Science & Sensibility

[Editor's note: This is a guest contribution about the concurrent session at the Normal Labour & Birth International Research Conference titled Assessing Interactions Between Culture and Choice. Priscilla Hall (a second year PhD student at Emory University Woodruff School of Nursing), Esther Shoemaker (a first year PhD student in the Population Health program at the University of Ottawa), and Kathrin Stoll (doctoral fellow at the Centre for Rural Health Research) each presented their research. - AMR]

Thank you Amy and readers for allowing me the great opportunity of contributing my conference analysis to Science & Sensibility.

At no other conference has choosing between concurrent sessions been so difficult. However, from the moment the schedule was posted some weeks ago I knew there was one I had to attend. Assessing Interactions Between Culture & Choice focused on today’s generation of mothers and what shapes their perceptions, experience and consequently choices about birth.

Generation Y women are today’s young mothers and will make up the bulk of midwives’ clients in the approaching years. What shapes their perspectives on pregnancy and birth? And how will their expectations impact the way they choose to give birth?

Demographics and Influences

Generation Y is loosely made up of adults born between the mid 1980s and the mid 1990s In the conference session, we reflected on what influences this generation of women:

1. This generation is extremely comfortable with technology, having craved the “toys that make the noise” including Nintendo/Sega/Xbox game consoles, mini laptops and iPods. The toys of this generation often involve one-on-one interactions with a computer rather than a friend.

2. The “Audit Society” (Power 1997) is the norm for this generation. The 1980s saw an explosion of auditing activity in UK and American society. Teachers chart performance and activities of students, employees audited their own activities for their employers and health workers began recording up to the minute activities of their patients and one another.

3. To this generation “the most desirable women aren’t women at all – they’re girls.” The womanly shape, once held in esteem by the Greeks all the way up to pre-Twiggy models is seen as overweight to this generation. Smaller frames, straight figures and other pre-pubescent qualities are idealized by Generation Y women (or at least the media they consume). Not ironically, Gen Y has also been referred to as the Peter Pan Generation.

The first two in this hardly exhaustive list of predictors can help to explain how medicalized birth is quickly being assumed as the norm by today’s women. (And as Dr. Eugene Declercq of Boston University pointed out over lunch, the majority of U.S. women are satisfied with their maternity care.) In fact, as UBC doctoral candidate Esther Shoemaker points out from her mixed methods research of young women and new mothers, “Natural” birth to them does not equal “Normal” to us. Natural birth, to most of the women in her study, is synonymous with vaginal birth. Even if labor was induced, an epidural administered or forceps used, the women who gave birth vaginally experienced their birth as natural. I have witnessed this in my own Generation Y peer group of young mothers.

Further, the majority of those Shoemaker interviewed desired a vaginal birth in their antepartum interview, but also voiced an ambivalence about whether or not they actually would give birth that way when the time came. “If something happens I of course will have a c-section.” Oddly enough, perception of safety was not mentioned but the women said they would default to whatever their individual practitioner suggested.

In some cases reported, the practitioner suggested procedures to the Shoemaker participants that increased the degree of medicalized beyond what they expected for their birth. When this occurred, each of the participants changed their plans for their second birth. They either embraced the medical model completely or rejected the medical model in favor of a physiologic birth. So while they were ambivalent or passive first time mothers, they actively created their birth plans for subsequent children. The finding has important implications for today’s mothers as this was true for all Shoemakers’ participant’s whose birth experience was more medicalized than her birth expectation.

Intriguing findings in the studies:

1. Birth, to this generation, is, as UBC scholar Kathrin Stoll points out, a normal physiological process (71%), inherently risky and filled with “unavoidable complications” which necessitate technological interventions.

2. Of the women Stoll interviewed, 70% worried about how they and/or their partners would perceive their bodies during and after pregnancy.

3. According to Shoemaker, who studied what happened in subsequent births among women whose first births were more medicalized than expected, one of two extremes were common. The women would either fully embrace the medical model (e.g., plan a c-section with all the bells and whistles) or she planned to birth at home with no interventions.

The findings of this session’s speakers are all interesting and important for us as midwives, childbirth educators, and activists. When shaping our message about normal birth it is important to meet women where they are, use their language and respect their experience of the world and their bodies. How will we “market” normal birth as we are privileged to know it to the coming mothers?

About Katie Fulmer:

Like many of you, I have birth on the brain and care deeply about the health and wellbeing of our mommas. I am currently a student midwife with Illysa Foster, author of Professional Ethics in Midwifery Practice. My academic focus was Medical Anthropology as an undergrad at the University of Texas in Austin and I look forward to continuing my study of maternity and child care at the PhD level.

Katherine Fulmer Uncategorized childbirth education, culture, Normal Labour & Birth Conference, qualitative

[Editor's Note: This marks the beginning of our coverage of the 5th International Normal Labour & Birth Research Conference, taking place July 20-23 in Vancouver. Sharon Dalrymple, staff development nurse, prenatal educator, doula, and Lamaze's first Canadian president, will present a session she developed with maternity care quality expert and Lamaze's president-elect, Debra Bingham. They were both part of a research team that investigated how women perceive terms like "normal birth" and "natural birth" and what that means for helping them understand evidence-based information to make health and healthcare choices. There are many reasons that women's perceptions and priorities matter in birth. One is that meaningful improvements in maternity care quality and safety are impossible without a strong consumer movement. Dalrymple's and Bingham's findings have major significance for "normal birth," however we each define it.

Remember, there's an Open Thread for conference attendees and enthusiasts to post messages. You can follow all of the updates from the conference on Twitter by following the #birthconf hashtag and find more analysis here on the blog - AMR]

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For the past 50 years Lamaze International has been promoting normal birth practices in North America and more recently worldwide. Despite these educational efforts women are being over-treated more now than they have been in over 30 years. For example, 31% of women in the United States give birth by cesarean surgery. The overuse of interventions with harmful side effects when there is little or no expected benefit for mother or baby has led to worsening maternity care outcomes in the United States and many other countries. In addition, women do not get adequate information so they are aware of the excess, unnecessary risks they and their infants are being exposed to.

One of the reasons these educational efforts may not have been as effective as desired is that our conversations may not be persuasive enough or clear enough. For example, it is not universally understood or agreed upon how to define a normal birth, the differences between normal and natural birth, and which behaviors constitute a normal birth. Conversations and language affect how persuaded others are to make changes. In fact, 50 years of diffusion of innovation research tell us that for women to demand safe, high quality maternity care, we must engage in clear conversations that outline specific desirable behavior changes and show that women and babies can expect better health outcomes if these changes are made.

Lamaze International hired a public relations market research firm to conduct research and identify which messages are the most effective for persuading women to adopt normal birth practices. Online surveys were conducted among 811 women aged 16-44  and 408 Lamaze Certified Childbirth Educators.

Indeed, the research showed that the meaning of the words “normal” and “natural” was not interpreted by the women and educators the same way. For example, 36% of women felt that ALL vaginal births are “normal birth”, while 63% of Lamaze Certified Childbirth Educators defined “normal birth” to be a birth without medical intervention. Women and Lamaze childbirth educators are likewise divided when deciding if the terms “natural birth” and “normal birth” are generally similar or generally different in meaning.

Lamaze International found that the words safe and healthy are the most effective words for communicating and promoting the birth practices Lamaze has endorsed for years. Everyone wants a safe and healthy birth. Mothers are particularly motivated to keep their baby and themselves safe and healthy. Most importantly, the practices are safe and healthy.

As a result of these and other findings, Lamaze International updated our six evidence-based key practice papers in Fall 2009 to ensure women realize that these practices simplify the birth process with a natural approach that helps alleviate fears and manage pain, with the ultimate goal of keeping labor and birth as safe and healthy as possible for each individual woman. Every woman needs clinicians who promote, support, and protect these six practices:

1. Let labor begin on its own

2. Walk, move around and change positions throughout labor

3. Bring a loved one, friend or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on your back and follow your body’s urges to push

6. Keep mother and baby together – It’s best for mother, baby and breastfeeding

Conflict of Interest Disclosure: The research was funded by Lamaze International.

Sharon Dalrymple Uncategorized childbirth education, lamaze, Normal Labour & Birth Conference

…is up! Go check it out at Giving Birth with Confidence. What a PHENOMENAL collection of contributions about the moments, hours, and days after birth. Each of our Blog Carnivals has vastly surpassed my own expectations. I hope you’ll agree.

Amy Romano Uncategorized breastfeeding, cesarean, childbirth education, Healthy Birth Blog Carnivals, Healthy Birth Practices, home birth, interventions, maternity care systems, newborns, no separation, postpartum, safety, skin-to-skin contact

I am impressed and surprisingly moved by this video of a NICU evacuation drill at Beth Israel Deaconess Medical Center in Boston. Drills like these are so important for patient safety.

As the hospital CEO points out in his blog, there is a “dearth of literature on NICU evacuations”. The same is almost certainly true for labor and birth, in which evacuating hospitals means telling at least some women to give birth at home. Other potential disasters, such as prolonged loss of electricity, can mean access to anesthesia and surgical care is rationed severely, or not available at all. And of course more widespread disasters such as pandemics, natural disasters, or terrorist attacks might mean that a labor and delivery unit is closed indefinitely.

In 2006, Lisa Summers wrote about representing the American College of Nurse-Midwives (ACNM) at a government meeting discussing healthcare system preparedness for pandemic flu. In an article in ACNM’s newsletter, she shared:

They are planning for three levels of care. There are pamphlets to educate the public about how to provide appropriate home care that will meet the needs of most flu victims (hydration, isolation, comfort measures); they are working with local hospitals to assess surge capacity and their ability to meet the needs of the sickest (perhaps ventilator dependent) victims; and they are designating places such as hotel ballrooms and convention centers (places with adequate bathroom and food facilities) to be used as influenza care centers for those too sick for home care but not in need of (or who cannot be accomodated in) limited hospital beds.

Summers goes on to ask, given that one-quarter of hospitalized people are childbearing women, and pregnant women and newborns may be among the most vulnerable populations to flu infection, “What plans are being made to determine the best level of care for childbearing women? Will the influenza care centers be appropriate places to give birth?” She provides two compelling reasons that midwives should be front-and-center in efforts to address these questions:

The fact that midwives are experts in normal birth – that we are comfortable and skilled at attending a birth outside of a standard delivery room and without an OR down that hall – makes us uniquely well prepared to care for childbearing women in a disaster situation…The other important skill that midwives have honed well is that of triage of childbearing women – knowing which women are likely to safely give birth without medical intervention, and which women need IVs and an OR.

She also points out that all hazards preparedness should involve educating the public about safe home birth and assessing the surge capacity of birth centers.

In addition to Summers’ article, the ACNM also offers a number of other resources on All Hazards Preparedness, including a handout for women who may be vulnerable to giving birth unexpectedly remote from a skilled provider or prepared birth setting. (Whether it’s because of a terrorist attack or the epidemic of roadside births due to the closure of community-based maternity units.) The handout notes that childbirth education classes and prenatal breastfeeding education, along with infant CPR classes, are essential to preparedness, and gives step-by-step instructions for supporting a woman to give birth at home, including how to handle the most common complications.

I’d love to know, what are the hospitals in your communities doing to prepare labor and delivery units for events such as fires, floods, and loss of electricity? Does anyone have a video of an L&D drill similar to the NICU drill from BIDMC? And how are your health departments preparing for disasters that render hospitals unsafe or inaccessible for childbearing women? How many of my readers have contacted their health departments to offer assistance for childbearing women and newborns in disasters?  (Confession: although I’ve been meaning to for ages, I haven’t!)  Do any of you teach about disaster preparedness in prenatal classes?

Amy Romano Uncategorized childbirth education, hospitals, maternity care systems, safety

I have felt a little bit like a slacker blogger lately, but it’s not for lack of thinking and writing about birth. I just wrapped up an article called Social Media, Power, and the Future of VBAC with Hilary Gerber from Mom’s Tinfoil Hat and Desirre Andrews from Preparing for Birth which we submitted to the 50th anniversary “Looking Back – Looking Forward” special issue of Lamaze’s Journal of Perinatal Education. I’ve also been working with Kristen Oganowski from Birthing Beautiful Ideas to coordinate the development of an NIH VBAC Statement Primer for consumers. We have a bunch of brilliant contributors on board and will be launching the primer later this month at Lamaze’s new (very cool!) social networking site for women, Giving Birth with Confidence.

Now the big looming work comes in the form of conference season. And I want you (yes YOU) to help me. I have a love-hate relationship with conferences. Mostly love. I love how much sharing, connecting, and learning happens. I love finding out what old friends and colleagues are up to and meeting the people doing the most interesting, innovative, and important work in the field. But attending (and especially speaking at) a conference is a lot of work, and often disrupts progress in my other (equally if not more important) work. Also, I hate that conferences take me away from my family.

So…I want to make the most of the opportunities these conferences offer. I want to maximize the amount of sharing, connecting, and learning we – collectively – do. And I want to leave these conferences not with tons of new projects and commitments for myself, but with tons of new opportunities for the broader maternity care community (that means YOU) to drive meaningful improvements for women, infants, and families.

Here’s some more about the conferences I’m attending, and how YOU can be part of them.

On June 7 I’ll be at Health 2.0 Goes to Washington.

Um, have I mentioned lately that I think social media is going to transform maternity care? Well I developed this delirious optimism by hanging around (online) with the Participatory Medicine crowd.  I get to actually meet most of them next week!

I first caught on to the Participatory Medicine train when I read a Grand Rounds blog carnival on the theme of “Meaningful Use” almost exactly a year ago. “Meaningful Use” is government speak for the goal of implementing electronic health records (with piles and piles of stimulus money) in a manner that actually improves care. The Participatory Medicine folks are front and center in the conversation, pushing for patient-access to be the defining characteristic of meaningful. It’s all about liberating the mounds of data that will exist in electronic health records and letting innovators, policy-makers, scientists, and – most importantly – patients themselves use that data to improve health.

I have 10 minutes to speak but a whole day to connect and learn.  Here are my questions for you to help me make the most of this opportunity:

1. What do you think are the most innovative ways women are using the internet or social media to have healthier, safer, and more satisfying childbearing experiences?
2. What are the types and sources of maternity care data that you would most like to see become available?
3. What kind of data do you think should be documented in electronic health records during pregnancy, birth, and the postpartum and newborn period? Think outside the box.
4. What do you think would be the most important benefits (and for that matter, risks or drawbacks) of having complete, unhindered, timely access to your maternity care records?
5. What ongoing or forthcoming projects in the maternity care world could use the insights or funds of outside (non-birth-enthusiast) social innovators?

The following week (June 12-16), I’ll be at the American College of Nurse-Midwives Annual Meeting.

I’m only attending ACNM for one day, but traveling with my family for my kids’ first-ever trip to the nation’s capitol.  I’m giving two educational sessions that couldn’t be more different from one another. First, I’m presenting a talk called, “How Not to Get Duped by Obstetric Research” about the importance of thinking critically about evidence, and how honing critical analysis skills can can help midwives practice and advocate for safe and effective care. The other talk is a panel discussion with Amie Newman from RH Reality Check and Mary Murry, CNM, from The Mayo Clinic “Pregnancy Week by Week Blog,” moderated by Melissa Garvey from ACNM’s own Midwife Connection Blog. We’ll be talking about why more midwives should be blogging and how they can get started.  We recorded a really lively discussion about these issues on The Feminist Breeder & Friends Radio Show on International Day of the Midwife – a preview of our ACNM panel – which you can listen to here:

My questions for YOU:

1. What do you think is the optimal role of midwives (specifically certified nurse-midwives and certified-midwives) in blogging and other social media?
2. How can we protect the privacy and dignity of the women and families we serve (and for that matter, the people we work with) when midwives share about our work in social media spaces?
3. What obstetric routines or beliefs would you most like to hear me critically analyze?  I promise to make at least a blog post or two out of my How Not to Get Duped talk. (Actually, what I’ll also do is write parts of the talk from my prior blog posts, so if you have any favorite posts from the archives that you think would make good case studies, please suggest them!)
4. What are the best DC outings to do with a 3 and an almost-6 year old?

Lastly but Oh-So-Not-Leastly, I’ll be attending the Normal Labour and Birth 5th International Research Conference in July.

I’m not speaking at this conference. I’m going for the sole purpose of blogging it! I wrote a proposal to the conference organizers suggesting that they let me attend and help disseminate the proceedings. They agreed!  I think this is a huge opportunity to learn from the people doing the research about how to optimize the health and safety of healthy women and their babies around the time of birth. We’ll also hear from leaders who are creating and maintaining integrated, midwife-led primary maternity care systems, the gold standard for achieving “woman-centered, safe, effective, timely, efficient, and equitable” care.

What happened when bloggers and other connected consumers attended the NIH Consensus Development Conference on VBAC was astounding and continues to deliver. Since that experience, I’m addicted to putting scientific findings in the hands of engaged, connected consumers, because, as Kay Dickerson from the Cochrane Collaboration says, “We’ll only get evidence-based healthcare in this country through consumer activism.” Today activists have more access than ever before to information and are getting increasingly social media savvy. There’s no telling what we can do if we put our innovative, passionate minds to it and work collaboratively.

So here’s what I want to know from YOU:

1. Whose research are you most interested in hearing about? (Look over the Normal Labour and Birth agenda to see who will be presenting about what.)
2. Would you rather have a little bit of information/analysis about more of the presentations or more in-depth analysis of fewer presentations?
3. Are there any researchers you would like me to conduct a “Consider the Source” Interview with?

Finally, any readers who are planning to attend any of these conferences – I invite you to submit a guest post. I’d love to share multiple perspectives (not to mention the tremendous work of blogging all of these meetings!) Just email me at amyromano [at] Lamaze [dot] org.

Amy Romano Uncategorized ACNM, announcements, cesarean, childbirth education, Healthy Birth Practices, hospitals, interventions, maternity care systems, media, midwives, NIH Consensus Conference, Normal Labour & Birth Conference, Participatory Medicine, Personal Health Records, safety