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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 (DeClercq, 2013) The common practice of restricting food and drink for laboring women is outdated and not supported by evidence.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 , , , , ,

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 , , , , , , ,

Remembering Doris Haire – A Great Leader in the Field of Maternal Infant Health

June 17th, 2014 by avatar

doris haireDoris Haire, a great leader in the campaign to improve maternal infant health in the USA has passed away.  Ms. Haire died on June 7, 2014.  She was 88 years old.  Doris was one of the first true proponents of evidence based maternity care. Throughout her professional life, Doris advocated and fought for a woman’s right to birth as the mother wanted, free of unnecessary interventions.  Doris led the way in bringing to light the conditions under which women were birthing in the USA with her 1972 essay “The Cultural Warping of Childbirth,” exposing the contemporary childbirth practices of the time.

Along with Drs. Kennell and Klauss and others, Doris sought to change the practice of isolating women from their support during labor and birth and keeping babies apart from their mothers after they were born.  Additionally, Doris also recognized the importance of professional midwives at a time when midwives barely were a blip on the radar after childbirth moved into the hospital at the beginning of the last century. Doris helped establish the first State Board of Midwifery in New York, the first of its kind in the United States which defined the practice of midwifery as a profession separate from nursing and medicine.

Doris traveled to 77 countries to learn about maternity care practices and meet with obstetric health care leaders around the world, in order to gather information that she could use to champion the cause of maternity rights and evidence based medicine here in her own country.  Doris was the Founder and President of the American Foundation for Maternal and Child Health.  Additionally, she served on many boards and committees, such as the World Health Organization, various Perinatal Advisory Committees and others, testified in front of Congress on the topics of obstetrical care and presented at obstetrical conferences around the world.  Doris also spoke at Lamaze International conferences as well.

Doris also examined how drugs are tested and used and published her research in a paper, “How the F.D.A. Determines the ‘Safety’ of Drugs — Just How Safe Is ‘Safe’?”  As a result of this publication, Doris testified at Congress and her actions resulted in changes in FDA regulation and clinical practices. Obstetricians curtailed their use of sedatives and other risky drugs being used for pain relief and millions of childbearing women and their babies have been spared from unnecessary exposure to these risks.

 Doris was also responsible for the passage of the New York Maternity Information Act, which requires every hospital to provide the information and statistics about its childbirth practices and procedures including rates of cesarean section, forceps deliveries, induced labor, augmented labor, and epidurals.

Doris Haire also wrote the following:

The Pregnant Patient’s Bill of Rights

  1. The Pregnant Patient has the right, prior to the administration of any drug or procedure, to be informed by the health professional caring for her of any potential direct or indirect effects, risks or hazards to herself or her unborn or newborn infant which may result from the use of a drug or procedure prescribed for or administered to her during pregnancy, labor, birth or lactation.
  2. The Pregnant Patient has the right, prior to the proposed therapy, to be informed, not only of the benefits, risks and hazards of the proposed therapy but also of known alternative therapy, such as available childbirth education classes which could help to prepare the Pregnant Patient physically and mentally to cope with the discomfort or stress of pregnancy and birth. Such classes have been shown to reduce or eliminate the Pregnant Patient’s need for drugs and obstetric intervention and should be offered to her early in her pregnancy in order that she may make a reasoned decisions.
  3. The Pregnant Patient has the right, prior to the administration of any drug, to be informed by the health professional who is prescribing or administering the drug to her that any drug which she receives during pregnancy, labor and birth, no matter how or when the drug is taken or administered, may adversely affect her unborn baby, directly or indirectly, and that there is no drug or chemical which has been proven safe for the unborn child.
  4. The Pregnant Patient has the right if Cesarean birth is anticipated, to be informed prior to the administration of any drug, and preferably prior to her hospitalization, that minimizing her intake of nonessential pre-operative medicine will benefit her baby.
  5. The Pregnant Patient has the right, prior to the administration of a drug or procedure, to be informed of the areas of uncertainty if there is NO properly controlled follow-up research which has established the safety of the drug or procedure with regard to its on the fetus and the later physiological, mental and neurological development of the child. This caution applies to virtually all drugs and the vast majority of obstetric procedures.
  6. The Pregnant Patient has the right, prior to the administration of any drug, to be informed of the brand name and generic name of the drug in order that she may advise the health professional of any past adverse reaction to the drug.
  7. The Pregnant Patient has the right to determine for herself, without pressure from her attendant, whether she will or will not accept the risks inherent in the proposed treatment.
  8. The Pregnant Patient has the right to know the name and qualifications of the individual administering a drug or procedure to her during labor or birth.
  9. The Pregnant Patient has the right to be informed, prior to the administration of any procedure, whether that procedure is being administered to her because a) it is medically indicated, b) it is an elective procedure (for convenience, c) or for teaching purposes or research).
  10. The Pregnant Patient has the right to be accompanied during the stress of labor and birth by someone she cares for, and to whom she looks for emotional comfort and encouragement.
  11. The Pregnant Patient has the right after appropriate medical consultation to choose a position for labor and birth which is least stressful for her and her baby.
  12. The Obstetric Patient has the right to have her baby cared for at her bedside if her baby is normal, and to feed her baby according to her baby’s needs rather than according to the hospital regimen.
  13. The Obstetric Patient has the right to be informed in writing of the name of the person who actually delivered her baby and the professional qualifications of that person. This information should also be on the birth certificate.
  14. The Obstetric Patient has the right to be informed if there is any known or indicated aspect of her or her baby’s care or condition which may cause her or her baby later difficulty or problems.
  15. The Obstetric Patient has the right to have her and her baby’s hospital- medical records complete, accurate and legible and to have their records, including nursing notes, retained by the hospital until the child reaches at least the age of majority, or, alternatively, to have the records offered to her before they are destroyed.
  16. The Obstetric Patient, both during and after her hospital stay, has the right to have access to her complete hospital-medical records, including nursing notes, and to receive a copy upon payment of a reasonable fee and without incurring the expense of retaining an attorney.

Comprehensive and forward thinking at the time of publication, unfortunately, many mothers are still finding it hard to have all 16 points complied with during a pregnancy, labor, birth and postpartum period.

Well known, well loved and deeply respected, Doris Haines was a leader advocating for the rights of mothers and babies for more than 50 years.  She never faltered and provided unlimited energy and dedication to improving childbirth in the United States.  Doris Haire was a role model for all of us and she will be certainly missed.

Donations to celebrate her life may be made to the American Foundation for Maternal and Child Health, P.O. BOX 555, Keswick, VA 22947.

A complete list of Doris Haire’s publications may be found here.

 

Childbirth Education, Do No Harm, Evidence Based Medicine, Infant Attachment, Maternal Quality Improvement, Maternity Care, Transforming Maternity Care , , ,

The Science Behind the Lamaze Exam and the Lamaze Certified Childbirth Educator Credentials

May 1st, 2014 by avatar

Last week, around the world, candidates for certification sat for the Lamaze Certified Childbirth Educator exam.  That test represented the culmination of weeks, months and often years of planning, preparation, studying and hard work.  While the results are still some weeks out, I thought it would be interesting to learn about the science behind the Lamaze exam and what makes it the gold standard of childbirth educator certifications from Judith Lothian, PhD, RN, LCCE, FACCE, the chairperson of the Lamaze Certification Council Governing Body. Today’s families deserve the best, so they can push for their baby, with all the evidence and research that stands behind the LCCE credentials of their childbirth educator. Learn more about attending a Lamaze workshop and explore becoming an LCCE yourself so you can offer families in your community the gold standard of childbirth education. – Sharon Muza, Science & Sensibility Community Manager.
LCCE

Lamaze International is extremely proud of the fact that the Lamaze certification examination is the only examination for childbirth educators that is accredited by the National Commission for Certifying Agencies (NCCA).  Achieving and maintaining this accreditation is a rigorous and ongoing process.

Accreditation by NCCA assures you that the exam you take will accurately measure the competencies of a childbirth educator. The seven competencies of a Lamaze Childbirth Educator are supported by job analysis research that is done every 5-7 years. The last job analysis was conducted in 2012. The results of that analysis were published in the latest issue of the Journal of Perinatal Education. Lamaze members may access the full journal online after logging in to the Lamaze website. Basing the exam on the results of a job analysis is an important way to ensure that the exam accurately evaluates the competencies of a childbirth educator. Fairness is a very important issue and to that end NCCA has evaluated our policies, our procedures and the actual exam, including the construction of items and the exam itself as well as the evaluation of its performance. The NCCA stamp of approval is a vote of confidence that experts in the certification field believe that the Lamaze certification policies are fair and that the certificate examination accurately evaluates the competencies of a Lamaze Certified childbirth educator.

Lamaze is the only childbirth educator certification program that has received NCCA accreditation. Professional standards set by the Institute for Credentialing Excellence describe the difference between professional certification and assessment based certificate programs. “Professional or personnel certification is a voluntary process by which individuals’ pre-acquired knowledge, skills, or competencies are evaluated against predetermined standards. The focus is on an assessment that is independent of a specific class, course, or other education/training program. Participants who demonstrate that they meet the standards by successfully completing the assessment process are granted the certification.” The American College of Nurse Midwives and the International Board of Certified Lactation Consultants are examples, like Lamaze, of professional certification.

In contrast, an assessment-based certificate program is a non-degree granting educational program that provides instruction and training to help participants gain specific knowledge and skills and then evaluates achievement of expected learning outcomes and awards a certificate to those who successfully pass the assessment. Childbirth educator certifications, other than Lamaze, are assessment-based certificate programs. Because of this, many educators who have childbirth educator credentials from other organizations  choose to sit for the Lamaze exam.

Why is this important? It assures you that the certification examination has met the rigorous standards of professional certification, that the exam is fair and actually measures what it is should to insure that you indeed have achieved the competencies to practice as a Lamaze childbirth educator.

The certification exam consists of 150 multiple choice questions and the questions reflect the essential information a childbirth educator should know (the competencies of a Lamaze Certified Childbirth Educator). An inside look at the process of item writing and exam construction and evaluation will give you a taste for how rigorous, and interesting, the process actually is.

The exams are put together by a test development committee that meets twice a year for 4-5 days. The committee includes expert childbirth educators, a public member who is not a childbirth educator, and, often a novice childbirth educator (a high scorer on a recent exam). Using the test blueprint (based on the latest job analysis) the committee writes questions and then a smaller group “constructs” individual exams from the item bank of questions.

nccaDraft items are written in small groups, usually 2 or 3 educators. It is actually very, very difficult to develop a fair question that measures knowledge and skills that are important for the childbirth educator to know. It is tedious work and challenges all of us without exception! Once a small group has developed an item they think has potential it is, often with great trepidation, presented to the entire committee for discussion. Leon Gross, PhD, the psychometrician (a testing specialist) is at the meetings and at this stage he will often point out potential psychometric issues related to the items, including things like “it’s too long”, “there is extraneous information,” “could there be 2 answers?” In developing and evaluating each item we ask ourselves: Is it clear? Is there only one right answer? Do we know the right answer (if we don’t then we most definitely do not use it)? Is there any overlap in the answers? We edit each draft item for content and language, keeping in mind, that the distracters (the wrong answers) should be “plausable”. It is an extremely honest and often raucous process! We all have to be prepared to have our questions torn apart! It helps to have a sense of humor and remind ourselves of the importance of the process. Then the committee decides to either put the questions in the permanent item bank or not. The entire process is done with expert psychometric support.

Our philosophy, in the writing of the items, in the evaluation of the items, and then ultimately choosing the items that will be on each exam, is that we only test what is really important to know. There are no intentional “trick” questions. It’s important to know that if the committee struggles with identifying the correct answer it is automatically not used. And, the questions are written in order to evaluate the competencies of what we constantly refer to as the ‘just good enough candidate.’ So, this is most definitely not an exam where you have to be an “expert” to pass. In order to pass this exam you need to be “just good enough”. This exam is intended to measure competencies of a beginning childbirth educator.

When the committee decides to put a question in the item bank we then establish the level of difficulty for the question. We look at each correct answer and then we look at distractors, the wrong answers. We discuss the distracters related to how plausible this distracter would be to a candidate who is just able to pass the exam. This is an example of the process:

What is the capital of Maryland?
1. Baltimore
2. Chevy Chase
3. Annapolis
4. Fredricksburg

There is one correct answer and three distracters. If you know the capital of Maryland, this is a very easy question. It’s straight recall. If you, however, don’t know what the capital of Maryland is, then you will be tempted to go for a plausible but wrong answer. The correct answer is Annapolis, but Baltimore is a plausible answer because it’s the largest city in Maryland and, of these four choices, it is the most well-known city. For someone who does not know for sure that Annapolis is the capital of Maryland they would be tempted to think it was Baltimore. Therefore, we would label Annapolis the correct answer and Baltimore a “sophisticated distracter”. We aim to have at least 50% of the exam questions with “sophisticated distracters”. The more questions with sophisticated distracters the higher the level of difficulty of the exam. It’s important to know this to understand how the passing score is determined for each test administration.

This exam is criterion referenced which means that the passing score is determined before the test is given based on the level of difficulty of the questions on the exam. Candidates who sit for the exam are never compared to each other and the passing scored is determined by how difficult the questions are, not a predetermined passing score. Candidates are evaluated against a standard not against the scores of the other candidates sitting for the exam. The more items on the exam that have sophisticated distracters, the higher the level of difficulty, the lower the score you need to pass. The fewer items with sophisticated distracters, the higher the score is that you need to pass the exam. The pass score, the cut score, for passing the Lamaze certification exam has over the last years ranged 70 to about 75.

After the exam is given, the exam is scored and reviewed by the psychometrician. A detailed statistical analysis is done. There is an analysis of each item on the exam. How many testing participants got the answer right? What distracters did those who got it wrong go for? The item analysis also identifies what percentage of the high scorers got the question correct and what percentage of the low scores got the question correct. A “good” question statistically is one that discriminates between the high scorers and low scorers. This means that you would expect a high percentage of the people that did well overall on the exam to get a question correct and those that did not perform as well on the overall exam to get the question wrong. If we find that there is an item that most of the low scores got correct and only a few of the high scorers got that question correct, we would wonder why.

After the psychometrician reviews the overall exam and each item, he will flag the questions that may look like they may not be “performing” well. The small group that constructed the exam meets by conference call to discuss both the flagged items and the comments the candidates have made related to the exam. Every comment is reviewed. Whether or not we keep an item, or don’t keep the item, is the decision of the committee. We also look at the performance of the exams that are translated into other languages and look at how individual questions performed for instance in Spanish compared to in English. We try to determine if there are cultural differences or whether there are translation problems. At times a question may be deleted from scoring in a language other than English and not in the English exam. Once we determine if there are items we will drop then the psychometrician will re-score the exam and determine, based now on the questions that remain on the exam (and their level of difficulty), a final cut score. It takes about 6 weeks to get exam results. During that time the certification team is working hard to make sure your exam is fairly evaluated.

The rigor of developing the exam, including the job analysis, and then the scoring of the exam are only one part of the requirements for NCCA accreditation. In addition, our policies and procedures related to everything from exam eligibility and grievance procedures, as well as confidentiality issues and the qualifications of both the staff and volunteers involved in the certification process, are rigorously evaluated. The end result, we hope, is a valid, reliable, fair certification exam that protects the value of the LCCE credential, and, most importantly, assures women and their families that the Lamaze Certified Childbirth Educator is competent. NCCA accreditation is a vote of confidence that we are indeed doing what we intend.

Are you an LCCE?  Can you share why you chose Lamaze International and your journey?  Are you considering becoming a childbirth educator?  Have you explored Lamaze as an option?  I invite you to consider certifying with Lamaze International and achieving the gold standard for childbirth educators. – SM

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).

Childbirth Education, Evidence Based Medicine, Guest Posts, Journal of Perinatal Education, Lamaze International, Lamaze Official Guide Book, Push for Your Baby, Research, Series: Journey to LCCE Certification , , , , , , ,