research paper: vitamin d in pregnancy

Vitamin D is a fat-soluble vitamin that has recently jumped into the forefront of health and nutrition. Previously thought of as a vitamin needed only in small amounts to prevent rickets in children, vitamin D deficiency is now recognized as important for much more than just bone health. Vitamin D status is important for everybody, but it is especially important during pregnancy, because low maternal vitamin D stores may contribute to problems such as low birthweight and small for gestational age babies (a serious problem in the United States) and an increased risk later on for many other diseases.

Vitamin D is not a simple vitamin but a prohormone, a complex molecule that plays many important roles in the body. These roles, in addition to the main function of regulating mineral salt deposition in bones, include regulation of body metabolism, mood, blood pressure, and immune function – maybe even protection against some forms of cancer (Wardlaw & Hampl, 2007). Vitamin D is synthesized in the skin when the right wavelength of sunlight is available, and it is found in a few foods such as cod liver oil and fortified milk. Unfortunately, these two routes of acquisition are seldom sufficient for vitamin D needs, especially for people living in northern climates (defined as above 42 degrees north latitude – a line between northern California and Boston, Massachusetts) and in climates with frequent cloud cover preventing the absorption of ultraviolet light from the sun (National Institutes of Health [NIH], 2008). Location and climate are not the only factors that can limit vitamin D synthesis from the sun; genetics and cultural practices can also play a role. Australian researchers Grover and Morley (2001) reported that among pregnant women who were either dark-skinned or regularly wore a veil, 80% were below reference values for vitamin D.

Insufficient amounts of vitamin D in the body can cause rickets (bone malformation) in children, osteomalacia (bone softening) in adults, and can contribute over a lifetime to the chance of developing osteoporosis in later life. Other health effects caused or influenced by inadequate vitamin D supply in the general population include muscle weakness and inflammation (NIH, 2008). In pregnancy, having an adequate supply of vitamin D is especially important because of the health impacts on the developing fetus. Mothers who do not have an adequate supply of vitamin D cannot provide their baby with an adequate supply of vitamin D. A study by Bodnar, Simhan, and Powers (2007) reports in the Journal of Nutrition that in pregnant women who were vitamin D deficient, newborns were either as deficient as their mother or more deficient (in some cases by as much as 16%) than their mother. This data was taken from women living in northern latitudes of the United States who used prenatal vitamins (which presumably provided vitamin D) as directed by their doctor.

Babies who are born deficient in vitamin D have lower birthweights and tend to remain smaller throughout life. Low birthweight is associated with a wide range of complications that can be lasting, including breathing difficulties, heart problems, and increased risk of infection (March of Dimes Foundation, 2009). A recent study showed that children whose mothers had insufficient levels of vitamin D during pregnancy had lower bone mass and mineralization both at birth and at a follow-up study nine years later (Gale et al., 2008), indicating that vitamin D deficiencies can prevent children from reaching their full potential. In a study completed in 1980 Brooke et al. showed that babies born to mothers in the control group (those not receiving vitamin D supplements) were twice as likely to be labeled “small for gestational age,” and they were more likely to have larger-than-normal fontanelles (or “soft spots”) which the authors thought was indicative of incomplete skull ossification during gestation. The authors recommended that all pregnant women be given supplements of at least 1,000 IU of vitamin D daily, but they received little attention at the time.

In addition to being smaller, vitamin D deficient babies also have an increased risk for a wide range of diseases later in life that may be linked to the innate immune system. These are mostly chronic, slowly developing diseases such as Type I and Type II diabetes, schizophrenia, autoimmune disorders such as multiple sclerosis and rheumatoid arthritis (Wagner, Taylor, & Hollis, 2008), and maybe even neural tube defects such as spina bifida (Hollis & Wagner, 2006).

The circulating form of vitamin D in the blood, called 25(OH)D, is utilized directly by many cells in the body, including monocytes and macrophages, important immune system components. Tissue cells such as prostate, breast, colon, lung, and keratinocytes (in the skin, hair, and nails) also have direct receptors for 25(OH)D, and there has been speculation about whether all body cells may contain receptors for vitamin D (Wagner, Taylor & Hollis, 2008). Vitamin D acts in the tissue cells to modulate cell proliferation (important in cancer), differentiation, and apoptosis (programmed cell death, also important in cancer) (NIH, 2008). Vitamin D is known to have a regulatory effect on the immune system, and high levels of vitamin D are associated with reduced risk of autoimmune diseases (Hyppönen, 2005).

Preeclampsia, a serious complication of pregnancy, may be related to autoimmune diseases and may be influenced by vitamin D status (Hyppönen, 2005). Preeclampsia causes the mother’s blood pressure to rise and may be fatal to the mother, the baby, or both. Preeclampsia is not uncommon, affecting about 10% of pregnancies in the United States and causing 18% of maternal deaths in the United States. Preeclampsia causes babies to be born prematurely because of the danger to both mother and baby if pregnancy is continued, thereby causing a wide range of lasting health problems (Preeclampsia Foundation, 2008). Preeclampsia is more common in women with a history of autoimmune disorders, and some research has already shown that women with adequate levels of vitamin D before and during pregnancy have lower incidences of preeclampsia (Hyppönen, 2005).

The current recommendations for vitamin D intake were made 40 years ago, and were based on the amount of vitamin D contained in a teaspoon of cod liver oil. This amount was thought to be sufficient based only on anecdotal evidence and before it was possible to measure blood levels of 25(OH)D, the usable form of vitamin D in the body (Hollis & Wagner, 2006). The recommendation for pregnancy of 400 IU per day has been shown in numerous studies to either have no effect on blood serum levels of 25(OH)D or to actually decrease circulating levels of 25(OH)D. This explains why women taking prenatal vitamins as directed are still deficient in vitamin D. The upper limits for vitamin D of 2,000 IU per day were also set somewhat arbitrarily based on reports of vitamin D toxicity from the 1920’s, when researchers gave children between 3,000,000 and 18,200,00 IU of vitamin D a day, extreme pharmacological doses (Wagner, Taylor & Hollis, 2008). One brief exposure of the entire body to sunlight can synthesize up to 25,000 IU of vitamin D, and several studies have given subjects up to 10,000 IU of vitamin D daily with no adverse effects (Hollis & Wagner, 2006). It has been found that in most people, between 1,000 and 5,000 IU of vitamin D daily will raise blood levels of 25(OH)D to normal, adequate levels (Wagner, Taylor & Hollis, 2008).

Vitamin D is no longer a simple vitamin to be easily overlooked. It is an important prohormone that regulates many body systems and can decrease the risk of some common diseases, many of which have no cure. Many people worldwide and most people residing in northern climates do not have sufficient levels of vitamin D, and cannot achieve sufficient levels through diet and sun exposure alone. Most people would benefit from taking a vitamin D supplement in order to maximize health. During pregnancy sufficient levels of vitamin D are especially important in order to provide the developing baby with the vitamin D it needs. Pregnant women should make sure to take a vitamin D supplement of at least 1,000 IU per day of vitamin D to reduce the risk of giving birth to a low birthweight or small for gestational age baby, to reduce the baby’s later risk for disease, and possibly to reduce the risk of developing preeclampsia during pregnancy.

SOURCES

Bodnar, L.M., Simhan, H.N., & Powers, R.W. (2007). High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates. Journal of Nutrition, 137(2), 447-452.

Brooke, O.G., Brown, I.R., Bone, C.D., Carter, N.D., Cleeve, H.J., Maxwell, J.P., et al. (1980). Vitamin D supplements in pregnant Asian women: effects on calcium status and fetal growth. British Medical Journal, 280(6216), 751-754.

Gale, C. R., Robinson, S.M., Harvey, N.C., Javaid, M.K., Jiang, B., Martyn, C.N., et al. (2008). Maternal vitamin D status during pregnancy and child outcomes. European Journal of Clinical Nutrition, 62, 68-77.

Grover, S.R., and Morley, R. (2001). Vitamin D deficiency in veiled or dark-skinned pregnant women. Medical Journal of Australia, 175, 251-252.

Hollis, B. W., and Wagner, C. L. (2006, April 25). Nutritional vitamin D status during pregnancy: reasons for concern. Canadian Medical Association Journal, 174(9), 1287-1290.

Hyppönen, E. (2005, July). Vitamin D for the Prevention of Preeclamsia? A Hypothesis. International Life Sciences Institute, 63(7), 225-232.

March of Dimes Foundation (2009). Low Birthweight. Retrieved April 20, 2009 from http://www.marchofdimes.com/professionals/14332_1153.asp#head5.

National Institutes of Health: Office of Dietary Supplements (2008). Dietary Supplement Fact Sheet: Vitamin D. Retrieved April 18, 2009 from http://ods.od.nih.gov/factsheets/vitamind.asp.

Preeclampsia Foundation (2008). About Preeclampsia. Retrieved April 20, 2009 from http://www.preeclampsia.org/about.asp.

Wagner, C. L., Taylor, S. N., and Hollis, B. W. (2008). Does Vitamin D Make the World Go ‘Round’? Breastfeeding Medicine, 3(4), 239-250.

Wardlaw, G.M., and Hampl, J. S. (2007). Perspectives in Nutrition (7^th ed.). New York: McGraw-Hill.

a doula story

I'm watching this movie right now, and my internet is slow so I have to keep pausing and waiting for it to load - so I'll take the time to pass it on here.

It's the story of a doula working with black teenage mothers in Chicago. While I wouldn't choose the birthing options that she does (hospital birth, medication), I can relate as a teenage mother myself. Unlike a lot of the young mothers in this film, I had great family support and my mom was with me through the whole experience. Rather than having a doula support me and go with me to the hospital when labor began, I had my wonderful midwives who met me at the birth center and took care of me throughout the entire process - acting as doula during labor, catching my baby as she was born, staying with me until I was ready to go home, and coming to my house every few days afterwards to check on us.

What runs through the film is that what young pregnant mothers need is love, trust, and most of all just being - being with them when they need it, not leaving when they're scared, listening when they need to talk, and talking when they need to listen. This is what teaches them how to be a mother. The word 'midwife' means 'with woman.' When you are with the woman, you are not only helping to bring a baby into the world, but bringing a mother into the world as well.

umbilical cord issues

I just read this post from Pamela with a great run-down of umbilical cord issues and what's actually going on.

I've heard so many times things like, "I would've died if my mom hadn't had me at a hospital, because my umbilical cord was wrapped around my neck and I couldn't breathe."

Ok... then how do babies breathe while they're in the womb? This mechanism doesn't just quit as soon as the head is born. Being born with the cord wrapped around the neck isn't an emergency, nor does it really compromise the baby in any way. More damage is done by cutting it prematurely, before the baby's body is born and it has a chance to start breathing on its own. As Pamela points out, you're effectively suffocating the baby by cutting the cord too soon.

I encourage everyone to read her post, it's excellent.

why waterbirth?

I feel helpless, stuck inside of a contraction – trapped inside of my head, feeling as if my entire being is being squeezed between the walls of my womb. I need to get on top of it, be one with it, be in control. My midwife finishes filling the Jacuzzi tub and I crawl over the side into the water. It feels amazing, and suddenly I am on the outside looking in. I can think again, I’m on top of it. I imagine this must be how my baby feels, floating inside of me.

Giving birth in water is a relatively new practice, although it has its roots in the age-old practice of using water for labor pain relief, and in some cultures of giving birth in shallow coastal waters. Since the first recorded “modern” water birth in 1977, giving birth in the water has gained popularity due to its relaxing, calming, and pain-relieving effects on the laboring mother.

Giving birth in the water (waterbirth) is beneficial to both mother and baby by reducing labor pain and tears for the mother and by creating a calmer transition for the baby.

Some formal studies and lots of anecdotal data report that birthing in the water reduces the number of tears and the amount of blood loss experienced by birthing women. There are also many anecdotal reports of babies born in water receiving higher Apgar scores (a scale of 1-10 used to assess the newborn’s condition at one and five minutes after birth) than “land-born” babies, and water-born babies being calmer and less stressed in the period following birth.

Two major groups of hormones play a role in birth: the endorphins and the adrenalines. When a laboring woman is stressed, fearful, or anxious, the adrenalines are in charge; this leads to a tightening of muscles and an increase in pain, as well as making labor slow down or stall out. On the other hand, when a laboring woman is relaxed, calm, and feeling in control, the endorphins are in charge, leading to decreased pain and faster labor.

When a laboring woman can immerse herself in warm water, a much greater degree of relaxation can be achieved than is otherwise possible (save with the use of synthetic drugs). This puts the endorphins in charge and paves the way for a smooth, uncomplicated labor.

The buoyancy of water helps with labor pain as well. When most of the body is supported by water, the laboring mother can let go of everything else and instead focus inwardly on the contractions as they come. In water it is possible to move in ways that would be very difficult on land – for instance, gliding your hips in circles and figure-eights, thus changing the angle of your pelvis and helping the baby move down and out (Kitzinger, 2000).

All of these things help women better handle their contractions and to feel like they are in touch with their bodies and their babies.

Water also decreases labor time - in one study by as much as 40 minutes on average (Geissbuhler & Eberhard, 2000). While 40 minutes may not seem like long enough to matter, when you are in labor, believe me - every last little minute counts!

Giving birth in water leads to fewer tears and less episiotomies. In a Swiss study of more than 6,000 births, the waterbirth group had 22.6% less episiotomies than bed births, hardly any 3rd or 4th degree tears, and many more women experienced no tearing at all (Geissbuhler & Eberhard, 2000).

Some people speculate that the reason so many less episiotomies are performed on women laboring in water is that the caregiver simply has less access to the perineum and is therefore more likely to leave it alone. I think that another factor to both the low number of episiotomies and the lower number of tears is that when a woman is more relaxed, she is better able to open up and let the baby come down without tensing her muscles. Water also gives a greater sense of privacy (than if you were laying exposed on a bed), which adds to a woman’s comfort and relaxation.

Waterbirth also has benefits for the baby. In the womb, a baby is suspended in body-temperature amniotic fluid. Going straight from body temperature fluid to cool room-temperature air is a big shock. Being born instead into a similar medium – body-temperature water – is a smoother transition.

Many parents and midwives report that babies who were born in water cry less after birth, and are calmer and mellower in the hours following birth. Many waterbirth babies (such as Sophie) do not cry at all and simply cough or sneeze to clear their lungs and then look around, observing their surroundings calmly.

Waterbirth may not work out for everybody. In some cases waterbirth is not in the baby’s best interest. Some women will have their contractions slow down or even stop altogether when they get into the water. Just as with any birth method or environment, every woman and every baby is different – one thing will not work for all.

But for the vast majority of women and babies, waterbirth will work – and be beneficial: waterbirth decreases labor pain and the number of tears and episiotomies for the mother, and creates a calmer birth experience for the baby.

---------------------------------------------------------------

Sources:
American Pregnancy Association (2007). Water Birth. Retrieved April 17, 2008 from http://www.americanpregnancy.org/labornbirth/waterbirth.html.
Geissbuhler, V., & Eberhard, J. (2000). Waterbirths: A Comparative Study: A prospective study on more than 2,000 waterbirths. Fetal Diagnosis and Therapy, 15. Retrieved April 17, 2008 from http://data.memberclicks.com/site/wi/FD_T_Waterbirth-AComparitiveStudy.pdf.
Kitzinger, S. (2000). Rediscovering Birth. New York: Pocket Books.
Robinson, J. (2000). Waterbirth – Looking for Bad News. AIMS Journal, 12 (2). Retrieved April 17, 2008 from http://data.memberclicks.com/site/wi/AIMS_journal.pdf.
Waterbirth International (2007). Waterbirth Research Documents. Retrieved April 17, 2008 from http://www.waterbirth.org/mc/page.do?sitePageId=38565&orgId=wi.

so who is this sophstar's mama anyways?

Or rather, what kind of Mama am I?

I am a cloth-diapering Mama. I am a co-sleeping Mama. I am an attachment-parenting Mama. I am a selectively-vaccinating Mama.

I was an exclusively breastfeeding Mama. I am a natural-childbirth Mama (my baby wasn't "delivered"... I birthed my baby into this world, into the water, into the hands of my midwife).

I am an energy-conserving Mama. I am a green cleaning Mama. I am a recycling Mama. I am an organics Mama. I am a teen Mama. I was a single Mama... now I am a married Mama. I am an Alaskan Mama (for Obama!).

So. I am all of these things, and I'm going to try to start getting more into these issues that I am passionate about here on my blog - so stay tuned!

Love,
Sophstar's Mama

big changes and new pictures

first the new pictures:

sophie loves to help, as you can see.

isn't she clever?

and for the big change:

sophie and i are moving to juneau for the next two semesters! i'm going to start apprenticing at the juneau family health and birth center.

thunder at midsummer

sophie loves watching the thunderheads just like i do.

a little off-subject, i am working on my final project for history of midwifery - if anyone knows of a good source for birth art (ancient times to present day) i would love to know about it.

birth stories

check out www.birthdiaries.com - i totally got sucked in last night in the homebirth section.

baby stuff

already?? dwayne thinks i'm crazy. but check out this awesome thing someone made that i just won on ebay:
it's a wool soaker sleepsack.... that means it's a diaper cover (it's lanolized) and a sleepsack in one. pretty much the coolest thing ever.
we met with the midwife today, her name is dana and she seems really cool. i have my first official prenatal visit on march 31.
now sophie and i are going to brave the wind and walk to the store to get protein shake powder (pregnant women are supposed to get 120g of protein a DAY!), liquid iron, liquid chlorophyll, and envelopes. haha kind of a strange grocery list i guess.
or maybe we'll wait until dwayne gets home and then we'll drive... the wind is really whipping out there and sophie's poor little cheeks get windburned so bad.
here is a picture of the twin giraffes nursing from yesterday:

a very bad day

so we were driving along - dwayne, esparza, sophie and i - academy and we saw dwayne and esparza's friend clark driving just ahead of us. so, they honk at him, and he speeds up. dwayne chases him. not a good idea... all of a sudden he switched lanes and right in front of us there was a car going about 30mph (we were going maybe 55). so dwayne swerved, but a truck in the other lane sped up so we couldn't go that way. so he swerved again, lost control by this point, and we hit the curb and the car rolled sideways, and then somehow we flipped completely around and landed facing the opposite direction that we were going. no one was hurt, we all walked away from it with just some bruises and sore muscles. it was crazy scary though. we took sophie to the er on post just to make sure she was fine (she was acting fine but the paramedics said to take her in just in case), and had to wait almost 5 hours to get seen. it was ridiculous. everybody else in there was just in for a cough or cold. never go to the evans army hospital emergency room. but sophie checked out fine, and we went home - to find that our house had been broken into. when it rains it pours, right? there's more. nothing was taken but it was creepy because they came in through our attic crawl space in our bedroom. so, we go to bed finally, and the next morning i was supposed to get my period, and i hadn't, so i took a pregnancy test - I'M PREGNANT! - oh my gosh. and a cop came that morning to investigate the break-in (he didn't find anything). and then our dryer broke. and then i cut my finger down to the bone chopping onions for breakfast.

so. dwayne's precious vehicross is dead (totalled), we got a used car the other day so we do have wheels which is good. and i'm pregnant! i'm meeting with a homebirth midwife next week.