Nutrition in Pregnancy
enjoyed and learned from Reifsnider and Gill’s article on nutrition in the childbearing years (January/ February 2000 J O G N N ).Many obstetricians have the good fortune to work with members of AWHONN. It might be helpful for AWHONN members to know about several documents that have been distributed to physicians by ACOG on this subject. They are Technical Bulletin 179 entitled Nutrition in Pregnancy and Technical Bulletin 229 entitled Nutrition in Women. The information in both of these publications is very similar to the content in the J O G N N article. Knowing this, there might be more consensus by members of the women’s health team when nutrition comes up in designing plans of care. In addition, the Institute of Medicine also published a companion book entitled Nutrition During Pregnancy and Lactation: An Implementation Guide. It is a clinically oriented manual that contains suggestions on ways to interact directly with patients in nutritional matters.
Ronald A. Chez, M D University of South Florida Tampa, FL
Long-term Effects of Labor Analgesia
read the article that discussed my research (“Is It Time to Change the Paradigm?” by Suzan KardongEdgren, September/October 1999 JO G N N) . It raised an issue that as an author I cannot. Whenever I am invited to speak about my research, people ask me what has been done 226
since the studies were published and why no one has replicated the work. 1 must then answer that I do not know-but I can guess. The general trend in using nitrous oxide (entonox) increased in Sweden. At a meeting for anesthesiologists regarding labor analgesia, they were asked for their opinions about our finding. The answer was that more studies were needed before changes could be made. Of course, you could then ask why nobody has replicated the studies, and one reason is probably that it is not so easy. If you choose the case-control design as we did, it demands records that are complete and have been gathered for decades. In Sweden we have a very good record-keeping system and can find about 95% of records, but that would not be possible in most other countries. If you choose a cohort design, you would have to get enormously big cohorts of thousands of participants, as drug addiction is an unusual outcome. And you would have to wait 20-30 years for the outcome of drug addiction to have reasonable time to occur. This may be one reason why no one has replicated our studies. Furthermore, results from epidemiologic studies may be less accepted than findings of a randomized controlled study and can therefore be questioned. In addition, people get upset when they see such results. When I look back at people’s reactions, I can see pharmacologists, psychiatrists, midwives, and psychologists have found interest in the studies. However, neonatologists in general and obstetricians to some extent have expressed concern about the findings. Our research suggested that what you do to newborns might have long-term effects. Maybe it is too painful to accept the
idea that what you do might cause harm and not only good. Kardong-Edgren claimed that we had reworked one data collection and written three articles based upon that, which is not correct. The first paper (1988) is based on one data collection and the second (1990) was performed 1-2 years later. It might be a weakness (but not really a major one) that the same researchers have done the work, but then, a lot of science would be weak as most researchers continue in the same field. The JOGNN article said that I had difficulties getting the studies published. However, I was rather surprised that all my articles on the subject were accepted at first submittals. Nonetheless, there was a local, strong reaction from some researchers here in Sweden. And, as Kardong-Edgren described, it has rather been surprisingly silent when you consider the findings. Research has been published recently regarding perinatal exposures affecting the future health of the individual-birth trauma as a risk factor for schizophrenia, intrauterine starvation as a risk factor for affective disorders, extreme use of medications and induction before planned birth date as a risk factor for autism, etc. This means perhaps and hopefully that the climate is good for these types of hypotheses-that short-term exposures during what might be sensitive periods might be harmful and may not be evident until decades later. Recently I and two co-authors have conducted a replication, which includes American subjects. If it is published we hope someone else will dive into this topic.
Karin Nyberg, C N M , PhD University of Goteborg Goteborg, Sweden Volume 29, Number 3