Abstract
In this issue of the Journal of Women's Health, the article by Muhlrad et al., is an extremely timely one in that it delves into a topic that is rarely discussed. 1 Namely, the long-term effects that events surrounding the gestation and birth of individuals have on their overall health, not only during infancy and childhood, but also throughout their entire life cycle. To most readers, including myself, this is a shocking concept. That our well-being may more directly relate to how eventful or uneventful our mother's pregnancy and our early birth experience was when she carried us rather than to our personal diet, exercise routine, and genetics!
As an obstetrician and gynecologist this is a topic that is typically not addressed, either during antenatal care and the delivery or in the postpartum period. When an adverse maternal or fetal condition does present during the pregnancy or during the birth process, the active management and ongoing counseling on potential outcomes occurs throughout the remainder of the pregnancy, the delivery and the postpartum period. After the delivery, when problems are identified in the infant, they also are addressed, and management strategies determined. But no counseling to parents is offered or management prescription given regarding the impact of these adverse natal conditions on the adult health of that baby who has been stabilized with no obvious health issues identified at hospital discharge; that adverse natal circumstances may increase the risk of long-term adverse outcomes when the infant reaches adulthood is not discussed with the parents.
Of course, it is well known in the medical community that there are lifelong adverse health conditions that can be directly traced to ante- and postnatal events, such as cerebral palsy, due to the interruption of adequate oxygen to the fetus or brachial plexus injury due to birth trauma. But these conditions usually present either after the delivery or during the early childhood years. Most medical conditions presenting in the adult are typically not associated with an adverse fetal event. In fact, a detailed obstetrical history of individuals is not included in the contemporary electronic medical record. Adult patients are not asked what the mode of their delivery was and whether there were birth complications.
But this practice may have to change. Muhlrad et al. 1 add to the literature that supports a birth history may indeed be important in all adults and that members of the health care team should ask adult patients about complications that occurred to them antenatally and postnatally. By examination of the medical records of women born in Sweden between 1973 and 2001, these investigators found that there was an association between documented adverse birth-related events and the patient's risk, as an adult, of developing provoked vestibulodynia (PVD)/vaginismus. That women who developed the studied conditions were more likely to have been underdeveloped at birth, preterm, low birthweight, and/or small for gestational age. There was, however, no relation of early pain exposure and adult onset of PVD/vaginismus.
Although these data add valuable new insight into two pain conditions experienced by many women, the premise of adverse fetal events being associated with adult medical conditions has been explored previously. Raju et al. did a review of 126 publications on this topic to evaluate the association between birth problems and adult medical disease. 2 Their conclusion supported the findings in the Muhlrad study. Specifically, that adverse conditions in the adult may be related to natal experiences, such as preterm birth. Furthermore, they noted that abnormal fetal life and birth trauma can be considered risk factors for chronic health condition in the adult, such as conditions adversely impacting neurological, pulmonary, and cardiovascular function.
It also is interesting to note that the concept of what happens at an infant's birth can have long-lasting implications that extend into their adult years actually dates back to antiquity. Many of the birth rituals practiced by our ancient ancestors were done to insure that the child became a healthy adult and no evil interrupted their long-term continuing wellness. For example, at the time of a boy's birth, the ancient Aztec's buried a piece of his umbilical cord, referred to as tonali, in enemy territory. For girls, a piece of umbilical cord was wrapped around a piece of wood and buried under the house. They believed that these practices ensured that the boy would grow up to be a strong and courageous adult warrior and the girl would be an outstanding homemaker. 3 In ancient Rome, many babies were given a bulla, which was a special locket that protected the child from evil. By this protection from evil, the male child was protected such that he would live to become a healthy adult Roman citizen and the female child was protected such that she would live to become a healthy adult woman capable of marriage. 4
Currently emerging data that studies long-term outcome of infants throughout the life cycle, however, have focused not only on the compromised fetus or infant, but also on the mode of delivery. This is due to innovative studies exploring the role of the microbiome in human health and, as related to this topic, the impact of the maternal microbiome on the long-term well-being of that individual throughout the life cycle. This new research is suggesting that infants born by cesarean delivery, including those healthy both during pregnancy and after birth, may be at increased risk for long-term health problems due to their lack of exposure to the mother's vaginal microbiome. Data, such as reported by Wampach et al., note that fetuses delivered by C section, which occurs in >30% of U.S. births, are deprived of maternal gut microbiota. 4 Because they lack their mother's healthy microorganisms, these researchers report that these infants appear to be at increased risk for many adverse health outcomes throughout their life cycle and into their adult years. 5
For both surgically delivered and vaginally delivered infants, skin-to-skin contact of the mother and infant pair also is encouraged to populate the infant with the healthy maternal microbiome. And this raises the issue of prematurity and adult health risk factors. That is, if an otherwise healthy infant is born preterm due to a maternal indication, is it their being preterm that promotes the long-term adverse health outcomes, such as the Muhlrad et al. 1 data suggest, or is it their surgical delivery that frequently occurs in these instances? Another risk fact and, perhaps, even more important, is the infant's long neonatal intensive care unit (NICU) stay that precludes skin-to-skin contact with the mother. Both a surgical delivery and a lack of contact with the mother in a preterm infant housed in the NICU will deprive the infant of exposure to the maternal microbiome. Therefore, the next question that follows is this: Will the large number of healthy infants who are delivered by C section and then bottle-fed be at increased risk of adverse health outcome in their adult life? Truly a topic that needs more research.
Regardless of scenario, because intrauterine and birth issues, such as preterm birth, are associated with adverse medical outcomes in adults, such as PVD/vaginismus, the current question to answer, as already implied, is this. Should all adults be asked about their gestational age at the time of birth, their birth weight and any antenatal and birth complications that they may have been subject to? In addition, should they be asked whether they were breast- or bottle-fed on a routine basis? My resounding answer to including these questions in the annual medical history is a resounding yes.