Introduction
The number of C Section births has increased dramatically from 15% in the 1990s to 27% in 2011, of all the births in the developed countries. This worrisome delivery by Caesarian section has been associated with morbidity in the early stages of life (Bosch et al., 2016). Whether a child is exposed to the maternal vaginal microbiota or skin microbiota, is dependent on the mode of delivery; vaginal or C section. This is the major cause of the distinction between the acquisitions of microbiota immediately after birth (Dominguez-Bello et al., 2016). There is evidence that vaginally delivered newborns have gut microbiota resembling the mothers vaginal microbiota whereas if the newborn is born by C section it has a microbiota similar to that of the skin which were dominated by Corynebacterium , Staphylococcus , and Propionibacterium (Dominguez-Bello et al., 2010). There are several known associations between health risks and the mode of delivery. Mueller et al., in their article examine the relationship between the mode of delivery and the development of the upper respiratory tract microbiota (2016). The results of this study showed that the mode of delivery significantly affected the early development of respiratory tract microbiota. Infants who were born vaginally were less susceptible to respiratory diseases such as asthma compared to infants delivered through c section. The primary article in this study deals on the partial restoration of infant microbiota. The result showed that swabbing can partially restore infant microbiota and hence reduce the health risks associated with the C section births. We can therefore confidently say that although it is undeniable that C section births are associated with poor development of intestinal, skin and even upper respiratory tract microbiota development, partial restoration is possible hence minimizing such risks.
The literature on the association between URT and microbiota development
To investigate the effect of delivery mode on the microbiota development of the upper respiratory tract, a sample of 102 children were collected. Of the total healthy children who participated, 62 were children born vaginally and 40 were delivered through C section. All the children involved in this study were born between December 2012 and June 2014 (Bosch et al., 2016). Data was collected on perinatal and prenatal characteristics. Participants’ follow-up was done 24-36 hours after delivery, at seven days, 14 days, and at two, three, four and six months after birth. Questionnaires and deep nasopharyngeal swabs were used to collect information on the child’s health status which included the respiratory system during each visit. A special clustering algorithm was used to all the 102 participants in order to analyze the microbiota composition trajectory (Bosch et al., 2016). SPSS 21 was used to perform the two-sided chi-square tests and the paired t-test in order to identify the differences in the baseline characteristics at a 0.05 level of significance.
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The results of this study showed that there was a significant difference between the upper respiratory tract microbiota developments. At 95% confidence level, the microbiota development was greater in children delivered vaginally as compared to children delivered through Caesarian section (Bosch et al., 2016). The delivery mode seems to be a critical factor for respiratory health. C section births have been associated with adaptive immunity and innate differences such as low levels of Thi-related cytokines or the chum oral mucosa responsiveness. The results in this study suggest the limited impact of the delivery mode on nasopharyngeal microbiota immediately after delivery, but over time, a significant difference in the development of respiratory microbiota between vaginally delivered children and those born through C section. This is a clear indication that differences in the microbiota development are not directly linked to the maternal characteristic, rather they are affected by other niches such as low intestinal microbiota; a characteristic that is also associated with C section (Bosch et al.,2016). With this background information, then any method that would ensure partial or even complete restoration of microbiota in infants delivered through C section would be of great impact to the health centers and the society at large.
The actual study on the partial restoration of infant microbiota
In this study, C-section-delivered infants were exposed to their respective maternal fluids immediately after birth and their microbiota composition determined longitudinally in order the assess whether its development was more similar to that of the babies born vaginally as compared to the unexposed infants. A sample of 18 infants and their mothers was collected; seven vaginally born and 11 delivered through Caesarian section. Four of the 11 infants were exposed to their maternal fluids immediately after birth. The partial microbiota restoration process involves inserting sterilized gauze in the mother’s vagina one hour before the C section is performed (Dominguez-Bello et al., 2016). The mother should not show any Vaginosis signs and should be negative for Streptococcus, group B and a vaginal pH less than 4.5. Within the first two minutes after birth, the babies were then swabbed with the gauze, starting with the mouth, face and then to the rest of the body in order to expose them to their maternal vaginal fluids.
Bacterial source-tracking of the composition of infant microbiome showed that there was a resemblance between the microbiome of the four exposed C section delivered babies and vaginally delivered infants during the first week after delivery. The bacterial composition between the microbiome infants who were exposed to their maternal fluids was, however, lower in skin and anal samples (Dominguez-Bello et al., 2016). During the first day of life, the microbiome composition of vaginally delivered babies and the exposed C section delivered babies were more comparable to the maternal microbiome composition as compared to the C section delivered but unexposed to the vaginal fluids. When a further body- site-specific configuration was performed, either quickly (skin or oral) or gradually (through the anus), it was evident that the four exposed C section delivered infants and the vaginally delivered infants had a vaginal microbiome that was absent in the unexposed infants delivered through C section. The differences in microbiome composition within the groups were reduced by building a random classifier for everybody site (blocking). The results confirmed that the microbiome composition of the infants was highly influenced by the mode of delivery.
Neonatal bacterial differences were highest during birth in the oral and anal sites but this slowly declined by day three of life. This phenomenon is yet to be understood and was also observed in a study involving mice. The postnatal increase in an oral decrease in the microbiome composition could be associated with the milk effect due to breastfeeding. In contrast, the skin microbiome composition was lowest during birth but gradually increased within the first month. Because the infants delivered by Caesarian section were exposed to their maternal vaginal fluids by the use of sterile gauze, a test to determine the similarity of the gauze microbiome and the microbiome composition obtained from the mothers’ body was conducted (Dominguez-Bello et al., 2016). It was confirmed that the sterile gauze incubated in the vagina of the mother was most similar to the samples obtained in the mothers’ vagina. The bacterial composition differences of each gauze compared to the vaginal samples was smaller than that of the mothers although the differences were insignificant.
Although the sample size used in this study was limited and follow-up was only done during the first month of life, the results obtained suggested that infant microbial composition can be restored partially by exposing the infants to the vaginal fluids immediately after C section in order to resemble that of vaginally delivered infants. The partial restoration of infant microbiota is associated with the compounded impacts of antibiotic medication accompanying C section procedures and the bacterial transfer the vagina to the gauze and then to the infant (such transfer is not completely optimal). However, there was no association between vaginal microbiota and the administration of the antibiotics (Dominguez-Bello et al., 2016). Lactobacillus was possibly not depleted I the mother’s vagina by intake of antibiotics; o clear differences were observed. The p-value obtained from the paired t-test was 0.618, which was not significant, indicating that there was sufficient no sufficient evidence to support the claim that antibiotics deplete the lactobacillus in the vagina.
Antibiotic exposure and feeding habits of both the unexposed and the exposed C section delivered babies were comparable and therefore the only differences in the microbiome composition can only be explained by the swabbing of the vaginal fluid immediately after the birth of the infant. To identify the actual influence of antibiotics, a larger sample size should be used. In order to replicate the benefits of partial restoration of infant microbiota, effective methods of transferring the maternal vaginal microbiota to the infants should be suggested. Additionally, key bacteria species to be transferred to the baby should be identified in order to enhance accuracy (Dominguez-Bello et al., 2016). The observed partial restoration of the vaginal microbiota in this study might be as a result of the one-time topical application of the maternal vaginal fluids to the infants. Additionally, specific body sites like the skin and mouth were more pliable to the application compared to the other body parts. A more improved protocol that repeatedly exposes the infants to the sterile gauze would yield better results of the effects of topical application of the vaginal fluids immediately after a successful C section. Proper screening for other Urinary tract infection should be done prior to swabbing the infant with the vaginal fluids.
The results of this study might give confidence to health practitioners and mothers from the fact that infant microbiota of C section delivered babies can be restored to resemble that of vaginally delivered infants. Several studies including a study by Stinson, Payne, & Keelan, suggest that swabbing should be halted until accurate reliable information about the benefits of partial restoration can be established (2018) especially due to the increased rate of elective C section. The authors suggest that the differences in the infant microbiota could be as a result of other factors such as antibiotics, labor, breastfeeding and maternal obesity (Stinson et al., 2018). Breast milk has several bacteria and other nutritional components which influence the gut microbiota of infants. Babies delivered through c section are subject to sub-optimal breastfeeding restrictions such as delayed breastfeeding and low volume of breast milk in the first five days of life. Considering the benefits associated with breast milk, it could be possible that this factor contributes to some of the observed differences between vaginally delivered and the C section infants. Secondly, Before C section, mothers are often administered with intrapartum antibiotics prophylaxis (IAP) which is known to have effects on the infant microbiome (Stinson et al., 2018). Particularly, IAP reduces the diversity of bacterial in the neonatal gut and increased morbidity. It would be important to consider the type of antibiotic used during c section if comparison between c section and vaginally born infants is to be done. Perhaps the insignificant differences observed in Dominguez et al. study are due to the small sample of only four infants. Labor causes several changes in the endocrine system which might have an influence in the microbiome development of the infant or even the maternal microbiome (Stinson et al., 2018). Moreover, the rupturing of walls during labor exposes the fetus to the maternal microbiome. The observed differences could be due to the labor period prior to delivery. Maternal obesity has been associated with delayed labor and consequently delivery is done through c section (Stinson et al., 2018). The microbial difference observed between vaginally delivered infants and those born through c section could be due to obesogenic or aberrant microbiota transmission from their obese mothers (Stinson et al., 2018). If researches take into consideration these four factors, they might be able to conduct more accurate research and provide more valid conclusions.
The study in by Dominguez et al., provides the readers with great, useful information (2016). However, the study cannot be used as a generalization of the study topic due to some critiques. The sample size used in this study is small and does not accurately represent the population. Only four infants were exposed to maternal vaginal fluids and used as a basis to make the conclusions. Considering the fact that this study impacts the health of infants in the future, careful selection of the samples should be used. On average a sample greater than 30 should be used for the C section delivered babies (exposed and unexposed) and also for the vaginally delivered babies. The method of sample selection also plays a great role in ensuring accuracy and unbiased results. The researchers would have considered using simple random sampling in more than five hospitals in order to come up with a sample that represents the population. If these two factors were carefully analyzed and rectified in the future, such a study would greatly impact the health centers.
It is evident that the Caesarian section is associated with health risks in the child’s future due to poor development of gut, oral and skin microbiota. There is a relationship between upper tract microbiota development and the mode of delivery; children who are vaginally delivered are not likely to experience health risks such as poor development of respiratory microbiota. Partial restoration of vaginal microbiomes to infants delivered through C section is possible through swabbing with a sterile gauge incubated in the mother’s vagina before C section. Careful protocols of transfer should be adopted to ensure the accuracy of the outcomes obtained. There are however several controversies that tend to explain the differences between infant microbiota of c section and vaginally delivered neonates. These factors include breastfeeding habits, labor, maternal obesity and use of antibiotics. This research cannot be used as a generalization but can rather be used to replicate another study or providing a hypothesis. Prior to making a decision on restoring infant microbiota through swabbing, these factors should be considered and if possible addressed.
References
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Dominguez-Bello, M. G., Costello, E. K., Contreras, M., Magris, M., Hidalgo, G., Fierer, N., & Knight, R. (2010). Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proceedings of the National Academy of Sciences , 107 (26), 11971-11975.
Dominguez-Bello, M. G., De Jesus-Laboy, K. M., Shen, N., Cox, L. M., Amir, A., Gonzalez, A., ... & Mendez, K. (2016). Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer. Nature medicine , 22 (3), 250.
Heijtz, R. D. (2016, December). Fetal, neonatal, and infant microbiome: perturbations and subsequent effects on brain development and behavior. In Seminars in Fetal and Neonatal Medicine (Vol. 21, No. 6, pp. 410-417). WB Saunders.
Mueller, N. T., Bakacs, E., Combellick, J., Grigoryan, Z., & Dominguez-Bello, M. G. (2015). The infant microbiome development: mom matters. Trends in molecular medicine , 21 (2), 109-117.
Stinson, L. F., Payne, M. S., & Keelan, J. A. (2018). A critical review of the bacterial baptism hypothesis and the impact of Caesarean delivery on the infant microbiome. Frontiers in Medicine , 5 , 135.
