Benyshek, Daniel C.

Bovbjerg, Marit L.

Cheyney, Melissa M.

Undetermined

ScholarsArchive@OSU

202 |   LETTERS TO THE EDITOR2.  Buser GL, Mato S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the field: late- onset infant group B streptococcus infec-tion associated with maternal consumption of capsules containing dehydrated placenta—Oregon, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(25):677‐678.3.  Schuette SA, Brown KM, Cuthbert DA, et  al. Perspectives from patients and healthcare providers on the practice of maternal pla-centophagy. J Altern Complement Med. 2017;23(1):60‐67.4.  Farr A, Chervenak FA, McCullough LB, Baergen R, Gruenebaum A. Human placentophagy: a review. Am J Obstet Gynecol. 2018;218(4):401.e1‐401.e11.5.  Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health. 2014;59(1):17‐27.Reply to Farr et al. Letter (Benyshek et al.)Reply:We welcome the opportunity to respond to the comments by Farr and colleagues in a Letter to Birth.Farr and colleagues raise four points: (1)“biased” data set used in our analyses, (2) insufficient acknowledgment of the lack of evidence supporting the efficacy of the most com-monly cited reason for engaging in placentophagy—prevent-ing postpartum depression, (3) “distortion” of their recent review of human placentophagy,1 and the article’s characteri-zation of the evidence basis of their clinical recommendation against it, and (4) “unprofessional” recommendations for ma-ternity care providers based on our study findings.1. The main objection to our work raised by Farr et  al is that we used data from the MANA Stats system. They erroneously claim that MANA Stats data are “self-reported”—on the contrary, they are based on medical records as are the vast majority of birth registries that track outcomes for midwifery care globally. We actually find it quite shocking that the authors would accuse an entire class of professional care providers of deliberately keeping inaccurate medical records. There is no evidence to support this claim.Farr et al also describe these data as having “well- known, scientific problems due to systematic bias” and that “no analy-sis based on MANA Stats can ever be evidence- based [because of this bias].” All data—including MANA Stats data—have bias. Good scientists seek to minimize possible sources of bias when collecting data and acknowledge and clearly discuss any remaining sources when reporting results. We openly acknowl-edge in all of our papers that our sample is not representative of all childbearing women in the United States, though it is repre-sentative of women who choose community birth. We openly acknowledge that not all midwives choose to participate, and thus the data set contains a sample of the total population of women planning community births. Both of these contribute to selection bias potentially affecting external validity. However, most clinical research is based on samples, as enrolling entire populations is rarely feasible. Indeed, in the most recent issues of JAMA and the New England Journal of Medicine, every re-search paper used a sample from the target population, ranging in size from n = 24 to n = 75 782. One- fourth of the papers were medical records– based cohort studies. Our methods are thus not unusual. Furthermore, to the extent that we explore re-search questions involving etiology (eg, is placentophagy harm-ful to neonates?) rather than demographic characteristics (eg, who engages in placentophagy?), external validity becomes less important,2 as basic human physiology varies little accord-ing to demographics. These concepts are so basic to epidemi-ology that to question them suggests a bias of their own on the part of the authors.In terms of limiting selection biases, there are extensive protocols in place to ensure that the MANA Stats system collects complete data from all midwives who do partic-ipate3—indeed, it is impossible, given the system’s checks and balances, for a midwife to “report only half of cases” or “not report adverse outcomes,” as Farr and colleagues sug-gest. To suggest that fellow health care professionals would misrepresent data—in the absence of any evidence—is a se-rious and deeply concerning allegation.There are, likely, numerous examples of misclassifica-tion bias in our data, just as would be found in any medical records– based data set. Some variables are highly accurate (eg, cesarean), and others more prone to inaccuracies (eg, time of labor onset). Again, we openly acknowledge these potential errors in our manuscripts, and when possible, conduct sen-sitivity analyses to determine the extent to which they might alter our conclusions. Numerous peer- reviewed papers have been published using MANA Stats data, in the last several years,3-8 and not a single peer reviewer, nor any postpublica-tion letters to the editor (other than the one written by Farr DOI: 10.1111/birt.12381   | 203LETTERS TO THE EDITORand his co- signers here), has ever suggested that these data are so biased that they should be entirely discounted. Results have been presented and favorably received at several national and international conferences, and MANA Stats data are in-cluded in the Gates Foundation’s Healthy Birth, Growth, & Development knowledge integration data consortium. Over 30 different midwifery, public health, and physician researchers from several countries are currently working with these data.2. Farr et al say “At no point did the authors make it clear that there is no indication for placentophagy.” We call our colleagues’ attention to four instances in our report where we do just that (Abstract: Conclusions; Section 1: second paragraph; Section 4: fifth paragraph; Section 4.2: first paragraph). For example, in the abstract we state, “The majority of women consumed their pla-centas in uncooked/encapsulated form and hoping to avoid postpartum depression, although no evidence cur-rently exists to support this strategy.”93. In their letter, Farr et al also say: “The citation of our paper is a distortion of it and violates the scholarly stand-ard of accurately reporting the content of papers cited,” in reference to the evidence-based rationale for their clinical recommendation against placentophagy. Firstly, we would point out that we reference nearly the identical suite of human studies investigating the purported benefits of pla-centophagy in our manuscript, and that four of the five studies highlighted by Farr et al in their review (Table 1)1 were conducted by the lead author of this paper. Dr. Benyshek is thus intimately familiar with the findings having conducted the studies in question. We also stand by our characterization of Farr et al’s rationale for their recommendation against placentophagy. Beyond pub-lished self-reports of minor maternal side effects of the practice by placentophagic mothers10 (which Farr et al dismiss as weak and unreliable evidence1), the only study cited by Farr et al which could be interpreted as direct evi-dence of harmful effects of placentophagy to neonates is the single Centers for Disease Control and Prevention (CDC) case report of an infant who was readmitted to the hospital with a late-onset group B Streptococcus agalac-tiae (GBS) infection that may have been transmitted via the mother’s placenta capsules, which tested positive for GBS (although the authors could not confirm with cer-tainty that the capsules were the source of the neonate’s infection).11 Epidemiology best practices would suggest that a single case study is insufficient evidence from which to extend a clinical recommendation. Clinical guidelines based on such limited evidence would be graded “I” for “insufficient” by the U.S. Preventive Services Task Force. On the contrary, our medical records–based study of more than 7000 placenta consumers, with a control group of over 10 000 non-consumers, found no evidence of harm to the neonate. We would also like to point Farr and col-leagues to a recently published study on the effects of various preparation methods on hormones, metals, and bacteria in placental tissue, which concludes that the ma-ternal and neonatal infection risk from dehydrated encap-sulated placenta is very low.12 These studies, and not a single case study alone, can and should inform shared de-cision making around maternal placentophagy.4. Finally, we take issue with the assertion that our team is “unprofessional” for not recommending directive coun-seling against placentophagy based on our findings. Our assessment of the current literature on maternal placen-tophagy is that there is no clear evidence of benefit and no evidence of harm. In such instances, recommending direc-tive counseling against the practice would not be sup-ported by evidence.We want to close by noting that part of why a growing num-ber of families are choosing community birth is that they fear just the sort of directive counseling that Farr and colleagues are advocating. We have all had the opportunity to work closely with numerous obstetricians over the course of our academic and pro-fessional lives, and we believe that the viewpoints conveyed in the Farr et al letter to the editor, and the willingness to level bla-tant ad hominem attacks, are not majority held perspectives.Daniel C. Benyshek PhD1Melissa M. Cheyney PhD, CPM, LDM2Marit L. Bovbjerg PhD, MS31Department of Anthropology, University of Nevada, Las Vegas, NV, USA2Department of Anthropology, Oregon State University, Corvallis, OR, USA3College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USAEmail: daniel.benyshek@unlv.eduREFERENCES 1. Farr A, Chervenak FA, McCullough LB, Baergen R, Gruenebaum A. Human placentophagy: a review. Am J Obstet Gynecol. 2018;218(4):401.e1-401.e11. 2. Rothman KJ, Gallacher JE, Hatch EE. Why representativeness should be avoided. Int J Epidemiol. 2013;42(4):1012‐1014. 3. Cheyney MJ, Bovbjerg ML, Everson C, Gordon W, Hannibal D, Vedam S. Development and validation of a national data registry for planned home and birth center births: The Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health. 2014;59(1):8‐16. 4. Cheyney MJ, Bovbjerg ML, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of care for 16,924 planned home births in the United States: The Midwives Alliance of North America Statistics Project 2004- 2009. J Midwifery Womens Health. 2014;59(1):17‐27.204 |   LETTERS TO THE EDITOR 5. Cox K, Bovbjerg ML, Cheyney M, Leeman L. Planned home VBAC in the United States, 2004- 2009: outcomes, maternity care practices, and implications for shared decision making. Birth. 2015;42(4):299‐308. 6. Bovbjerg ML, Cheyney MJ, Everson C. Maternal and newborn outcomes following water birth: The Midwives Alliance of North America Statistics Project, 2004- 2009 cohort. J Midwifery Womens Health. 2016;61(1):11‐20. 7. Bovbjerg ML, Cheyney M, Brown J, Cox K, Leeman L. Perspectives on risk: assessment of risk profiles and outcomes among women planning community birth in the United States. Birth. 2017;44(3):209‐221. 8. Nethery E, Gordon W, Bovbjerg ML, Cheyney M. Rural commu-nity birth: maternal and neonatal outcomes for planned commu-nity births among rural women in the United States, 2004- 2009. Birth. 2018;45(2):120‐129. 9. Benyshek DC, Cheyney M, Brown J, Bovbjerg ML. Placentophagy among women planning community births in the United States: frequency, rationale, and associated neonatal outcomes. Birth. 2018;00:1‐10. 10. Selander J, Cantor A, Young SM, Benyshek DC. Human maternal placentophagy: a survey of self- reported motivations and expe-riences associated with placenta consumption. Ecol Food Nutr. 2013;52(2):93‐115. 11. Buser GL, Mato S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the field: late- onset infant group B streptococ-cus infection associated with maternal consumption of capsules containing dehydrated placenta—Oregon, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(25):677‐678. 12. Johnson S, Groten T, Pastuschek J, Rödel J, Sammer U, Markert UR. Human placentophagy: effects of dehydration and steaming on hor-mones, metals and bacteria in placental tissue. Placenta. 2018;6:8‐14.

Reply to Farr et al. Letter (Benyshek et al.)

https://ir.library.oregonstate.edu/downloads/wh246z47d

Reply to Farr et al. Letter (Benyshek et al.)

Abstract

Similar works

Full text

Available Versions

ScholarsArchive@OSU