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You Are Invited to Participate in an Online Learning Opportunity: Patient, Staff, and Family Support Following a Severe Maternal Event

October 10th, 2014 by avatar

council women safety

Past posts on Science & Sensibility – CDC & ACOG Convene Meeting on Maternal Mortality & Maternal Safety in Chicago and U.S. Maternal Mortality Ratio is Dismal, But Changes Underway, and You are Invited to Participate have shared information on the National Partnership for Maternal Safety, a multidisciplinary initiative focused on reducing the rates of maternal morbidity and mortality in the United States.  This partnership falls under the umbrella of The Council on Patient Safety in Women’s Health Care. This unique consortium of organizations across the spectrum of women’s health has come together to promote safe health care for every woman, at every birthing facility in the U.S. through implementation of safety bundles for common obstetric emergencies (hemorrhage, preeclampsia/hypertension and venous thromboembolism) as well as supplemental bundles on Maternal Early Warning Criteria, Facility Review after a Severe Maternal Event, and Patient/Family and Staff Support after a Severe Maternal Event.

The public Safety Action Series has introduced topics including an overview of the Partnership, efforts underway to define and measure Severe Maternal Morbidity, identify and implement Maternal Early Warning Criteria, Quantification of Blood Loss, and the outlines of the OB Hemorrhage Patient Safety Bundle. These slide sets and audio recordings have been archived and are available to the public.

christine morton headshotThe next event will be Tuesday, October 14 at 12:30 pm EST, with presenters Cynthia Chazotte, MD, FACOG, and Christine Morton, PhD, on Patient, Staff, and Family Support Following a Severe Maternal Event, and you can register for the event here. Registering for any event puts you on a list to be informed of upcoming events and future activities of the Partnership. Childbirth educators and other birth professionals may have students and clients who experience a serious medical event during labor and birth.  Having resources for families and for yourself is absolutely critical.  This information will be covered during the online event.

Christine Morton is a board member on the Lamaze international Board of Directors.   We are lucky to have such an active and knowledgeable professional to serve and support the Lamaze mission and values. Please share this information and get involved.

Childbirth Education, Lamaze International, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Pregnancy Complications , , , ,

Lamaze Releases Useful New Infographic: “No Food, No Drink During Labor? NO WAY!”

July 22nd, 2014 by avatar

piece Lamaze_RestrictedFoodDrinkInfographic_FINALToday, Lamaze International releases their newest infographic “No Food, No Drink During Labor? NO WAY!” This useful infographic is available on both the Lamaze International for Professionals website and the Lamaze Parents website. The most recent Listening to Mothers III survey indicated that 60% of women did not drink and 80% did not eat during labor! (DeClercq, 2013) The common practice of restricting food and drink for laboring women is outdated and not supported by evidence.  Unfortunately, most laboring women still face resistance from health care providers and facilities when they desire to eat or drink during their labor.

Lamaze International is hosting a Twitter Chat today, July 22nd, 2014 at 9 PM EST.  Professionals and parents are invited to participate in this live Twitter discussion moderated by Kathryn Konrad, MS, RNC-OB, LCCE, FACCE (@KkonradLCCE) and Robin Weiss, PhDc, MPH, CPH, CD(DONA), CLC, LCCE, Lamaze International’s President Elect. Tonight’s topic is “Restrictions in Labor” including this infographic on eating and drinking along with last month’s infographic on moving in labor (“We Like To Move It, Move It!”) Follow the hashtag #LamazeChat.  New to participating in a Twitter chat?  Check out this article for information on how to participate and get the most out of your experience.

Lamaze International’s Healthy Birth Practices, first released in 2009, discussed in great length the benefits to moving and changing position in labor in the 2nd Healthy Birth Practice: “Walk, Move Around and Change Positions Throughout Labor“ as well as the risks to restricting food and drink in the 4th Healthy Birth Practice: “Avoid Interventions That Are Not Medically Necessary.”

These useful infographics complement the Healthy Birth Practices, are easy to share on social media and can be used in the classroom as a poster to help parents to understand how to have the safest and healthiest birth possible.

Won’t you take a moment to check out this newest infographic and share with the expectant families that you work with!  Consider sharing it on your favorite social media outlet (Facebook, Twitter, Pinterest, Instagram) and making it available in your classrooms!

If you have an interesting way you are using these infographics, or would like to just share your thoughts on the infographic topics, please let us know in the comments section. I would love to hear how you use this info in your practice.

Click here to download the newest infographic “No Food, No Drink During Labor? NO WAY!”

You may access all the infographics available here!

References

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to mothers III: Pregnancy and birth. New York, NY: Childbirth Connection.

Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Lamaze International, Maternity Care, Medical Interventions, Push for Your Baby , , , , ,

Non-Drug Pain Coping Strategies Improve Outcomes

July 17th, 2014 by avatar

 Today, contributor Henci Goer reviews a recently published study in the journal Birth, that compared the outcomes of births in women who received non pharmacological pain management techniques with women who received the “usual care” treatment.  The researchers found that maternal and infant outcomes were improved.  Take a moment to read Henci’s review to get a glimpse at the results and her analysis.- Sharon Muza, Science & Sensibility Community Manager

© Patti Ramos Photography

© Patti Ramos Photography

In 2012,  the Cochrane Database published an overview of systematic reviews of forms of pain management that summarized the results of the Cochrane database’s suite of systematic reviews of randomized controlled trials (RCTs) of various pain management techniques. Reviewers reached the rather anemic conclusion that epidurals did best at relieving pain—no surprise there—but increased need for medical intervention—no surprise there either—while non-drug modalities (hypnosis, immersion in warm water, relaxation techniques, acupressure/acupuncture, hands on techniques such as massage or reflexology, and TENS) did equally well or better than their comparison groups (“standard care,” a placebo, or a different specific treatment) at relieving pain, at satisfaction with pain relief, or both, and they had no adverse effects (Jones 2012). Insofar as it went, this finding was helpful for advocating for use of non-drug strategies, but it didn’t go very far.

Fast forward two years, and we have a new, much more robust review: Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Its ingenious authors grouped trials of non-drug pain relief modalities according to mechanism of action, which increased the statistical power to determine their effects and avoided inappropriately pooling data from dissimilar studies in meta-analyses (Chaillet 2014). The three mechanisms were Gate Control Theory, which applies nonpainful stimuli to partially block pain transmission; Diffuse Noxious Inhibitory Control, which administers a painful stimulus elsewhere on the body, thereby blocking pain transmission from the uterine contraction and promoting endorphin release in the spinal cord and brain; and Central Nervous System Control, which affects perception and emotions and also releases endorphins within the brain.

Overall, 57 RCTs comparing non-drug strategies with usual care met eligibility criteria: 21 Gate Control (light massage, warm water immersion, positions/ambulation, birth ball, warm packs), 10 Diffuse Noxious Inhibitory Control (sterile water injections, acupressure, acupuncture, high intensity TENS), and 26 Central Nervous System Control (antenatal education, continuous support, attention deviation techniques, aromatherapy). Eleven of the Central Nervous System Control trials specifically added at least one other strategy to continuous support. More about the effect of that in a moment.

Now for the results…

Compared with Gate Control-based strategies, usual care was associated with increased use of epidurals (6 trials, 3369 women, odds ratio: 1.22), higher labor pain scores (3 trials, 278 women, mean difference 1 on a scoring range of 0-10), and more use of oxytocin (10 trials, 2672 women, odds ratio: 1.25). Usual care also increased likelihood of cesarean in studies of walking (3 trials, 1463 women, odds ratio: 1.64).

Compared with Diffuse Noxious Inhibitory Control strategies, usual care was associated with increased use of epidurals (6 trials, 920 women, odds ratio: 1.62), higher labor pain scores (1 trial, 142 women, mean difference 10 on a scoring range of 0-100), and decreased maternal satisfaction as measured in individual trials by feeling safe, relaxed, in control, and perception of experience.

We hit the jackpot with Central Nervous System Control strategies (probably because female labor support, which has numerous studies and strong evidence supporting it, dominate this category [19 labor support, 6 antenatal education, 1 aromatherapy]). As before, usual care is associated with more epidurals (11 trials, 11,957 women, odds ratio: 1.13), more use of oxytocin (19 trials, 14,293 women, odds ratio: 1.20), and decreased maternal satisfaction as measured in individual trials by perception of experience and anxiety. In addition, however, usual care is associated with increased likelihood of cesarean delivery (27 trials, 23,860 women, odds ratio: 1.60), instrumental delivery (21 trials, 15,591 women, odds ratio: 1.21), longer labor duration (13 trials, 4276 women, 30 min), and neonatal resuscitation (3 trials, 7069 women, odds ratio: 1.11).

© Breathtaking Photography http://flic.kr/p/3255VD

© Breathtaking Photography http://flic.kr/p/3255VD

The big winner, though, was continuous support combined with at least one other strategy. Usual care in these 11 trials was even more disadvantageous than in central nervous system trials overall with respect to cesareans (11 trials, 10,338 women): odds ratio 2.17 versus 1.6 for all central nervous system trials, and instrumental delivery (6 trials, 2281 women): odds ratio 1.78 versus 1.21 for all central nervous system trials.

The strength of the data is impressive. Altogether, Chaillet et al. report on 97 outcomes, of which 44 differences favoring non-drug strategies achieve statistical significance, meaning the difference is unlikely to be due to chance, while not one statistically significant difference favors usual care. And there’s still more: benefits of non-drug strategies are probably greater than they appear because on the one hand, “usual care” could include non-drug strategies for coping with labor pain and on the other, many institutions have policies and practices that make it difficult to cope using non-drug strategies alone, strongly encourage epidural use, or both.

The reviewers conclude that their findings showed that:

Nonpharmacologic approaches can contribute to reducing medical interventions, and thus represent an important part of intrapartum care, if not used routinely as the first method for pain relief…however, in some situations, nonpharmacologic approaches may become insufficient…the use of pharmacologic approaches could then be beneficial to reduce pain intensity to prevent suffering and help women cope with labor pain…birth settings and hospital policies . . . should facilitate a supportive birthing environment and should make readily available a broad spectrum of nonpharmacologic and pharmacologic pain relief approaches. (p. 133)

No one could argue with that, but a persuasive argument alone is unlikely to carry the day given the entrenched systemic barriers in many hospitals. States an anesthesiologist: “While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go” (quoted in Leeman 2003). The Cochrane reviewers concur, writing that using non-drug strategies is “more realistic” (p. 4) outside of the typical hospital environs.

So long as this remains the case, attempts to introduce non-drug options are likely to make little headway. As Lamaze International’s own Judith Lothian trenchantly observes:

If we put women in hospitals with restrictive policies—they’re hooked up to everything, they’re expected to be in bed—of course they’re going to go for the epidural because they’re unable to work through their pain. . . . I go wild with nurses and childbirth educators who say, . . . “[Women] just want to come in and have their epidural.” I say, “And even if they don’t . . ., they come to your hospital, and they have no choice. . . . They can’t manage their pain because you won’t let them.” (quoted in Block 2007, p. 175)

Success at integrating non-drug strategies will almost certainly depend on addressing underlying factors that maintain the status quo. Can it be done? You tell us. Does your hospital take a multifaceted approach to coping with labor pain? If so, how was it implemented and how is it sustained?

Resources

Block, Jennifer. (2007). Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press.

Chaillet, N., Belaid, L., Crochetiere, C., Roy, L., Gagne, G. P., Moutquin, J. M., . . . Bonapace, J. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137. doi: 10.1111/birt.12103 http://www.ncbi.nlm.nih.gov/pubmed/24761801

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. doi: 10.1002/14651858.CD009234.pub2 http://www.ncbi.nlm.nih.gov/pubmed/2241934

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). Management of labor pain: promoting patient choice. Am Fam Physician, 68(6), 1023, 1026, 1033 passim. http://www.ncbi.nlm.nih.gov/pubmed/14524393?dopt=Citation

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach winner of the American College of Nurse-Midwives “Best Book of the Year” award.An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

Childbirth Education, Doula Care, Epidural Analgesia, Guest Posts, Maternity Care, Medical Interventions, Newborns, Research , , , , ,

Evidence on Water Birth Safety – Exclusive Q&A with Rebecca Dekker on her New Research

July 10th, 2014 by avatar

 

Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just today published a new article, “Evidence on Water Birth Safety“ that looks at the current research on the safety of water birth for mothers and newborns.  Rebecca researched and wrote that article in response to the joint Opinion Statement “Immersion in Water During Labor and Delivery” released in March, 2014 by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.  I had the opportunity to ask Rebecca some questions about her research into the evidence available on water birth, her thoughts on the Opinion Statement and her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: First off, is it waterbirth or water birth?

Rebecca Dekker: That’s actually good question! Research experts tend to use the term “waterbirth.” Google prefers “water birth.” So I used both terms in my article to satisfy everyone!

SM: Have you heard or been told of stories of existing water birth programs shutting down or being modified as a result of the recent AAP/ACOG opinion?

RD: Yes, definitely. There was a mother in my state who contacted me this spring because she was 34 weeks pregnant and her hospital decided not to offer waterbirth anymore. She had given birth to her daughter in a waterbirth at the same hospital two years earlier. With her current pregnancy, she had been planning another hospital waterbirth. She had the support of her nurse midwife, the hospital obstetricians, and hospital policy. However, immediately after the release of the ACOG/AAP opinion, the hospital CEO put an immediate stop to waterbirth. This particular mother ended up switching providers at 36 weeks to a home birth midwife. A few weeks ago, she gave birth to her second baby, at home in the water. This mother told me how disheartening it was that an administrator in an office had decided limit her birth options, even though physicians and midwives at the same hospital were supportive of her informed decision to have a waterbirth.

In another hospital in my hometown, they were gearing up to start a waterbirth program this year—it was going to be the first hospital where waterbirth would be available in our city—and it was put on hold because of the ACOG/AAP Opinion.

Then of course, there were a lot of media reports about various hospital systems that suspended their waterbirth programs. One hospital system in particular, in Minnesota, got a lot of media coverage.

SM: Did you attempt to contact ACOG/AAP with questions and if so, did they respond?

RD: Yes. As soon as I realized that the ACOG/AAP Opinion Statement had so many major scientific errors, I contacted ImprovingBirth.org and together we wrote two letters. I wrote a letter regarding the scientific problems with the Opinion Statement, and ImprovingBirth.org wrote a letter asking ACOG/AAP to suspend the statement until further review. The letters were received by the President and President-Elect of ACOG, and they were forwarded to the Practice Committee. We were told that the Practice Committee would review the contents of our letters at their meeting in mid-June, and that was the last update that we have received.

SM: What is the difference between an “Opinion Statement” and other types of policy recommendations or guidelines that these organizations release? Does it carry as much weight as practice bulletins?

RD: That’s an interesting question. At the very top of the Opinion Statement, there are two sentences that read: “This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.” But, as you will see, some hospitals do see this statement as dictating an exclusive course of treatment, and others don’t.

I have heard that “opinions” do not carry as much weight as “practice bulletins,” but it really depends on who the audience is and who is listening. In other words, some hospitals may take the Opinion Statement word-for-word and feel that they must follow it to the letter, and other hospitals may ignore it. A lot of it probably depends on the advice of their risk management lawyers.

For example, a nurse midwife at a hospital in Illinois sent me a letter that their risk-management attorneys had put together to advise them on this issue. (She had the attorney’s permission to share the letter with me). These lawyers basically said that when a committee of two highly-respected organizations says that the practice of waterbirth should be considered an experimental procedure, both health care providers and hospitals are “charged with a duty to heed that statement,” unless they find research evidence that waterbirth has benefits for the mother or fetus, and that the evidence can override the Committee’s conclusions.

On the other hand, another risk management lawyer for a large hospital system told me that of course hospitals are not under any obligation to follow an ACOG/AAP Opinion Statement. It’s simply just that—an opinion.

So as to how much weight the Opinion Statement carries—I guess it is really dependent on who is reading it!

SM: How would you suggest a well-designed research study be conducted to examine the efficacy and safety of waterbirth? Or would you say that satisfactory research already exists.

RD: First of all, I want to say that I’m really looking forward to the publication of the American Association of Birth Centers (AABC) data on nearly 4,000 waterbirths that occurred in birth centers in the U.S., to see what kind of methods they used. From what I hear, they had really fantastic outcomes.

And it’s also really exciting that anyone can join the AABC research registry, whether you practice in a hospital, birth center, or at home. The more people who join the registry, the bigger the data set will be for future research and analysis. Visit the AABC PDR website to find out more.

I think it’s pretty clear that a randomized trial would be difficult to do, because we would need at least 2,000 women in the overall sample in order to tell differences in rare outcomes. So instead we need well-designed observational studies.

My dream study on waterbirth would be this: A large, prospective, multi-center registry that follows women who are interested in waterbirth and compares three groups: 1) women who have a waterbirth, 2) women who want a waterbirth and are eligible for a waterbirth but the tub is not available—so they had a conventional land birth, 3) women who labored in water but got out of the tub for the birth. The researchers would measure an extensive list of both maternal and fetal outcomes.

It would also be interesting to do an additional analysis to compare women from group 2 who had an epidural with women from group 1 who had a waterbirth. To my knowledge, only one study has specifically compared women who had waterbirths with women who had epidurals. Since these are two very different forms of pain relief, it would be nice to have a side-by-side comparison to help inform mothers’ decision making.

SM: What was the most surprising finding to you in researching your article on the evidence on water birth safety?

RD: I guess I was most surprised by how poorly the ACOG/AAP literature review was done in their Opinion Statement. During my initial read of it, I instantly recognized multiple scientific problems.

A glance at the references they cited was so surprising to me—when discussing the fetal risks of waterbirth, they referenced a laboratory study of pregnant rats that were randomized to exercise swimming in cold or warm water! There weren’t even any rat waterbirths! It was both hilarious and sad, at the same time! And it’s not like you have to read the entire rat article to figure out that they were talking about pregnant rats—it was right there in their list of references, in the title of the article, “Effect of water temperature on exercise-induced maternal hyperthermia on fetal development in rats.”

These kind of mistakes were very surprising, and incredibly disappointing. I expect a lot higher standards from such important professional organizations. These organizations have a huge influence on the care of women in the U.S., and even around the world, as other countries look to their recommendations for guidance. The fact that they were making a sweeping statement about the availability of a pain relief option during labor, based on an ill-researched and substandard literature review—was very surprising indeed.

SM: What was the most interesting fact you discovered during your research?

RD: With all this talk from ACOG and the AAP about how there are “no maternal benefits,” I was fascinated as I dug into the research to almost immediately find that waterbirth has a strong negative effect on the use of episiotomy during childbirth.

Every single study on this topic has shown that waterbirth drastically reduces and in some cases completely eliminates the use of episiotomy. Many women are eager to avoid episiotomies, and to have intact perineums, and waterbirth is associated with both lower episiotomy rates and higher intact perineum rates. That is a substantial maternal benefit. It’s kind of sad to see leading professional organizations not even give the slightest nod to waterbirth’s ability to keep women’s perineums intact.

In fact, I’m puzzled as to why keeping women’s perineums intact and uncut is not perceived as a benefit by anyone other than the women themselves. And here is the heart of declaring waterbirth as “not having enough benefits” to justify its use: Who decides the benefits? Who decides what a benefit is, if not the person benefitting? Who should be weighing the potential harms and the potential benefits of waterbirth, and making an informed decision about their options? Should it be the mother? Or should it be the obstetrician?

SM: What can families do if they want waterbirth to be an option in their local hospital or birth center and it has been taken away or not even ever been offered before?

RD: That’s a hard question. It’s a big problem.

Basically what it boils down to is this—there are a lot of restraining forces that keep waterbirth from being a pain relief option for many women. But there are also some positive driving forces. According to change theory, if you want to see a behavior change at the healthcare organization level, it is a matter of decreasing the restraining forces, while increasing the driving forces. Debunking the ACOG/AAP Opinion Statement is an important piece of decreasing restraining forces. On the other side, increasing consumer pressure can help drive positive change.

SM: Do you think that consumers will be responding with their health dollars in changing providers and facilities in order to have a waterbirth?

RD: I think that if a hospital offered waterbirth as an option to low-risk women, that this could be a huge marketing tool and would put that hospital at an advantage in their community, especially if the other hospitals did not offer waterbirth.

SM: The ACOG/AAP opinion sounded very reactionary, but to what I am not sure. What do you think are the biggest concerns these organizations have and why was this topic even addressed? Weren’t things sailing along smoothly in the many facilities already offering a water birth option?

RD: I don’t know if you saw the interview with Medscape, but one of the authors of the Opinion Statement suggested that they were partially motivated to come out with this statement because of the increase in home birth, and they perceive that women are having a lot of waterbirths at home.

I also wonder if they are hoping to leverage their influence as the FDA considers regulation of birthing pools. You may remember that in 2012, the FDA temporarily prohibited birthing pools from coming into the U.S. Then the FDA held a big meeting with the different midwifery and physician organizations. At that meeting, AAP and ACOG had a united front against waterbirth. So I guess it’s no surprise for them to come out with a joint opinion statement shortly afterwards.

My sincere hope is that the FDA is able to recognize the seriously flawed methods of the literature review in this Opinion Statement, before they come out with any new regulations.

SM: How should childbirth educators be addressing the topic of waterbirth and waterbirth options in our classes in light of the recent ACOG/AAP Opinion Statement and what you have written about in your research review on the Evidence on Water Birth Safety?

RD: It’s not an easy subject. There are both pros and cons to waterbirth, and it’s important for women to discuss waterbirth with their providers so that they can make an informed decision. At the same time, there are a lot of obstetricians who cannot or will not support waterbirth because of ACOG’s position. So if a woman is really interested in waterbirth, she will need to a) find a supportive care provider, b) find a birth setting that encourages and supports waterbirth.

You can’t really have a waterbirth with an unwilling provider or unwilling facility. Well, let me take that back… you can have an “accidental” waterbirth… but unplanned waterbirths have not been included in the research studies on waterbirth, so the evidence on the safety of waterbirth does not generalize to unplanned waterbirths. Also, you have to ask yourself, is your care provider knowledgeable and capable of facilitating a waterbirth? It might not be safe to try to have an “accidental” waterbirth if your care provider and setting have no idea how to handle one. Do they follow infection control policies? Do they know how to handle a shoulder dystocia in the water?

SM: What kind of response do you think there will be from medical organizations and facilities as well as consumers about your research findings?

RD: I hope that it is positive! I would love to see some media coverage of this issue. I hope that the Evidence Based Birth® article inspires discussion among care providers and women, and among colleagues at medical organizations, about the quality of evidence in guidelines, and their role in providing quality information to help guide informed decision-making.

SM: Based on your research, you conclude that the evidence does not support universal bans on waterbirth. Is there anything you would suggest be done or changed to improve waterbirth outcomes for mothers or babies?

RD: The conclusion that I came to in my article—that waterbirth should not be “banned,” is basically what several other respected organization have already said. The American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives have all said basically the same thing.

How can we improve waterbirth outcomes? I think continuing to be involved in clinical research studies (such as the AABC registry) is an important way to advance the science and provide evidence on which we can base practice and make more informed decisions with. Also, conducting clinical audits (tracking outcomes) in facilities that provide waterbirth would be important for quality control.

SM: Let’s look into the future. What is next on your plate to write about?

RD: I recently had a writing retreat with several amazing clinicians and researchers who flew from across the country to conduct literature reviews with me. We made an awesome team!! The topics that we have started looking at are: induction for post-dates, induction for ruptured membranes, and evidence-based care for women of advanced maternal age. I can’t decide which one we will publish first! The Evidence Based Birth readers have requested AMA next, but the induction for ruptured membranes article is probably further along than that one. We shall see!!

SM: Is there anything else you would like to share with Science & Sensibility readers on this topic?

RD: Thanks for being so patient with me! I know a lot of people were eagerly awaiting this article, and I wish it could have come out sooner, but these kinds of reviews take a lot of time. Time is my most precious commodity right now!

Has the recent Opinion Statement released by ACOG/AAP impacted birth options in your communities?  Do you discuss this with your clients, students and patients?  What has been the reaction of the families you work with? Let us know below in the comments section! – SM.

ACOG, American Academy of Pediatrics, Babies, Childbirth Education, Evidence Based Medicine, Home Birth, informed Consent, Maternity Care, New Research, Newborns, Research , , , , , , , ,

A Celebration of Midwifery – Supporting Safe, Healthy Birth!

July 1st, 2014 by avatar

In June, midwives were making news all around the world in person and in print.   Maternity care researcher Judith Lothian presented at the International Congress of Midwives conference in Prague, an enormous international gathering of thousands of midwives from all the corners of the globe that occurs every three years. Dr. Lothian shares her impressions of the Congress gathering today.  Additionally, the journal, The Lancet released its Series on Midwifery, long awaited and recognizing that if normal, safe birth is to be supported, midwifery care is the key to achieving that goal.  Dr Lothian summarizes this important series and shares what it means for women and their babies. – Sharon Muza, Community Manager, Science & Sensibility

@ Barbara Harper

@ Barbara Harper

In the US, where midwives attend around 10% of births and around 1% of women have planned out of hospital births, most women and many health care providers know little, if anything, about midwifery. Several decades ago, I began to write about midwifery and out of hospital birth as a way of promoting, protecting and supporting normal birth.  More recently, I’ve done research on women’s and midwives’ experiences of home birth. I’ve also spent a great deal of time with midwives, with my daughters during the births of my grandchildren, at two historic Home Birth Summits, at Normal Birth conferences and, in the last 2 years working with the American College of Nurse Midwives on their Normal Birth Initiative. I count many midwives among my most respected and cherished friends.

I’ve wanted to spread the good news about midwifery and women and babies for a very long time, but the last month has me wanting to ring bells, light candles, and shout from the rooftops to celebrate the tremendous accomplishments of midwives and midwifery, the courage of midwives, and the commitment of midwifery to women and children here in the United States and across the globe.

In early June I attended the International Congress of Midwives in Prague. Thirty eight hundred midwives (and a smaller group of nurses, sociologists, epidemiologists, birth advocates and researchers) came together as they do every three years to share what they know, learn what they don’t know, and recommit themselves to women and babies around the world.  Midwives from 85 countries, most often in the traditional dress of their country, paraded into the opening ceremony. The video and pictures from this event can’t begin to capture what it was like to be there, but it does give you a taste of the excitement and the pride.  It was truly amazing.

ICM.Frances_open

@ Barbara Harper

The number of sessions was mind boggling. In each time slot there were multiple sessions on normal birth. It was difficult to choose and impossible to get to even a small percentage of what was offered. I am sharing some of the standouts for me.

Lisa Kane Low, from the University of Michigan, and a champion of midwifery and evidence based maternity care, was a plenary speaker. Her talk on access to care highlighted the importance of meeting women where they are and putting their needs, not ours, first. Toyin Saraki is the newly appointed ICM Global Goodwill Ambassador. The former First Lady of Nigeria, she is the founder and director of the Wellbeing Foundation Africa. The work of the foundation has reduced maternal mortality in Nigeria by 20%.

Ms. Saraki shared a Nigerian saying with us: If you want to go fast, go alone. If you want to go far, go together.  I can’t stop thinking about that, and its implications for our work.  Cecily Begley, the Chair of Nursing and Midwifery at Trinity College Dublin, participated in a plenary panel, Education: The Bridge to Midwifery and Women’s Autonomy. Professor Begley talked about “communities of change” and she described education and research as necessary in crossing the bridge to change. Ray DeVries and Saras Vedam participated in a symposium on ethics related to birth place. Both Ray and Saras contributed to the Journal of Clinical Ethics Fall 2013 special issue on place of birth. The audience participation was lively.

© Barbara Harper

© Barbara Harper

The ethical issues related to pushing women to unassisted births when there is no real choice related to planned, assisted out of hospital birth and the ethical issues of hospitals and providers stonewalling efforts to make transfer seamless, safe, and without recrimination were discussed. Dr. Marianne Nieuwenhuijze from the Netherlands, presented her excellent work on shared decision making. Tanya Tanner from ACNMEllie Daniels from National Association of Certified Professional Midwives, and I presented the collaborative work of ACNM, MANA and NACPM developing a consensus statement on normal, physiologic birth, and more specifically, our work developing a consumer statement based on the consensus statement, Normal, Healthy Childbirth for Women and Families: What You Need to Know.

It was wonderful meeting midwives from Australia, Canada, Ghana, the UK, and Ireland. The challenges are not exactly the same as ours in the US, but we are all fighting uphill battles in support of normal birth.

On the heels of the ICM, The Lancet launched its eagerly awaited Lancet Series on Midwifery.  In Ireland for the summer, I was glued to my computer savoring every moment of the launch online on June 23.    The lead author of each of the four major papers provided a summary and there were comments from a wide array of noted scholars, researchers, practitioners and policy makers from around the world. There were many familiar faces from the International Congress of Midwives. Toyin Saraki gave a stirring speech applauding midwifery, noting that midwifery is not a job, but a passion, a vocation.  Holly Kennedy, who co-authored a paper, and is working on a follow up paper, brought congratulations from the ACNM.

Why did the Lancet do a series on midwifery? Richard Horton, who was involved in the project from the beginning , has this to say in his commentary, The Power of Midwifery:

“Midwifery is commonly misunderstood. The Series of four papers and five Comments we publish today sets out to correct that misunderstanding. One important conclusion is that application of the evidence presented in this Series could avert more than 80% of maternal and newborn deaths including stillbirths. Midwifery therefore has a pivotal, yet widely neglected, part to play in accelerating progress to end preventable mortality of women and children”.  Horton and Astudillo  go on to note that the work is based on a set of values and philosophy that are distinctive. “These values include respect, communication, community knowledge and understanding, and care tailored to a woman’s circumstances and needs. The philosophy is equally important—to optimise the normal biological, psychological, social, and cultural processes of childbirth, reducing the use of interventions to a minimum. “

The four papers include

  • Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care by Mary J Renfrew, Alison McFadden, Maria Helena Bastos, James Campbell, Andrew Amos Channon, Ngai Fen Cheung, Deborah Rachel Audebert Delage Silva, Soo Downe, Holly Powell Kennedy, Address Malata, Felicia McCormick, Laura Wick, Eugene Declercq
  • The projected effect of scaling up midwifery by Caroline S E Homer, Ingrid K Friberg, Marcos Augusto Bastos Dias, Petra ten Hoope-Bender, Jane Sandall, Anna Maria Speciale, Linda A Bartlett
  • Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality by Wim Van Lerberghe, Zoe Matthews, Endang Achadi, Chiara Ancona, James Campbell, Amos Channon, Luc de Bernis, Vincent De Brouwere, Vincent Fauveau, Helga Fogstad, Marge Koblinsky, Jerker Liljestrand, Abdelhay Mechbal, Susan F Murray, Tung Rathavay, Helen Rehr, Fabienne Richard, Petra ten Hoope-Bender, Sabera Turkmani
  • Improvement of maternal and newborn health through midwifery by Petra ten Hoope-Bender, Luc de Bernis, James Campbell, Soo Downe, Vincent Fauveau, Helga Fogstad, Caroline S E Homer, Holly Powell Kennedy, Zoe Matthews, Alison McFadden, Mary J Renfrew, Wim Van Lerberghe

The Lancet Series on Midwifery makes a major contribution to the literature bringing together the evidence basis for midwifery, its outcomes, and how to affect policy. We need to translate that evidence into action, into the education of the women we teach, and into our advocacy efforts on behalf of safe, healthy birth.

The Lancet Series on  Midwifery can be accessed at through this link. The series includes an executive summary, commentaries, and the four major papers. You need to register on the Lancet site but everything can be accessed for free.

The time has come to recognize and celebrate the incredible work that midwives do. In the US, it is time for women to know about midwifery, and to see the connection of midwifery and normal, physiologic birth.  It is time for childbirth educators to encourage women to choose midwifery care, and time to collaborate with midwives both in our communities and on organizational and governmental levels.  If we want to promote safe, healthy, normal physiologic birth, we need to promote and support midwifery. Healthy low risk women need to know that if they want the safest, healthiest birth for themselves and their babies that they need to find a midwife.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery , , , , , , ,