Annual Maternity Guides

. March 15, 2013.
Matus-Coral

Beautiful beginnings to circumcise or not?

From the moment you become a parent, you worry about how the choices you make may affect your children. Although the circumcision of infant males is still considered the norm by most families in the U.S., more parents are questioning the practice. Toledo Area Parent spoke with local medical professional Coral D. Matus, M.D. to uncover some thoughts on this debated topic.

TAP: Generally speaking, what percent of newborn boys in the U.S. are circumcised?
CDM:  Rates of male circumcision vary in the United States by region.  Most recent data indicates overall rates of circumcision are around 80-85 percent across the United States.
How has this rate changed over the past few decades?
Rates of circumcision have decreased slightly since the 1970s, although there was a period of increasing circumcision rates from 1988-2000 to reach the level we are at today.
What are the health benefits of male circumcision?
Besides making hygiene (taking care of yourself) easier, infant males who are circumcised have lower rates of urinary tract infections (UTI’s), especially in the first year of life.  Although the overall incidence of UTI’s in infants is small, the incidence in circumcised males is about 1/3 that of uncircumcised.  If circumcision was performed on 100 newborns, that would prevent about 1 urinary tract infection in that population over the first year of life.  Circumcised men also have lower rates of penile inflammation (a condition called balanitis or phimosis), penile cancer as they get older, and decreased risk of certain sexually transmitted infections, specifically trichomonas, human papilloma virus (HPV), and human immunodeficiency virus (HIV).

There is much ongoing research regarding the effect of male circumcision on HIV and HPV (the virus related to female cervical cancer) transmission.  Women who have uncircumcised partners have a 4 times higher rate of cervical cancer compared with those who have circumcised partners.  The World Health Organization (WHO) is conducting ongoing research regarding HIV rates as they relate to circumcision.  Early data from South Africa, Kenya, and Uganda indicate that acquisition rates of HIV in these countries, where infection rates are very high, are 50-60% lower in circumcised men compared with uncircumcised.  In fact, the WHO is considering circumcision of adult males as a part of a universal HIV prevention strategy.
What are the risks associated with male circumcision?
The most common “risk” associated with the procedure is bleeding.  This is typically taken care of very easily with some simple measures at the time of the procedure.  Other things that can possibly happen include infection and abnormal scarring.  We instruct parents on the proper care of the area after the procedure, which helps reduce these risks.  We also warn parents that an “unacceptable cosmetic outcome” is possible.  Since circumcision is primarily a cosmetic procedure, this becomes very important.  As the child grows, it may appear that either “too much” or “too little” foreskin was removed.  In most cases, as the child grows this will resolve itself.  Occasionally a repeat procedure, or revision, is required.
Also, there are occasions when a newborn boy should not be circumcised.  If the male anatomy is abnormal in any way (a couple of more common conditions are called “hypospadias” and “chordee”), a urologist should be consulted.  Often, the foreskin will be used later to “repair” these abnormalities.
What role does culture play in the decision parents face when considering male circumcision?
Culture and religion certainly play a large role in the decision of many parents to have their children circumcised.  The practice of circumcision dates back to ancient Egypt, and is an important religious symbol in Judaism and Islam cultures.  Some aboriginal tribes in Africa and Australia use the procedure as a “rite of passage” into manhood.  Often, the decision as to whether to proceed with circumcision is based largely on “if Dad is circumcised” or not.  Many parents fear that their child will feel out of place or be ridiculed if he “looks different from the other boys.”  Unfortunately, this is often a deciding factor for parents.
Are there any common myths regarding male circumcision (false health benefits or risks, inaccurate information, etc.) that parents should be aware of?
Some groups have reported that babies who are circumcised may “remember” the experience and be traumatized by it.  There are also groups that believe that circumcision will eliminate masturbation in adolescent boys.  I don’t have reason to believe that either of these is true.
What is your advice to parents considering circumcision for their newborn son?
Circumcision is an elective procedure that should be chosen based on complete information.  If you think you will want your son to be circumcised at some point in his life, the first few days of life is absolutely the best time to do it.  Gather as much information as you can, and make the decision based on your best assessment of the best interests of your son.

Coral D. Matus, M.D. is the Associate Director at The Toledo Hospital Family Medicine Residency Program.

Beautiful beginnings born in convenience 

Arising trend among pregnant women is to have elective births, where an infant can be delivered at a prescheduled date and time.  In response to the increasing number of requests for elective births from pregnant mothers, some hospitals have adopted the 39 Week Rule where they commit not to perform elective deliveries before 39 weeks of pregnancy.  Mercy St. Vincent Medical Center was one of the first hospitals in the nation to adopt the 39 Week Rule, and has since seen admissions to its Neonatal Intensive Care Unit (NICU) for problems such as rapid breathing decrease by 30%.  Toledo Area Parent did a Q&A with Mercy’s Dr. Claudel Jean-Pierre to shed some light on this new trend and St. V’s position:

TAP: How is the term “elective delivery” defined?
CLP: Elective delivery is defined as a primary cesarean delivery at maternal request or a vaginal delivery following a maternal induction or augmentation of labor at maternal request in the absence of any medical or obstetric indication. 
How prevalent are elective deliveries in Ohio?  In the U.S.?
The exact number of elective deliveries is not known.  However, in some states, including Ohio, the indication for induced delivery has to be documented.  In 2006, 13% of Ohio’s induced deliveries left the indication absent or marked it as “other.”
What are the benefits associated with elective deliveries?
There are no identified medical benefits to an elective delivery performed on maternal request without medical indication.  The non-medical benefits are economical and social where performing the delivery may allow the family to benefit by coordinating the presence of family members, such as a member serving in the military, or benefit from potential tax deductions available for a child born on December 31 rather than January 1.
What are the risks?
The major risk is severe respiratory distress syndrome.  The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network conducted from 1999 – 2002 analyzing repeat cesarean section data of women with viable singleton pregnancies delivered electively.  As compared with births at 39 weeks (gestational age should be determined by a 20 week ultrasound and not solely the last menstrual period), births at 37 weeks and 38 weeks were associated with an increased risk of neonatal death, respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the NICU.  Potential risks of cesarean delivery on maternal request include longer medical stay and greater complications in subsequent pregnancies that increase with each subsequent cesarean delivery.
Mercy Children’s and Mercy St. Vincent Medical Center’s Obstetrics and Gynecology Department have committed to perform no elective deliveries before 39 weeks of gestation?
In March 2008, we launched an initiative to reduce the elective deliveries to accomplish a goal of a 60% reduction in scheduled births lacking indication.  We have met our goal with no elective deliveries from September 2008 through the end of 2009.  As a result, the rates of respiratory distress have been reduced dramatically.
In 2009, the Ohio Perinatal Quality Collaborative announced its goal to reduce by 60% the number of women in Ohio who have an elective delivery without medical indication between 36.1 and 38.6 weeks gestation.  Has St. Vincent’s or other Toledo area hospitals played a role in helping the OPQC achieve that goal?
Twenty Ohio maternity hospitals collected baseline data for 60 days and then selected locally appropriate Institute for Healthcare Improvement Breakthrough Series interventions to reduce the incidence of scheduled births.  Rates of scheduled births without a documented indication, birth certificate data, and implementation issues were shared regularly among sites.  Mercy St. V’s and Toledo Hospital were the only 2 institutions in Northwest Ohio who were included in the survey.
Is there any additional information you would like to offer regarding elective deliveries?
I would like to conclude with some words from a landmark article on the subject from The New England Journal article on this topic by Dr. Frank Chervenak, preeminent authority on OB/GYN ethics, in 2003: “The clinician must also attempt to understand the genesis of the woman’s request.  Although physicians must recognize the expanding part played by maternal autonomy in advancing the argument in favor of elective cesarean delivery, they should also be aware that a woman’s choice may reflect anxiety.  With appropriate counseling, anxiety can be assuaged, and when it is, the request for cesarean delivery is often withdrawn.”

Stinky Myths. Uncovering the truths of cloth diapering

Cloth diapers have come a long way since the bulky bottoms fastened with pins used generations ago. Amanda Ballard, owner of Tender Loving Cloth Diapers (www.tlcdiapers.com), made the switch to cloth before her first child turned one. In 2009 she founded her company, which offers free informational workshops about cloth diapering. Toledo Area Parent asked Ballard to help us dispel some cloth diapering myths:

1. CLOTH DIAPERS
ARE EXPENSIVE.

“I was tired of spending the money on disposable diapers and buying the big, bulky packages that were still expensive,” said Ballard. She’s not the only one who converted to cloth for financial reasons. According to Thirsties.com (a diaper brand Ballard offers), 45.5 percent of cloth diapering families recently surveyed said they are committed to cloth for the financial savings.
“Some people may be hesitant about the initial outlay,” explained Ballard, “but many are one size fits all.” Ballard is currently reusing cloth diapers she bought for her first child on her second child. Plus, “there’s a market for used diapers,” she said, so you can sell them once you know you won’t be needing them again.
Twenty cloth diapers is a good amount, said Ballard. With diapers ranging from $11-19 per diaper, it’s a significant savings when you add up the cost of disposables — $1600 for two years according to the Real Diaper Association’s website, www.realdiaperassociation.com.

2. CLOTH DIAPERS ARE DIRTY AND DISGUSTING.
Many cloth diapers, such as the ones Ballard uses, have flushable liners. These can be washed and reused 2-3 times if just wet or not too messy. They can also be flushed away with any solids your little one has left behind. Ballard suggests getting to know your septic system before using the flushable liners.
Whether using a traditional cloth diaper or one with a liner, a diaper sprayer attached to the toilet helps to quickly spray the mess into the pot. Then, the diapers go into the washer to be cleaned and reused. If using a cover, you can rinse the cover if needed and reuse it immediately.
And, it doesn’t have to be all or nothing. Disposable diapers can be an option when traveling or in a pinch.

3. THEY AREN’T THAT MUCH BETTER FOR THE EARTH.
Ballard says that according to the Real Diaper Association, disposable diapers take 250-500 years to decompose in a landfill.  “Cost savings was my number one factor (for switching to cloth), but when I started cloth diapering I realized I had been throwing away so much waste.
Ballard also says that using cloth diapers allows solid waste to go into the sanitary system, rather than in a landfill.

4. MY BABY WON’T KNOW
THE DIFFERENCE.

With the re-emerging popularity of cloth diapers comes a wide variety of styles —  from snaps to Velcro, from prefolds to fitted — making your selection more customizable than disposable options. Ballard suggests buying a small sampling of different kinds to test with your child, since some may be a better fit.

Because cloth diapers aren’t made with plastic or paper, Ballard says they are “so much more comfortable for baby”. Plus, children, like her daughter, enjoy the trendy prints and matching their diaper to their outfits.

5.CLOTH DIAPERING
IS HARD!

It may seem hard to imagine, but Ballard said cloth diapers are “just as easy as disposable diapers.” Even her once-reluctant husband and babysitter have no problem using them. Ballard said some local day care centers, such as Maria Early Learning Center, are open to cloth diapering little ones.