On June 30th, the CDC published a case report of a neonate who suffered a recurrent invasive infection involving group B Streptococcus, commonly known as GBS. Although recurrence is uncommon, occurring in about 1% of cases, that’s not what made this report newsworthy. Revealed in the CDC publication, and focused on in numerous, news, reports over the past several days, is the fact that the patient’s mother had been consuming her placenta, a practice known as placentophagy (which we have discussed here before).
The media didn’t do a bad job (this time) covering the issue. For the most part they simply repeated the facts of the case per the CDC discussion, and echoed their call for caution. Where many, if not most, failed was in leaving out the nuance of the CDC recommendation and assuming a causal relationship between placentophagy and the child’s illness. I’ll explain shortly.
Wait…what? She ate her placenta?
The mother of the ill newborn did consume some of her own placenta. If you have never heard of this practice before, take a minute to pick your jaw up off of the floor. Harriet Hall actually wrote about placentophagy back in 2011, and the supporting evidence of benefit in humans remains in the “we asked a bunch of women if they enjoyed it and would recommend it to a friend” stage.
Placentophagy is the norm in mammals, exceptions being marine mammals, camels, and humans. There was some use of the placenta in traditional Chinese medicine, although no known examples of a new mother consuming her own. And there have also been rare reports in the medical literature going back to early last century, again with none involving consumption by a mother soon after delivery.
The current trend of maternal placentophagy can be traced to proponents of “natural birth” in 1970s California. But it wasn’t until the past decade, as the practice was reported among celebrities such as Kim Kardashian and Alicia Silverstone, that it started to go a bit more mainstream. Another driving factor in its increased popularity is that, rather than eating the placenta raw, in smoothie form, or as part of one of many available recipes involving cooked afterbirth, people are increasingly having it dehydrated and encapsulated. Taking placenta via a pill is considerably more palatable than slapping it on the grill or making it into jerky.
Many reasons have been offered up by placentophagy proponents over the years to support the practice, none of which hold up to critical evaluation. And the evidence is virtually non-existent. I’ll quickly run through the most common proposed justifications.
- Animals do it. Nobody knows why, but it must be for a good reason that also applies to us.
- Hormones are good. Hormones in the placenta prevent postpartum depression and improve breastfeeding success.
- The placenta is full of great nutrition, particularly iron. And iron deficiency is common in pregnant women. Women who eat their placenta will have more energy.
Dr. Hall goes into more detail in her 2011 post, but none of the above reasons really makes any sense for humans. There are numerous behaviors seen in the animal kingdom that are not observed in humanity and would not be beneficial, such as the coprophagia that is common in dogs and rabbits. And again, not all mammals even eat their placenta. And honestly, dolphins are really smart and I would trust a camel over a weasel any day of the week.
It is a fallacy to assume that all widespread behaviors must have an evolutionary benefit. Animals may consume the placenta for nutrition or to reduce the risk of predation at a vulnerable time. Maybe they do eat their placenta to replace hormones, but ultimately claims made by proponents are arguments from ignorance. We just don’t know why they do it.
There is no evidence that the consumption of the placenta raises levels of beneficial hormones in any animal, including humans. There is no evidence that any hormones in the placenta are present in clinically meaningful amounts after cooking or encapsulating. There is no evidence of benefit regarding postpartum depression or breastfeeding other than testimonials and survey data, which are essentially just a collection of selected anecdotes.
I have little doubt that the placenta is nutritious, particularly when food is a scarce resource. And to be completely honest, I would eat any placenta that I could get my hands on before starving to death. If the argument is that Kim Kardashian and Alicia Silverstone were facing starvation, then I feel compelled to disagree.
Is placentophagy risky?
Eating your own placenta, especially if thoroughly cooked, is probably less risky than driving without a seat belt or bullfighting drunk, but it still isn’t a good idea considering the absence of any proven benefit. There has been chatter over the possibility of various heavy metals and other toxins being absorbed by placental tissue, but there is as much a lack of evidence regarding this risk as there is for any benefit.
The exception, however, is the potential risk of contamination with pathogenic viruses and bacteria either during pregnancy, such as with HIV infection, or during delivery when the placenta is exposed to vaginal and intestinal flora. We used to think that the placenta is typically sterile prenatally, but that is proving to be a myth as studies are now showing that oral bacteria are colonizing the placenta during pregnancy. The placenta may also be contaminated after delivery if not handled properly.
That being said, I’m much less worried about the risk to the mother than I am to the baby. Which is where the new CDC report comes into play. They are raising the concern that the infant’s recurrence of GBS disease was potentially a result of maternal placentophagy. This is extremely plausible, as I’ll explain shortly, but first a quick primer on GBS.
What is GBS and how does it hurt babies and make me very, very angry?
Though first isolated in the 1930s by Rebecca Lancefield, GBS wasn’t fully recognized as the etiologic agent in the majority of neonatal sepsis cases worldwide for another few decades. In many people, however, it asymptomatically colonizes the lower intestines and, in females, the vagina. And although it can cause disease in patients of all ages, particularly if immune compromised in some way, it truly does love babies.
There are many risk factors for invasive GBS disease in neonates, but the most important by far is maternal colonization of the lower GI tract and/or the vagina. This is why routine prenatal care since the mid-1990’s has involved some type of risk assessment. Since 2002, this risk assessment has universally involved culturing maternal rectovaginal swabs for GBS that are obtained at 35 to 37 weeks of gestation.
Mothers who are “GBS+”, or “GBS unknown” with certain other risk factors, will typically receive intrapartum antibiotic prophylaxis (IAP) ideally at least 4 hours prior to delivery. An exception is when a baby is being born via a scheduled C-section without labor or rupture of membranes prior to delivery. IAP has been shown to significantly reduce the likelihood that a newborn will be colonized and subsequently develop an invasive infection in the first week of life, so-called early-onset GBS disease, which had historically affected 1.5 out of every 1,000 babies born.
Unfortunately, IAP does not decrease the likelihood of late-onset GBS disease that occurs after the first week of life, likely because it doesn’t decolonize the mother and the baby may also be exposed to other colonized caregivers over time. The early-onset variety used to be much more common, but because of IAP recommendations it is now a smidge less likely to occur than the late-onset variety. The overall risk for either is now roughly 0.2-.3 per 1,000 births, but there are serious disparities in populations less likely to receive routine prenatal care.
It’s important to point out that our current approach to GBS screening and the use of IAP is not perfect. There are false negative culture results and women can become colonized during the time between screening and delivery. In fact, currently most cases of invasive early-onset GBS disease now occur in babies born to “GBS-” mothers.
GBS disease tends to involve sepsis, and death occurs in around 5% of early-onset cases and as many as 7% of late-onset overall. But when looking specifically at certain populations, mortality is much higher in premature infants and when the central nervous system is involved. With meningitis, which occurs in 7% of the early-onset cases and 27% of late-onset, there is an increased risk of death and almost half of these babies will have long term neurologic impairment of some kind.
Just the CDC facts
The case presented by the CDC involved a term newborn born to a mother without pregnancy or delivery complications. Her prenatal screening for GBS was even negative, although as I explained earlier this doesn’t count as a protective factor. We still pay close attention to early signs and symptoms of disease in all newborns, even if low risk. As with this baby, early-onset GBS disease almost always presents in the first 12, if not 24 hours, just one of many reasons why I’m not a fan of home deliveries.
The infant was transferred to the NICU and found to have GBS growing in his blood, but thankfully not his spinal fluid, and he was discharged home after eleven days of IV antibiotics. Five days after discharge he was again admitted to the hospital for treatment of GBS infection involving only the bloodstream. It was during this hospitalization that the treating team discovered that the mother had been ingesting her encapsulated placenta beginning three days after delivery.
Testing of the mother’s breast milk, a known potential source of GBS recurrence, was negative. However, culture of a sample taken from the encapsulated placenta revealed a GBS isolate genetically identical to the GBS found in both blood cultures. A rectovaginal culture was not obtained on the patient’s mother, but the very plausible assumption was made that she was colonized and that the ingested placenta increased the burden of her colonization, thus likely increasing the risk of recurrence.
The company that encapsulated the mother’s placenta was not identified, however it was revealed that they could not guarantee that the dehydration process would reach a temperature sufficient for sterilization. The authors were clear that they could not rule out another caregiver as the potential source of GBS with any certainty. They then specifically warned against the ingestion of encapsulated placenta without commenting on raw or cooked consumption, although one could perhaps argue that it is implied.
What does it all mean?
I don’t know if the mother’s ingestion of placenta resulted in her child developing a recurrence of invasive GBS disease. I can confidently say that it had nothing to do with the initial infection, however. The mother clearly had a false negative GBS screen or became colonized in the interim between screening and delivery.
We know that recurrence happens in a small percentage of patients without maternal placentophagy, somewhere around 1 out of every 100 cases. It is very possible that another family member with close contact to the mother and the baby was also colonized with the same strain of GBS. We know that family members can spread GBS around either during intimate sexual contact or through the fecal-oral route.
But the claim that placentophagy increased the burden of GBS in the mother’s GI tract is extremely plausible. And taking into account the utter lack of proven benefit from the practice, I think it is reasonable to recommend that new mothers not eat their placenta. But we didn’t really need this new report to say that now did we?
A response from the Association of Placenta Preparation Arts
Soon after publication, proponents of placentophagy responded. The APPA response is interesting and I’ll focus on it in this post, but there are plenty of additional examples if any readers feel the desire to ride that snake. The APPA tells parents that encapsulated placenta is probably safe, which doesn’t seem all that reassuring, and they throw the encapsulation company under the bus:
A well-trained placenta arts specialist will make sure that your placenta is prepared safely for consumption, unfortunately, it seems that this specialist may not have done so.
They claim that dehydration alone is not sufficient to kill pathogenic bacteria such as GBS, and that their method, which incorporates steam heat followed by dehydration, is effective. Also, according to the APPA guidelines, one of their certified practitioners would have rejected the placenta because of the initial case of GBS disease. But considering that plans for encapsulation are typically made prior to delivery, the person picking up the placenta would have to ask about the development of maternal infection at the time of delivery or early-onset infection in the baby. The family may be a bit too distracted to think about notifying them on their own, and the company would not have access to medical records, so having this contraindication is likely not a foolproof measure of protection.
As a rebuttal to the CDC concerns regarding the safety of the placenta encapsulation process, the APPA twice cites research out of Jena University in Germany performed by Dr. Sophia Johnson. They claim that this research demonstrated “that in properly prepared placenta capsules, there were no unsafe organisms found.” They add that the study also found levels of potential toxins such as heavy metals to be safe.
I looked into this research and found it to be extremely unimpressive. The experiment, was funded through public donations in a manner similar to GoFundMe. This doesn’t invalidate it, I merely point this out because I wasn’t aware of this concept.
The research, which hasn’t been published or even presented anywhere, is very preliminary. Furthermore, it only involved collection of 6 placentas, each of which was divided into half, with one half being frozen and the other dehydrated. But their preliminary report mentioned comparing raw placenta to placenta that was dehydrated alone or exposed to steam followed by dehydration. So I’m not sure exactly how they divided up the samples, and ultimately they still only had 6.
According to the preliminary results, dehydration reduced bacteria counts but not as effectively as steam followed by dehydration. This makes sense, but still it’s only 6 samples and this can’t necessarily be generalized to all placenta encapsulation facilities. Of note, they found that there were significant reductions in all hormones in the steamed samples, a little nugget conveniently not included in the APPA response.
Don’t eat your placenta. It’s ridiculous. There is absolutely no proven benefit, and very little plausibility to any of the theoretical benefits. And it may increase your child’s risk of developing a serious bacterial infection. But if you insist on practicing placentophagy, at least make sure it’s well done.