registered midwives join the mass hypnotism, scolding the mother for being irresponsible, advising checks to see whether the baby is okay and then threatening to induce immediately if they perceive that something is wrong! I thought that mothers had a choice about being induced! Are people not afforded the right to choice anymore? Is childbirth now governed by numbers? Surely babies were born before numbers! Yes, now I am ranting, but I feel very strongly in reaction to the strength of force that is being used to convince mothers that just waiting for their baby to come naturally is irresponsible! Help! Words of wisdom and knowledge gratefully received!
— Lara Stockbridge
I gave birth to a baby girl on April 12, 2007. I was planning a homebirth but ended up birthing at Sunrise hospital in Las Vegas, Nevada, due to medical concerns. Her birth was absolutely amazing and included lots of twists and turns. Her entire birth story and PhotoShow can be viewed at http://hypnobirthinglasvegas.com/announce.html. While her birth wasn't quite as I had planned, I am so thankful that I had my HypnoBirthing skills to keep me calm and comfortable.
Before entering the OR and birthing my daughter, I asked to have my placenta saved to take with me for encapsulation upon discharge from the hospital. The hospital denied me my placenta; a court case is now pending. Details can be found on this blog: http://diva-mama.com. For those who don't know, the placenta has many benefits for the postpartum period and is believed to aid in healing. (Details on the benefits of the placenta can be found at: http://placentabenefits.info) The Las Vegas Review Journal (LVRJ) became interested and wrote a story (www.lvrj.com/news/7358361.html?numComments=1000) which came out in the Sunday, May 6, 2007, newspaper.
A peaceful and legal rally was held on Monday, May 7, at 10 am on the sidewalks around Sunrise Hospital. I really appreciate everyone who came out to support us (both physically and in thoughts) while we were at the rally. Channel 13 ABC KTNV ran the piece all day yesterday and has a link to the video on their Web site (www.ktnv.com). The LVRJ also did a follow up piece (www.lvrj.com/news/7387976.html). Las Vegas AM 840 also had several segments discussing the issue. The http://diva-mama.com blog has 14 pictures of the rally.
The original reason that the hospital gave as to why they would not release my placenta was, they did not "feel comfortable." Even after agreeing to sign a waiver releasing the hospital of liability, they still refuse to release my placenta. No law prohibits me from obtaining my placenta and other hospitals release placentas. This is a civil liberties issue and is likely to be a precedent-setting case that may go all the way to the Supreme Court, as there is no appellate court in Nevada.
I did hear from Sunrise's lawyer again; they still won't give my placenta back without a judge ordering them to release it, and planned to hold it only until May 15, 2007. They now claim that OSHA won't allow it because the placenta has been cross-contaminated.
Since so much time has passed and with the possibility that my placenta has been contaminated (which is negligent on the part of the hospital), I will no longer be able to use my placenta as originally intended. However, I am still pressing forward in the hopes that my struggle with make positive changes for other women. All women should have the implicit right to their (and their baby's) placenta.
While I have been working with a lawyer who wants to take the case pro bono, he had not taken the case as of May 9, so, I still don't have committed legal representation. However, I do have an MD who is willing to testify that there is no health risk to release the placenta to the mother and that the ingestion of it actually could be beneficial. I am contemplating contacting ACLU in hopes that they may be able assist.
Those who are interested can sign a petition (contact email@example.com for details) to help change the law.
— Anne Swanson, BS, HBCE
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Calling in the Voices of Midwifery: The California Association of Midwives will be holding our 2007 conference June 1–3 in Occidental, California. See our list of classes and register at www.californiamidwives.org
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