Lauren on Living

A Lifestyle Blog about Simplifying Healthy Living

Natural Birth & The Great Intervention Epidemic

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Maybe it has something to do with the fact that my mother had three natural, unmedicated births but I have always known that natural birth was something I wanted to do.  Fast forward to Graduate school, where I learnt all the startling statistics about the gross over use of birth interventions in this country, which factor into the alarmingly high cesarean section rate and I became an ardent natural birth advocate.

I can’t tell you how many times I’ve heard things like: “I will for sure be getting an epidural” or “I want a c-section because I don’t want to be all stretched out down there” or “I want to get induced so I can plan when the baby will arrive.”  And the list goes on and on.  The truth is, there is a lack of proper education about childbirth.  Many young women have no real idea about what to expect and most of their knowledge comes from the media, which portrays birth as a harrowing experience.  Couple this naivete with the current treatment of pregnancy and birth by much of the medical field as an illness or disability and we have ourselves an intervention epidemic.

I found it so aggravating when people would ask me if I was planning on having an epidural and they responded with shock when I told them that I was planning on a natural birth. I mean, really people?!  Childbirth is a totally natural process and the female body was designed to carry out this function perfectly.  Granted there are times when interventions are 100% necessary and life saving but for the vast majority of births this is simply not the case.  In fact for the majority of births added interventions can actually be a hindrance and can have a snow ball effect.

The World Health Organization recommended that the upper limit for the cesarean section rate was 15%, while the optimal rate should be 5%.  In the United States the most recent data show that the c-section rate is a staggering 32.8%, meaning that 1 in 3 women deliver by cesarean section.  The Healthy People 2020 goal is to reduce the number of cesareans among low risk women with no prior cesarean births by 10% and yet in some hospitals throughout the country the c-section rate is as high as 50%.  Furthermore there is no evidence to show that having a c-section rate that is higher than 15% does anything to reduce maternal and/or infant mortality or morbidity, in fact just the opposite may be true.  An increased rate of interventions often leads to highers levels of death and disease among mothers and babies.

So what’s going on here?  Well there isn’t a simple answer since there are a lot of factors at play.  Birth weight plays a large roll, the fact is that we are having bigger babies than ever and it’s becoming increasingly more difficult for our bodies to deliver them naturally.  This is why it’s so important to eat right and exercise during pregnancy.  In fact eating right and exercising are vitally important before and after pregnancy as well, but that’s a topic for another day.  Another large factor is the elective and rampant use of interventions during childbirth and I believe this stems in large part from a lack of adequate education about the topic.

The most common major interventions used other than a cesarean section itself are pitocin (used to induce or augment labor) and epidurals. The use of epidurals have become the norm and natural birth is something that is viewed as extreme.  When I told people I wanted to have a natural birth, I was told ‘you don’t have to be a hero’ and asked ‘why would you do that to yourself’.  Child birth is a natural process not an illness or disease and treating it as such can impair the body’s ability to do what it does best.

I said before that interventions can be a slippery slope and here is what I meant.  Epidurals can weaken the contractions that your body has naturally, which then requires you to go on pitocin to strengthen the contractions, but now your contractions are stronger and longer than they should be so you get a stronger epidural to manage the pain, which in turn requires more pitocin, which finally sends the baby into distress (due to the stronger and longer contractions) and you are wheeled off the the OR for a cesarean section.  The same cycle can also be true when labor is induced.  While all this is true it must still be noted that many women do receive epidurals and/or pitocin without needing further intervention.

You have to remember that pitocin and epidurals are serious drugs and whatever you’re receiving your baby is receiving.  Of course these interventions are wonderful and life saving when they’re necessary but they are performed far more than what is medically necessary.  Too many people opt to schedule a c-section or elect to have interventions without really educating themselves about the process.  A cesarean section is MAJOR abdominal surgery, which involves slicing through 6 layers of skin, tissue and muscle and then sewing the individual layers back up again.  Recovery is no picnic especially considering you can’t just relax but instead you have to care for a newborn and be up all hours of the night.  The International Cesarean Awareness Network is a great place to go to learn more.

The last contributing factor I’ll discuss here and perhaps the biggest are policy instruments acting at the health system level. OB-GYNs are faced with more lawsuits than nearly every other medical specialty.  This is because sadly and unfairly if something goes tragically wrong during labor blame is often placed on the medical staff present.  So in order to reduce liability systems are in place to push for more interventions because it is wrongly believed that more interventions means better care.  In order to change this we must change policy, which starts with education.

My intention here is not to demonize birth interventions and I don’t presume to tell women how they should have their babies or ostracize women who opt for birth interventions but I do think it is important to educate yourselves about child birth.  I highly recommend taking a birth class as well as watching The Business of Being Born.  You can also go to The Beauty of Being Born to read real women’s birth stories and share in their experiences.  Also you may want to consider opting to deliver with a midwife that practices out of a hospital or birth center.

If you read Asher’s birth story then you know that I did in fact require the use of interventions.  They were all medically necessary with the exception of one: breaking my water.  This was the first intervention that I  received and I believe that making this choice is what lead to the complications that required me to need further interventions, but that’s just a theory, since there is no way to know for sure.

At the end of the day when it comes to labor and delivery the most important thing is to have a healthy mother and baby, no matter how you get there, I just believe that in the vast majority of cases the best way to ensure that is to have a natural childbirth.

Asher and Raf, 2 hours old

Breastfeeding // Thrush

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When many people hear the word “thrush” they either think I’m referring to a bird or they have no idea what I’m talking about at all.  The term thrush is commonly used to refer to a yeast infection in the mouth.  It is fairly common in breastfed babies but it can also occur in the nipples and breasts of breastfeeding women and can be passed back and forth between the mother and child.  It is caused by an overgrowth of the candida fungus.  Candida is present in our bodies all the time, but it is normally kept in check by good bacteria that feed on it, however when this bacteria is compromised, say by taking antibiotics for example, it can lead to an overgrowth of yeast.  Yeast in the breast is much harder to get rid of than a vaginal yeast infections because the yeast thrive in sugar rich, dark, moist environments. Which brings me to my story.

Remember when I tore while pushing Asher out?  Well, as luck would have it, I developed a lovely infection.  At my two week postpartum checkup I was told that I had an infection, which meant two things.  First, some of my stitches didn’t take and second that I would need to go on antibiotics for 2 weeks.  Honestly, I was relieved because it meant that the excruciating pain I had been experiencing was in fact NOT par for the course and that with the use of the antibiotics relief was at last in sight.

HA!

I started to notice that breastfeeding was becoming INCREDIBLY painful and that Asher had developed a fuzzy white patch on his tongue.  So, I took him to the pediatrician and I went and saw a lactation consultant and we were told in both cases that we had thrush.  This seriously bummed me out, because I knew that thrush could be really difficult to get rid of.

I was put on a two week course of fluconazole and Asher was put on a nystatin rinse.  Well, after the two weeks were up, we still had thrush and our treatments had done little to improve the symptoms.  So, we were put on a second round of our respective treatments, along with strict instructions to sterilize everything that touched my breasts or his mouth. In addition, I was told that I should stop using a breast pump until the thrush was cleared up.  Luckily at this point my milk supply was established and stable so I was able to take a break from pumping.  I also rinsed my nipples with a solution of vinegar and water, cut out all sweets, exposed my bare breasts to sunlight (in doors) every day I could and we both went on probiotics all in an attempt to get rid of the nasty thrush.

Well, after all that and completing round two of our treatments, we still had thrush!  Luckily, Asher didn’t seem to mind at all, in fact I don’t think he even noticed.  I on the other hand was not a happy camper, seeing as that I was saddled with stinging nipples and shooting pains in my breasts.  Finally, our lactation consultant recommended that we try gentian violet.

Gentian violet

After going on a wild goose chase searching for the stuff, I was finally able to find some at a small independent pharmacy.  I applied it once a day to my nipples before nursing and that way we both got treated where we needed it most.  We used it for one week and once the purple wore off I noticed that Asher’s white patch was gone and my pain had subsided. Success!

Except within two weeks both symptoms had returned.  So, we did another week of gentian violet.  This time I applied it to my nipples before and after every feeding as well as directly to Asher’s tongue.  This no nonsense approach paid off.  After a long fought battle we had conquered our thrush, albeit, after staining many articles of clothing with bright purple splotches.

This and this are is a great resources for anyone considering using gentian violet to treat thrush.  I’ll warn you, it is incredibly messy, but it is well worth the relief.  I put olive oil around Asher’s mouth to try and cut down on the mess and this helped a lot.

*UPDATE* You can find gentian violet here but I was also told that you can find it at some Targets, although I didn’t see it on their online store.  Just make sure you look for a 1% solution, if you can only find a 2% solution that’s fine too but you will need to dilute it yourself.

Pregnancy Weight Gain

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In general the amount of weight that a woman should gain during pregnancy varies significantly depending on her body type, lifestyle and health factors.  Women who are underweight before getting pregnant generally gain more weight than women who are overweight before getting pregnant.  Many women within a normal weight range for their height (Body Mass Index, BMI) are told that they should gain between 25-30 pounds by the end of their pregnancies, with the majority of the weight being gained in the second half of the pregnancy.

My Weight Gain Timeline:

March 13th:  I had a doctor’s appointment 2 days before I conceived and I weighed in at 130 pounds (I’m 5 feet 5.5 inches tall), this was a little heavier than my normal weight of 125 pounds but my body was still getting back to normal after my first pregnancy and subsequent miscarriage.

April 25th:  At my first prenatal appointment I was 8 weeks pregnant and I weighed 139 pounds, which meant I had already gained 9 pounds, which was slightly unusual.

So things get a little hazy from here, until my 25 week appointment, but in general I was gaining smaller amounts of weight each month, 4 pounds here, 2 pounds there.

August 24th: At my 25 week appointment I weighed 153 pounds!! Meaning a total of 23 pounds gained thus far.  At this point I totally freaked out, because I was only just over half way through my pregnancy and most women gain the most weight during the third trimester.

September 14th:  151 pounds…odd that I lost 2 pounds, but I had been making a conscious effort to eat better and exercise more. Total weight gain = 21 pounds.

September 25th: 153 pounds.  Total weight gain 23 pounds

Fast forward a bit, since my weight pretty much stayed between 153-155 pounds and would just fluctuate back and forth at each appointment I had.

November 14th: 37 weeks pregnant and I weigh 154 pounds…so still staying right around where things have been for the past 12 weeks .  Total weight gain = 24 pounds.

It’s pretty atypical for a woman to gain all her weight during pregnancy during the first half and hardly anything in the second half, but this just goes to show that pregnancy weight gain can look very different on different people.  Some women (like me) gain weight in clusters, while some gain weight gradually over time.

November 20th: 38 weeks pregnant and I weigh 155 pounds. Total weight gain = 25 pounds

November 26th: 39 weeks pregnant and I weigh 159 pounds.  Gained 4 pounds this week, which is not surprising after I gorged myself and was completely sedentary during Thanksgiving. Total weight gain = 29 pounds

December 6th: 40 weeks pregnant and I weigh 157 pounds.  Lost 2 pounds from last week, which is odd, since I haven’t been very active and I’ve had more junk food than normal, but my midwife says the baby is a good size. Total weight gain = 27 pounds

December 11th:  Asher Nathan Anvari is born at 11:36pm, weighing in at 7 pounds 11.5 ounces.

December 24th:  2 weeks postpartum, and weighing 139 pounds. I think the large quantities of water I have been drinking curbed my appetite and I haven’t been consuming as many calories as I need to.  Lost 18 pounds, still have 14 more to go.

January 8th: 4 weeks postpartum and weighing 139 pounds.  I have been making an active effort to eat more to help support my milk supply.

January 22nd: 6 weeks postpartum and weighing 137 pounds.  Lost 20 pounds, still have 12 more to go, but I’m in no rush, the most important thing is that I eat enough to maintain my milk supply and that I start to regain some muscle tone so I don’t feel so weak.

So there you have it.  I could fit into some of my pre-pregnancy pants by 9 days postpartum, even if I did need to squeeze into them, however my maternity pants are too loose, so I’m in an awkward in-between stage, luckily I spend 95% of my time in pajamas or sweatpants.

I’m Going Cloth

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Prefold on Teddy

Cloth diapers that is.  I don’t exactly remember when I first started thinking about using cloth diapers, but I think it was while I was living and working in Israel.  A good friend of mine was expecting her first child and I did a lot of research to help her navigate all the information out there.  While doing all that researching I came across cloth diapers and how they were better for your baby, the environment and your wallet.  I was sold.  Even though it would be close to 4 years later that I would be expecting my first child, I knew I wanted to use cloth diapers.

So why cloth?  Here are my reasons:

1.  They are better for your baby.  Babies who are kept in cloth diapers generally get changed more often because they can feel when they are wet sooner, which results in fewer diaper rashes.  *However it should be noted that if you don’t change your child’s diaper soon after they have wet or soiled it, the “ increased skin wetness, may lead to increased friction and increased abrasion damage, skin permeability, and microbial growth.”  This is a fairly old study, and there have been many advances in cloth diapers since then, such as the use of fabrics like micro-fleece that wick the moisture away from the skin, leaving your baby feeling dry. Personally, I would prefer to change my baby’s diaper promptly anyway, because who wants to hang out in their own waste? *

2.  Children who are cloth diapered generally potty train at a younger age because they learn what it feels like to be wet.

3.  It is better for the environment, although only slightly.  Disposable diapers are estimated to take 250-500 years to decompose and represent 4% of all solid waste.  In fact disposables are the third largest single consumer item in landfills.  Even though this is really gross, when you look at the issue from a Life Course Perspective, the cumulative water requirements, waste water particulates and environmental emissions associated with laundering cloth diapers at home outweighs those associated with using disposable diapers. While, the cumulative solid waste volume of disposables is far greater than that of cloth.  However when you factor in the energy value of converting raw cotton and trees into these products, disposables and cloth diapers (that are laundered at home) have about the same impact, while cloth diapers that are laundered using a diaper service come out a little bit ahead.   Check out THIS article for all the specifics, the cloth vs. disposables portion begins on page 11.  Now, many people argue that there are many ways to wash cloth diapers that don’t have such a negative environmental impact, this includes using energy-efficient machines, line drying and using the correct water temperature as opposed to very hot water.  So this point could be up for debate.  *I will say however, that whether you choose to use cloth or disposable diapers the only proper disposal of poop is in the toilet.  Most people who use disposable diapers don’t take the time to dump the poop in the toilet before throwing the diaper out and this has HUGELY negative public health consequences.  Human feces are about as foul and bacteria riddled as anything comes and when you throw it in the trash it can get into the soil and water and then you have e. coli contamination or cholera outbreaks.  Something to think about.  HERE’S a statement by the APHA on the topic.*

4.  It is easier on your wallet.  When using disposable diapers you will spend roughly $1500-$2500 from birth to potty training PER child.  With cloth there are so many options that you could spend anywhere from $200 for a basic stash to around $800 on a large and fancy stash and that stash will generally last you through multiple children AND you can even sell them and recoup some of the cost once you’re done using them.  That’s a HUGE savings for something that your child is just pooping and peeing in anyway.

So there you have my reasons for going cloth.  I know a lot of parents out there also site the cuteness factor as a reason that they love using cloth diapers, but I can’t really speak to that yet.  I’ll definitely let you know more once my child is actually born.

Stay tuned to learn all about my cloth diaper stash!

Did You Know? Pregnancy Weeks Vs. Months

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When you get pregnant your due date is calculated roughly 40 weeks from the first day of your last period.  40 weeks.  I once heard a guest lecturer in one of my graduate classes say that most people believed that pregnancy was 9 months long, when in fact it was 10 months long and she backed this up by saying that 40 weeks, with 4 weeks in each month added up to 10 months.  At the time my mind was totally blown, but then I started thinking about it and I realized something that should have been blatantly obvious all along:  Most months are longer than 4 weeks.  There are exactly 4 weeks in the month of February (when it isn’t a leap year) but that’s the only month where that rule applies, for the rest of the months, that leaves 2 or 3 days unaccounted for, which over the course of a pregnancy can really add up.

So what am I getting at?  Well, if you want to wait until you’re 3 months pregnant to announce your pregnancy and you announce it when you’re 12 weeks pregnant, then you are announcing just over a week early.  During my first pregnancy I was one of those people.  I announced I was pregnant at 12 weeks exactly only to find out at 13 weeks that I had miscarried.   Had I waiting until I was actually 3 months pregnant I would have known about the miscarriage before making the announcement and I would have been able to avoid a lot of questions and explanations that I didn’t want to deal with at the time.

I can’t tell you how many times I hear women say that they are 5 months pregnant when they go for their 20 week ultrasound, or 7 months pregnant when they are 28 weeks along.  This just is not correct.  It’s like when someone says: “for all intense and purposes” rather than “for all intents and purposes.” More than anything I just want to educate people about what’s accurate and correct.

My 40 week mark is December 5th.  I was exactly 9 months pregnant as of December 1st, which means that by my 40 week mark I will be 9 months and 4 days pregnant…nowhere NEAR 10 months.  Just saying.

*As a side note, I think it’s worth mentioning that the average pregnancy actually lasts 41 1/7 weeks, which is why even though my due date is December 5th, I tell everyone I have until December 19th in the hopes that this will help quell all the calls and messages I have been getting from people who are lovingly over eager for the baby to arrive.*

Guidelines for Nutrition in Pregnancy

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I decided to wait to post this until after Thanksgiving as to not make anyone feeling guilty for indulging in the holiday.  I am a patient of Wisdom Midwifery and I think they are absolutely great!  Here’s a link to their blog as well.  When it comes to normal, low risk pregnancies, birth outcomes are often better when they are attended by Midwives as opposed to Obs, but more on that later.

Right now I am here to talk about nutrition in pregnancy, which is something I get asked about quite often.  Since Wisdom Midwifery has complied a list that I think it pretty on the money, I have included their guidelines below.   I will add the caveat however that I believe it’s ok to stray from these guidelines in moderation from time to time.  Nine months is a LONG time to go without having ANY refined sugar, white food or junk food.  If you’re one of those people who are able to do it then more power to you, but I found that I just didn’t have the will power to follow the guidelines to the letter and in fact attempting to do so stressed me out and gave me a lot of anxiety because I was constantly worrying about what I was eating.  In any case, I digress.

The most important thing is that you are consuming the right amount of nutrients for you and your baby and the food listed bellow will definitely get you there.  For many women their appetites change during pregnancy and as the pregnancy progresses they aren’t able to eat as much in one sitting as they were before (due to their stomach being squished).   Due to this, it is important that the foods you choose to put in your stomach (for the most part) have as many good healthy nutrients as possible.

Wisdom Midwifery Nutritional Guidelines

Every day, consume the following:

10-12 glasses of fresh water
Fruits and veggies: 6-8 servings per day including two leafy greens, one yellow one and one orange one
Whole grains: 3-4 servings
Calcium rich foods – dairy or soy products : 2-4 servings per day
Protein foods: eggs, meat, fish, chicken, beans: 2-4 servings per day
Flax seeds 1-2 Tbs ground

Eliminate from your diet, to the best of your ability:

All refined sugar
All white foods: white bread, rice, flour, sugar, potatoes
No more than one glass of fruit juice, preferably orange, per day
Hydrogenated or partially hydrogenated vegetable oil
Alcohol
Caffeine: No more than 1 cup per day
Nicotine

These dietary guidelines are designed to do three very important things:

(1) Keep your blood sugar at an even level throughout the day.

(2) Expand your blood volume properly so that you can circulate for both yourself and the baby. Not accomplishing these things can make you feel poorly during pregnancy and can lead to serious complications.

(3) Grow a baby that is appropriately sized for your body and pelvis: consuming the processed and fast foods so readily available to us may promote the growth of a baby that is larger than your body can deliver.

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In addition to these guidelines, I also add that it’s a good idea to avoid: raw or under cooked meat, raw or under cooked eggs, unpasteurized cheeses or dairy, processed meat (unless they have been heated to steaming, these include: deli meat, bacon, etc.) and fish that is high in mercury.

As always you should talk to your care provider about what you should and shouldn’t be eating while pregnant.

Did You Know? Eating for Two

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Did you know that the whole “you’re eating for two and therefore you can eat twice as much” while you’re pregnant philosophy is a complete myth?  Well it is.  While it is true that you are technically providing sustenance for 2 people, yourself and your baby, it is not true that that means you can or should eat twice as much.  In fact during pregnancy you only need 300 extra calories a day (that’s like an apple and a yogurt cup).  So when people try to add food to your plate or tell you to eat more because you’re “eating for two”, just smile polity and go about your business OR you can give them a lesson on caloric intake during pregnancy, however I have found that this isn’t always received very warmly.  I generally recommend that pregnant women eat when they’re truly hungry.  I say ‘truly’ hungry because I find that a lot of women give themselves a free-pass to eat as much and as often as they want during pregnancy and that doesn’t always translate into eating because they’re hungry.  It could mean eating because they feel like indulging, or are bored and they justify it by telling themselves that they are eating for two.  Also what you eat matters, but I’ll be doing a separate post about nutrition in pregnancy so check back for that.

On Getting Pregnant

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In March 2011 Rafaan and I decided that we were ready to start a family and much to our surprise I got pregnant after only 1 month of trying.  Sadly that pregnancy ended in a miscarriage in June 2011 and after waiting the two months that were recommended by my care provider we decided to start trying again in August 2011.  Well things did not happen as quickly the second time around, it took us 7 months to get pregnant, which in the grand scheme of things isn’t very long, but after having a miscarriage it felt like an eternity and I began to worry that something was wrong.  So this is our journey with trying to conceive (TTC), what worked for us and some general preconception health information.

First off let me say that ANY and ALL women who are sexually active should be taking a daily prenatal vitamin, even if you are not intending to get pregnant and even if you are actively trying to prevent pregnancy.  The reason for this being that accidents happen.  In fact in the US nearly half of all pregnancies are unintended.  Prenatal vitamins specifically contain folic acid which helps prevent neural tube defects and in the 2 weeks between fertilization and a missed period those neural tubes have already begun to form, so it’s important that folic acid already be in the mother’s system.  Just take a prenatal vitamin in place of a daily women’s multi-vitamin and go about your merry way.

The first thing you should do when you begin thinking about having a baby is to go see your doctor for some pre-conception counseling.  You want to make sure you are in the best health possible when you get pregnant and going to pre-conception counseling can help get you there if you aren’t already.

Back to my story:  In August we started trying again and at first we decided that we wouldn’t actively try but that we would just stop using contraception and see what happens.  Well that plan went out the window really fast after I realized that I was still consciously trying to get pregnant regardless of us wanting to just “go with the flow.”  So that’s when I decided to buy a bunch of ovulation predictor kits (OPks) and started peeing on them every day, well despite getting positive reading from the OPKs and timing our baby making sessions around them, I still wasn’t getting pregnant and I started to feel like I didn’t have a clue about my body, and being that my chosen field was maternal and child health, this kind of made me feel a bit lost.  A friend of mine recommended the book Taking Charge of Your Fertility, which is an AMAZING resource. I seriously can’t say enough about how great this book is.  I believe all women should own a copy of this book because it’s about so much more than just pregnancy.  Seriously, take a look!  Through using this book I learnt how to chart my fertility cycles and to become in tuned with my body so that I could recognize when I was nearing ovulation. It only took 3 months of charting my cycles for me to get pregnant and during the process I felt really empowered and that I finally understood my body again.   For those of you who don’t know what charting your cycles entails, you basically take your waking temperature every morning using a basal body thermometer and you also keep track of your cervical mucus.  It sounds complicated, but it really is SUPER simple and easy.  If anyone wants more details about how exactly to do it or you have been charting and are confused by what you’re seeing please just leave a comment or send me an email and I’d be happy to help.

I also went to see a fertility acupuncturist, who again came highly recommended by a friend AND did fertility acupuncture work at Johns Hopkins.  She put me on 2 herbal supplements; Fertile Garden and Astra Essence  and told me that I needed to take 6 pills of each a day.  Now I can’t say whether or not these pills actually had an effect on me getting pregnant, but I can say that I got pregnant the first full month I was taking them.  The friend who recommended me also got pregnant using these pills not once but twice!  The first time it was after 10 months of TTC and she got pregnant the first month she was on the pills and then again the same thing happened with her third child.  I have since recommended these pills to a cousin of mine and she got pregnant the first month she used them too. Maybe this is all a coincidence, I can’t say for sure, but what I can say is that you should talk to a medical professional before taking any and all supplements.  Don’t self medicate!

Once I got a confirmed pregnancy test reading on April 1st, 2012, I stopped taking the herbal supplements and then tried to be as positive as possible, but actually being pregnant is a whole other story all together, so stay tuned.

Here are some articles for anyone interested in learning more about folic acid as prevention for neural tube defects:

Blencowe, H., Cousens, S., Modell, B., & Lawn, J. (2010). Folic acid to reduce neonatal mortality from neural tube disorders. International Journal of Epidemiology , 110-121.

Laurence, K. M., James, N., Miller, M. H., Tennant, G. B., & Campbell, H. (1981 ). Double-blind randomised controlled trial of folate treatment before conception to prevent recurrence of neural-tube defects. British Medical Journal , 1509-1511.

Werler, M. M., Shapiro, S., & Mitchell, A. A. (1993). Periconceptional Folic Acid Exposure and Risk of Occurrent Neural Tube Defects. JAMA , 1257-1261.  *Sorry I couldn’t find a free link to the full text of this one*