Strategies to reduce the medicalization of birth, michel odent

ACAPULCO 4

Strategies to reduce the medicalization of birth

Thanks to the organizers for suggesting this subject. I’ll first modify slightly the phrasing of the title by referring to the medicalization of birth as the ultimate phase of the socialization of birth that started some 10 thousands years ago with the Neolithic revolution: then the increasing domination of nature by human groups included not only the advent of agriculture and animal husbandry, but also the control of physiological processes related to human reproduction. We have a sufficient amount of documents at our disposal to claim that, before the Neolithic revolution, women used to isolate themselves to give birth, like mammals in general. Since that turning point in the history of our species, cultural milieus have controlled the birth process different ways: beliefs, rituals, power of institutions, such as religious institutions and, today, medical institution.

It is easy to interpret in modern scientific language what is intuitively perceived by an increasing number of health professionals and the general public as well. In the age of synthetic oxytocin and easy fast techniques of cesareans, one can observe that, at a planetary level, the number of women who give birth to babies and placentas thanks to the release of their natural hormones – now considered “cocktails of love hormones” - is becoming insignificant. In the age of the “microbiome revolution”, one can also observe that, immediately after birth, a crucial phase of the programmation of the immune system of most human neonates is not the effect any more of contacts with familiar and therefore friendly microorganisms (the human placenta is particularly effective at transferring the IgG): births in bacteriologically unfamiliar environments, exposure to antibiotics, and birth by the abdominal route.

The current turning point in the history of childbirth is reached at the very time when emerging scientific disciplines raise questions about the long term consequences – including transgenerational effects – of the modes of birth. Epigenetics, microgenomic bacteriology, the branch of epidemiology called ''primal health research'' are among the most influential fast developing disciplines.

I’ll suggest that the only way to overcome the current crisis is to understand the birth process in the light of modern physiology.

 From this perspective, the birth process appears as an involuntary process under the control of archaic brain structures. As a general rule, one does not try to help an involuntary process. The point is to identify possible inhibitory factors. From a practical perspective, the key word is protection. Several physiological concepts clearly indicate the factors that can negatively interfere with the process of parturition. The concept of adrenaline-oxytocin antagonism is essential where mammals in general are concerned: mammals postpone the delivery when releasing emergency hormones of the adrenaline family. Although this concept is well established, in practice it is not always taken into account, as if it is not perfectly assimilated.

The concept of neocortical inhibition

When considering the case of human birth, the focus should be on the concept of neocortical inhibition, a key to understanding human nature in general. We should keep in mind that some human abilities are usually obscured by neocortical activity. There has been until now a lack of interest in this essential particularity of our species. Human parturition is better understood if introduced in the framework of functions usually obscured by neocortical activity. A first example is offered by olfactory abilities. An ingenious experiment has explored the human sense of smell after neocortical desinhibition by alcohol consumption.27 Another example is offered by the human swimming abilities: the capacity to adapt to immersion and have coordinated swimming movements when submerged disappears around the age of three or four months, when the neocortex is reaching a certain degree of power.28 

When the concept of neocortical inhibition is understood and taken into account, it is easy to challenge the assumption that mechanical factors are the main reasons for difficult births in our species.  In fact, the mechanical factors are undoubtedly overestimated, since there are women with no morphological particularities who occasionally give birth quickly without any difficulty. There are anecdotes of women who give birth before realizing that they are in real labour. There are in particular countless anecdotes of teen-ages who, at the end of a hidden or undiagnosed pregnancy, just go to the toilet and give birth within minutes. These facts alone suggest that the main reasons for difficult human births are not related to the shape of the body. The best way to clarify the nature of the specifically human handicap during the period surrounding birth is to consider the case of civilised modern women who have given birth through an authentic ''fetus ejection reflex''.29 It is exceptionally rare in the context of socialised birth. The birth is suddenly preceded by a very short series of irresistible, powerful, and highly effective uterine contractions without any room for voluntary movement. 

The important point is that when the “fetus ejection reflex” is imminent, women are obviously loosing neocortical control. They become indifferent to what happens around. They forget what they previously learned. They forget their plans. They behave in a way that, in other situations, would be considered unacceptable regarding a civilised woman. For example they dare to scream or to swear. There are anecdotes of women who have bitten a person perceived as intrusive . Women in hard labour can find unexpected, complex, and usually bending forward asymmetrical postures. Such scenarios clearly indicate the solution Nature found to make birth possible in our species: it is a reduced neocortical control.

This essential aspect of birth physiology in our species offers an ideal perspective to reach the simple conclusion that a labouring woman needs to be protected against all possible stimulants of her neocortex. Since language is a major stimulant, silence appears as a basic need that is culturally ignored or underestimated after thousands of years of socialisation of childbirth. In this respect, rational language and language expressing questions have particularly powerful effects.

Light has not been scientifically studied as a powerful cortical stimulant until recent advances regarding the functions of melatonin, the''darkness hormone''. However, the long history of blinds and curtains is the confirmation of a deep rooted transcultural empiric knowledge that is pushing us, today, to switch off electric lights in order to reduce neocortical activity at sleeping time. Recent studies of the interactions inside the triad oxytocin-melatonin-GABA offer a promising avenue for research. It is already understood that the GABA(A) receptors mediate the effects of melatonin on neocortical activity.30,31 Until now, the interactions between the oxytocin and the GABA systems in the perinatal period have been mostly studied in the framework of the shift of the effects of GABA at the end of fetal life, when this primary excitatory neurotransmitter becomes inhibitory.32 When considering the effects of melatonin, and therefore light, on human parturition, we have to deviate from the concept of neocortical inhibition and refer to recent advances regarding peripheral effects. It is now established that there are melatonin receptors in the human myometrium, and that melatonin is synergistic with oxytocin to enhance contractility of human myometrial smooth muscle cells. 33,34,35,36,38  Today melatonin appears as an important hormonal agent in human parturition. This is confirmed by the significant amount of melatonin in the blood of neonates, except those born by pre-labour caesareans.11   The importance of these findings appear clearly when the  protective anti oxidative properties of melatonin are taken into account. 

In the age of electric lights, the reasons to improve our understanding of melatonin release and melatonin properties are obvious. It is already well established that short-wavelength light (in practice ''blue'' light) is the most melatonin suppressive. This is an important fact, since it is the kind of light typically emitted by devices such as televisions, computer screens, cellphones, and even lamps in conventional delivery rooms. It is probable that, when birth physiology is better understood, the practical implications of these recent scientific advances will be seriously considered. Until now preliminary practical implications have been limited to attempts to facilitate shift work and also to facilitate the initiation of sleep through the use of amber glasses that block blue light.39,40  Can we imagine a  time when it will be considered rational to give birth in the light of a candle? Can we imagine a time when women familiar with the use of amber glasses when in front of computer screens will also use such glasses when in labour?

After mentioning language and light, we might summarize the most important points by emphasizing that all attention enhancing situations are stimulants of neocortical activity. This is the case of feeling observed: it implies that one of the basic needs of a labouring woman is privacy. The perception of a possible danger is another example of attention enhancing situations: it implies that a labouring woman need to feel secure. We'll notice that similar conclusions can be reached when using as a starting point the concept of adrenaline-oxytocin antagonism. 

In the current scientific context, the physiological perspective and the concept of “protection of an involuntary process” have the power to challenge the dominant paradigm we may call the helping-guiding-coaching-managing-supporing paradigm.  

Another step

When the physiology of parturition is better understood, another step will be to identify the obstetric interventions that should be used with more  caution than in the past. There is an accumulation of new reasons  to avoid, when possible, prelabor cesareans (data about neonatal lung functions, olfaction, levels of melatonin, levels of adiponectine, milk microbiome, maturation of particular brains structures). There are also obvious reasons to avoid last minute cesareans performed in a context of real emergency. The long term consequences of the main components of pharmacological assistance during labor have not been seriously studied until now.  Finally it appears today that, in general, the best alternative to a birth by the vaginal route is, in many cases, an in-labor non-emergency cesarean.

Renewed strategies inspired by a better understanding of birth physiology will give a particular importance to predictive scores and tests in order to decide, before the stage of real emergency, an in-labor cesarean. In this framework we'll mention what we have called the birthing pool test. 

References:

1-Glavind J, Uldbjerg N. Elective cesarean delivery at 38 and 39 weeks: neonatal and maternal risks. Curr Opin Obstet Gynecol 2015 Apr;27(2):121-7. doi: 10.1097/GCO.0000000000000158.

2-Condon JC1, Jeyasuria P, Faust JM, Mendelson CR. Surfactant protein secreted by the maturing mouse fetal lung acts as a hormone that signals the initiation of parturition. Proc Natl Acad Sci U S A. 2004 Apr 6;101(14):4978-83. Epub 2004 Mar 25.

 3-Hauth JC, Parker CR Jr, MacDonald PC, Porter JC, Johnston JM. A role of fetal prolactin in lung maturation. Obstet Gynecol. 1978 Jan;51(1):81-8.

4- Varendi H, Porter RH, Winberg J. The effect of labor on olfactory exposure learning within the first postnatal hour. Behav Neurosci. 2002 Apr;116(2):206-11

5-Odent M. The early expression of the rooting reflex. Proceedings of the 5th  International Congress of Psychosomatic Obstetrics and Gynaecology, Rome 1977. London: Academic Press, 1977: 1117-19. 

6-Odent M. L’expression précoce du réflexe de fouissement. In : Les cahiers du nouveau-né 1978 ; 1-2 : 169-185

7-Hermansson H. · Hoppu U. · Isolauri E. Elective Caesarean Section Is Associated with Low Adiponectin Levels in Cord Blood. Neonatology 2014;105:172-174 (DOI:10.1159/000357178). 

8-Cabrera-Rubio R, Collado MC, Laitinen K, et al. The human milk microbiome changes over lactation and is shaped by maternal weight and mode of delivery. Am J Clin Nutr. 2012 Sep;96(3):544-51. doi: 10.3945/ajcn.112.037382. Epub 2012 Jul 25.

9- Azad MB, Konya T, Maugham H, et al. Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. CMAJ February 11, 2013 cmaj.

10- Dogra S, Sakwinska O, Soh S, Ngom-Bru C, Brück WM, Berger B, Brüssow H, Lee YS, Yap F, Chong Y, Godfrey KM, Holbrook JD. 2015. Dynamics of infant gut microbiota are influenced by delivery mode and gestational duration and are associated with subsequent adiposity. mBio 6(1):e02419-14. doi:10.1128/mBio.02419-14.

11-Bagci S, Berner AL, et al. Melatonin concentration in umbilical cord blood depends on mode of delivery. Early Human development 2012; 88(6):369-373.

 12-Christensson K, Siles C, et al. Lower body temperature in infants delivered by caesarean section than in vaginally delivered infants. Acta Paediatr 1993;82(2):128-31.

13-Simon-Areces J, Dietrich M O, Hermes G, et al. Ucp2 Induced by Natural Birth Regulates Neuronal Differentiation of the Hippocampus and Related Adult Behavior. PLoS ONE, 2012; 7 (8): e42911 DOI: 10.1371/journal.pone.0042911

14-Tyzio, R, Cossart, R., Khalilov, I., Minlebaev, M., Hubner, C.A., Represa, A., Ben-Ari, Y, Khazipov R. Maternal oxytocin triggers a transient inhibitory switch in GABA signaling in the fetal brain during delivery. Science 2006; 314: 1788-1792.

15-Downes KL, Hinkle SN, Sjaarda LA, et al. Prior Prelabor or Intrapartum Cesarean Delivery and Risk of Placenta PreviaAmerican Journal of Obstetrics and Gynecology 2015http://www.ajog.org/article/S0002-9378(15)00005-8

16-Prior E, Santhakumaran S, Gale S, et al. Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. Am J Clin Nutr. 2012 May;95(5):1113-35. doi: 10.3945/ajcn.111.030254. Epub 2012 Mar 28.

17- Zanardo V, SavolnaV, Cavallin F, et al. Impaired lactation performance following elective cesarean delivery at term: role of maternal levels of cortisol and prolactin. J Matern Fetal Neonatal Med. 2012 Sep;25(9):1595-8. doi: 10.3109/14767058.2011.648238. Epub 2012 Feb 6.

18- Levine LD, Sammel MD, Hirshberg A, et al. Does stage of labor at time of cesarean affect risk of subsequent preterm birth? Am J Obstet Gynecol. 2014 Sep 30. pii: S0002-9378(14)01020-5. doi: 10.1016/j.ajog.2014.09.035. [Epub ahead of print]

19-Hannah ME, Hannah WJ, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000;356:1375-83.

20-- Beilin Y, Bodian C, Weiser J, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study. Anesthesiology 2005 Dec;103(6):1211-7 

21- Marín Gabriel M, Olza Fernández I, Malalana Martínez AM, et al. intrapartum synthetic oxytocin reduce the expression of primitive reflexes associated with breastfeeding. Breastfeeding Med 2015; 10(4):209-13.

22-Hattori R, Desimaru M, Nagayama I, Inoue K. Autistic and developmental disorders after general anaesthetic delivery. Lancet 1991; 337:1357-58. 

23-Glasson EJ, Bower C, Petterson B, et al. Perinatal factors and the development of autism. Arch Gen Psychiatry 2004; 61: 618-27. 

24-Stein D, Weizman A, Ring A, Barak Y 2006. Obstetric complications in individuals diagnosed with autism and in healthy controls. Compr Psychiatry  Jan-Feb;47(1):69-75. 

25- Gregory SG, Anthropolos R, Osgood CE, et al. Association of autism with induced or augmented childbirth in North Carolina Birth Record (1990-1998) and Education Research (1997-2007) databases. JAMA Pediatr. 2013 Oct;167(10):959-66. doi: 10.1001/jamapediatrics.2013.2904. 

 26-Weisman O, Agerbo E, Carter CS, et al. Oxytocin-augmented labor and risk for autism in males. Behav Brain Res. 2015 May 1;284:207-12. doi: 10.1016/j.bbr.2015.02.028. Epub 2015 Feb 20.

27-Endevelt-Shapira Y, Shushan S, Roth Y, Sobel N. Disinhibition of olfaction: Human olfactory performance improves following low levels of alcohol. Behav Brain Res. 2014 Jun 25;272C:66-74. doi: 10.1016/j.bbr.2014.06.024. [Epub ahead of print]

28-Mc GrawMB. Swimming Behavior of the Human Infant. Journal of Pediatrics 1939;15:485-90.

29-Odent M. The fetus ejection reflex. Birth 1987; 14: 104-105.

30-Wang F, Li J, et al.The GABA(A) receptor mediates the hypnotic activity of melatonin in rats. Pharmacol Biochem Behav 2003 Feb;74(3):573-8.

31Wang F, Zou D, et al. The role of melatonin receptor and GABAA receptor in the sleeping time prolonged by melatonin in mice. Zhongguo Ying Yong Sheng Li Xue Za Zhi. 2003 Nov;19(4):402-5.

32-Tysio R, Nsardou R, et al. Oxytocin-mediated GABA inhibition during delivery attenuates autism pathogenesis in rodent offspring. Science. 2014 Feb 7;343(6171):675-9. doi: 10.1126/science.1247190.

33-Cohen M, Roselle D, Chabner B, Schmidt TJ, Lippman M.Evidence for a cytoplasmic melatonin receptor. Nature. 1978;274:894-895.

34-Sharkey, James Thomas, "Melatonin Regulation of the Oxytocin System in the Pregnant Human Uterus" (2009). Electronic Theses, Treatises and Dissertations. Paper 1791.http://diginole.lib.fsu.edu/etd/1791

35-Olcese J, Beesley S.  Clinical significance of melatonin receptors in the human myometrium. Fertil Steril 2014 Jul 8. pii: S0015-0282(14)00566-4. doi:10.1016/j.fertnstert.2014.06.020. [Epub ahead of print]

36-Schlabritz-Loutsevitch N, Hellner N, Middendorf R, Muller D,Olcese J. The human myometrium as a target for melatonin. J ClinEndocrinol Metab. 2003;88(2):908-913.

37-Sharkey JT, Puttaramu R, Word RA, Olcese J. Melatonin synergizes with oxytocin to enhance contractility of human myometrial smooth muscle cells. J Clin Endocrinol Metab 2009 Feb;94(2):421-7. doi: 10.1210/jc.2008-1723. Epub 2008 Nov 11.

38-Sharkey J, Cable C, Olcese J. Melatonin sensitizes humanmyometrial cells to oxytocin in a PKCa/ERK-dependent manner.J Clin Endocrinol Metab. 2010;95(6):2902-2908.

39-Jump up^ Kayumov L, Casper RF, Hawa RJ, Perelman B, Chung SA, Sokalsky S, Shapiro CM (May 2005). "Blocking low-wavelength light prevents nocturnal melatonin suppression with no adverse effect on performance during simulated shift work". J. Clin. Endocrinol. Metab. 90 (5): 2755–61. doi:10.1210/jc.2004-2062. PMID 15713707.

40-Jump up^ Burkhart K, Phelps JR (26 December 2009). "Amber lenses to block blue light and improve sleep: a randomized trial". Chronobiol Int 26 (8): 1602–12. doi:10.3109/07420520903523719. PMID 20030543. 

41-Odent MR. Making sense of rising caesarean section rates: reducing caesarean section rates should not be the primary objective. BMJ. 2004 Nov 20;329(7476):1240.

42-Wilkes PT, Wolf DM, et al. Risk factors for cesarean delivery at presentation of nulliparous patients in labor. Obstet Gynecol. 2003 Dec;102(6):1352-7.

43-Odent M. Birth under water. Lancet 1983: 1476-17

44-Odent M. The birthing pool test. In: Michel Odent. The Caesarean. Free Association Books 2004: 103-104.