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Epidural Analgesia: To Delay or Not to Delay, That Is the Question

October 23rd, 2014 by avatar

By Henci Goer

Unless you have been “off the grid” on a solitary trek, surely you have read and heard the recent flurry of discussion surrounding the just released study making the claim that the timing of when a woman receives an epidural (“early” or “late” in labor) made no difference in the rate of cesarean delivery.  Your students and clients may have been asking questions and wondering if the information is accurate.  Award winning author and occasional Science & Sensibility contributor Henci Goer reviews the 9 studies that made up the Cochrane systematic review: Early versus late initiation of epidural analgesia for labour to determine what they actually said.  Read her review here and share if you agree with all the spin in the media about this new research review. Additionally, head on over to the professional and parent Lamaze International sites to check out the new infographic on epidurals to share with your students and clients.- Sharon Muza, Science & Sensibility Manager. 

Epidural infographic oneArticles have been popping up all over the internet in recent weeks citing a new Cochrane systematic review- Early versus late initiation of epidural analgesia for labour, concluding that epidural analgesia for labor needn’t be delayed because early initiation doesn’t increase the likelihood of cesarean delivery, or, for that matter, instrumental vaginal delivery (Sng 2014). The New York Times ran this piece. Some older studies have found that early initiation appeared to increase likelihood of cesarean (Lieberman 1996; Nageotte 1997; Thorp 1991), which is plausible on theoretical grounds. Labor progress might be more vulnerable to disruption in latent than active phase. Persistent occiput posterior might be more frequent if the woman isn’t moving around, and fetal malposition greatly increases the likelihood of cesarean and instrumental delivery. Which is right? Let’s dig into the review.

The review includes 9 randomized controlled trials of “early” versus “late” initiation of epidural analgesia. Participants in all trials were limited to healthy first-time mothers at term with one head-down baby. Five trials further limited participants to women who began labor spontaneously, three mixed women being induced with women beginning labor spontaneously, and in one, all women were induced. Analgesia protocols varied, but all epidural regimens were of modern, low-dose epidurals. So far, so good.

Examining the individual trials, though, we see a major problem. You would think that the reviewers would have rejected trials that failed to divide participants into distinct groups, one having epidural initiation in early labor and the other in more advanced labor, since the point of the review is to determine whether early or late initiation makes a difference. You would think wrong. Of the nine included trials, six failed to do this.

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

The two Chestnut trials (1994a; 1994b) had the same design, differing only in that one was of women who were laboring spontaneously at trial entry and the other included women receiving oxytocin for induction or augmentation. Women were admitted to the trial if they were dilated between 3 and 5 cm. Women in the early group got their epidural immediately while women in the late group could have an epidural only if they were dilated to 5 cm or more. If late-group women were not dilated to 5 cm, they were given systemic opioids and could have a second dose of opioid one hour later. They could have an epidural when they attained 5 cm dilation or regardless of dilation, an hour after the second opioid dose. Let’s see how that worked out.

Among the 149 women in the trial that included women receiving oxytocin (Chestnut 1994b), median dilation in the early group at time of epidural initiation was 3.5 cm, meaning that half the women were dilated more and half less than this amount. The interquartile deviation was 0.5 cm, which means that values were fairly tightly clustered around the median. The authors state, however, that cervical dilation was assessed using 0.5 increments which meant that dilation of 3-4 cm was recorded as 3.5. In other words, women in the early group might have been dilated to as much as 4 cm. The median dilation in the late group was 5.0 cm, again with a 0.5 cm interquartile deviation. Some women in the late group, therefore, were not yet dilated to 5 cm when their epidural began, and, in fact, the authors report that 26 of the 75 women (35%) in the late group were given their epidural after the second dose of opioid but before attaining 5 cm dilation. The small interquartile deviation in the late group tells us that few, if any, women would have been dilated much more than 5 cm. Add in that assessing dilation isn’t exact, so women might have been a bit more or less dilated than they were thought to be, and it becomes clear that the “early” and “late” groups must have overlapped considerably. Furthermore, pretty much all of them were dilated between 3 and 5 cm when they got their epidurals, which means that few of these first-time mothers would have been in active labor, as defined by the new ACOG standards.

Overlap between early and late groups must have been even greater in Chestnut et al.’s (1994a) trial of 334 women laboring spontaneously at trial entry because median dilation in the early group was greater than in the other trial (4 cm, rather than 3.5) while median dilation in the late group was the same (5.0 cm), and interquartile deviation was even tighter in the late group (0.25 cm, rather than 0.5 cm). As before, dilation was measured in 0.5 cm increments, which presumably means that women in the early group dilated to 4-5 cm would have been recorded as “4.5,” thereby qualifying them for the “early” group even though they might have been as much as 5 cm dilated.

Based on my analysis, I would argue that there was no clinically meaningful difference in dilation between early and late groups in either trial.

A second pair of trials, one a mixed trial of spontaneous labor onset and induction and the other all induced, also had the same design in both trials (Wong 2005; Wong 2009). All women were less than 4 cm dilated at first request for pain medication. In the early group, women had an opioid injected intrathecally, i.e. the “spinal” part of a combined spinal-epidural, and an epidural catheter was set. At the second request, an epidural was initiated. In the late group, women were given a systemic opioid. At second request, they were given a second dose of systemic opioid if they hadn’t reached 4 cm dilation and an epidural if they had dilated to 4 cm or more. At third request, they were given an epidural regardless of dilation. Women who had no vaginal exam at second request and were given an epidural were “assumed,” in the authors’ words, to be dilated to at least 4 cm. What were the results?

Wong (2005) included 728 women, some beginning labor spontaneously and some induced. You may already have noticed the flaw in the trials’ design: Wong and colleagues confused the issue by considering intrathecal opioid to be equivalent to epidural anesthetic in the early group, although women didn’t actually receive anesthetic until their second request for pain medication some unknown time later. So far as I know we have no evidence that opiods, spinal or epidural, have any effect on labor progress. As to dilation at the time of epidural initiation, 63% of women in the so-called “early” group were either determined or assumed to be at 4 cm dilation or more while in the late group, some unknown proportion were less than 4 cm dilated either because they got their epidural at third pain medication request regardless of dilation or they were assumed to be at 4 or more cm dilation at second request, but weren’t assessed.

Wong (2009), a study of 806 induced women, was set up the same way but reported data somewhat differently. Early-group women were administered a spinal opioid at a median of 2 cm dilation and an interquartile range of 1.5 to 3 cm, which means that values in the middle 50% of the dataset ranged from 1.5 to 3 cm. We have no information on dilation at the time they received their epidural. The median dilation at which late-group women had their epidural initiated was 4 cm with an interquartile range of 3 to 4 cm, that is, in the middle 50% of the dataset ranged from 3 to 4 cm dilation.

As with the Chestnut trials, dilation at time of epidural initiation in the two Wong trials must have overlapped considerably between groups. And, again, few women in the late epidural group would have been in active labor. The Wong trials, however, muddy the waters even further by considering spinal opioid to be the same thing as epidural anesthetic, and while the authors were careful to use the term “neuraxial analgesia,” the Cochrane reviewers made no such distinction.

This brings us to Parameswara (2012), a trial of 120 women that included both spontaneous onset and induced labors. This trial defined the early group as women less than 2 cm dilated at time of epidural initiation and the late group as women more than 2 cm dilated. That’s all the information they provide on group allocation.

Last of the six, we have Wang (2011), a trial of 60 women in spontaneous labor. All women were given intrathecal anesthetic plus opioid. The early group was started on epidural anesthetic plus opioid 20 minutes later whereas the late group had their epidural initiated when they requested additional pain relief. No information is given on dilation at time of epidural initiation. Not only do we have no idea whether early and late groups differed from one another, women in both groups received neuraxial anesthetic at the same time.

In summary, “garbage in, garbage out.” No conclusions can be drawn about the effect of early versus late epidural administration from these six studies.

The other three studies are a different story. They achieve a reasonable separation between groups. Luxman (1998) studied 60 women with spontaneous labor onset. The early group had a mean, i.e., average, dilation of 2.3 cm with a standard deviation of + or – 0.6 cm while the late group had a mean dilation of 4.5 cm + or – 0.2 cm. Ohel (2006) studied a mixed spontaneous onset and induced group of 449 women. The mean dilation at initiation in the early group was 2.4 cm with a standard deviation of 0.7 cm, and the late group had a mean dilation of 4.6 cm with a standard deviation of 1.1 cm. Wang (2009), the behemoth of the trials, included 12,629 women who began labor spontaneously. The early epidural group had a median dilation of 1.6 cm with an interquartile range of 1.1 to 2.8 and the late group a median of 5.1 cm dilation with an interquartile range of 4.2 to 5.7. Cesarean and instrumental delivery rates were similar between early and late groups in all three trials, so had reviewers included only these three trials, they would still have arrived at the same conclusion: early epidural initiation doesn’t increase likelihood of cesarean and instrumental delivery.

We’re not done, though. Wang (2009) points us to a second, even bigger issue.

The Wang (2009) trial, as did all of the trials, limited participants to healthy first-time mothers with no factors that would predispose them to need a cesarean. The Wang trial further excluded women who didn’t begin labor spontaneously. Nevertheless, the cesarean rate in these ultra-low-risk women was an astonishing 23%. Comparing the trials side-by-side reveals wildly varying cesarean and instrumental vaginal delivery rates in what are essentially homogeneous populations.

© Henci Goer

© Henci Goer

© Henci Goer

© Henci Goer

Comparing the trials uncovers that epidural timing doesn’t matter because any effect will be swamped by the much stronger effect of practice variation.

Analysis of the trials teaches us two lessons: First, systematic reviews can’t always be taken at face value because results depend on the beliefs and biases that the reviewers bring to the table. In this case, they blinded reviewers from seeing that two-thirds of the trials they included weren’t measuring two groups of women, one in early- and one in active-phase labor. Second, practice variation can be an unacknowledged and potent confounding factor for any outcome that depends on care provider judgment.

Conclusion

So what’s our take home? Women need to know that with a judicious care provider who strives for spontaneous vaginal birth whenever possible, early epidural administration won’t increase odds of cesarean or instrumental delivery. With an injudicious one, late initiation won’t decrease them. That being said, there are other reasons to delay an epidural. Maternal fever is associated with epidural duration. Running a fever in a slowly progressing labor could tip the balance toward cesarean delivery as well as have consequences for the baby such as keeping the baby in the nursery for observation, testing for infection, or administering prophylactic IV antibiotics. Then too, a woman just might find she can do very well without one. Epidurals can have adverse effects, some of them serious. Comfort measures, cognitive strategies, and all around good emotionally and physically supportive care don’t. Hospitals, therefore, should make available and encourage use of a wide range of non-pharmacologic alternatives and refrain from routine practices that increase discomfort and hinder women from making use of them. Only then can women truly make a free choice about whether and when to have an epidural.

After reading Henci’s review and the study, what information do you feel is important for women to be aware of regarding epidural use in labor?  What will you say when asked about the study and timing of an epidural?  You may want to reference a previous Science & Sensibility article by Andrea Lythgoe, LCCE, on the use of the peanut ball to promote labor progress when a woman has an epidural. – SM 

References

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology210(3), 179-193.

Chestnut, D. H., McGrath, J. M., Vincent, R. D., Jr., Penning, D. H., Choi, W. W., Bates, J. N., & McFarlane, C. (1994a). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor? Anesthesiology, 80(6), 1201-1208. http://www.ncbi.nlm.nih.gov/pubmed/8010466?dopt=Citation

Chestnut, D. H., Vincent, R. D., Jr., McGrath, J. M., Choi, W. W., & Bates, J. N. (1994b). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin? Anesthesiology, 80(6), 1193-1200. http://www.ncbi.nlm.nih.gov/pubmed/8010465?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Luxman, D., Wolman, I., Groutz, A., Cohen, J. R., Lottan, M., Pauzner, D., & David, M. P. (1998). The effect of early epidural block administration on the progression and outcome of labor. Int J Obstet Anesth, 7(3), 161-164. http://www.ncbi.nlm.nih.gov/pubmed/15321209?dopt=Citation

Nageotte, M. P., Larson, D., Rumney, P. J., Sidhu, M., & Hollenbach, K. (1997). Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med, 337(24), 1715-1719. http://www.ncbi.nlm.nih.gov/pubmed/9392696?dopt=Citation

Ohel, G., Gonen, R., Vaida, S., Barak, S., & Gaitini, L. (2006). Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol, 194(3), 600-605. http://www.ncbi.nlm.nih.gov/pubmed/16522386?dopt=Citation

Parameswara, G., Kshama, K., Murthy, H. K., Jalaja, K., Venkat, S. (2012). Early epidural labour analgesia: Does it increase the chances of operative delivery? British Journal of Anaesthesia 108(Suppl 2):ii213–ii214. Note: This is an abstract only so all data from it come from the Cochrane review.

Sng, B. L., Leong, W. L., Zeng, Y., Siddiqui, F. J., Assam, P. N., Lim, Y., . . . Sia, A. T. (2014). Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev, 10, CD007238. doi: 10.1002/14651858.CD007238.pub2 http://www.ncbi.nlm.nih.gov/pubmed/25300169

Thorp, J. A., Eckert, L. O., Ang, M. S., Johnston, D. A., Peaceman, A. M., & Parisi, V. M. (1991). Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas. Am J Perinatol, 8(6), 402-410. http://www.ncbi.nlm.nih.gov/pubmed/1814306?dopt=Citation

Wang, F., Shen, X., Guo, X., Peng, Y., & Gu, X. (2009). Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology, 111(4), 871-880. http://www.ncbi.nlm.nih.gov/pubmed/19741492?dopt=Citation

Wang, L. Z., Chang, X. Y., Hu, X. X., Tang, B. L., & Xia, F. (2011). The effect on maternal temperature of delaying initiation of the epidural component of combined spinal-epidural analgesia for labor: a pilot study. Int J Obstet Anesth, 20(4), 312-317. http://www.ncbi.nlm.nih.gov/pubmed/21840705

Wong, C. A., McCarthy, R. J., Sullivan, J. T., Scavone, B. M., Gerber, S. E., & Yaghmour, E. A. (2009). Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial. Obstet Gynecol, 113(5), 1066-1074. http://www.ncbi.nlm.nih.gov/pubmed/19384122?dopt=Citation

Wong, C. A., Scavone, B. M., Peaceman, A. M., McCarthy, R. J., Sullivan, J. T., Diaz, N. T., . . . Grouper, S. (2005). The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med, 352(7), 655-665. http://www.ncbi.nlm.nih.gov/pubmed/15716559?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 She is the 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.  

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, informed Consent, Medical Interventions, New Research, Systematic Review , , , , , , ,

Ideas for Commemorating Pregnancy and Infant Loss Awareness Month

October 9th, 2014 by avatar

By Robin Elise Weiss, PhDc, MPH, CPH, LCCE

October is Pregnancy and Infant Loss Awareness Month and Lamaze International President Robin Elise Weiss challenges all of us to make some time this month to recognize this somber topic.  Robin provides some creative ideas about how you can honor and remember those families and babies who were separated too soon in your community. – Sharon Muza, Community Manager, Science & Sensibility.

© Vicki Zoller

© Vicki Zoller

October has been identified as Pregnancy and Infant Loss Awareness Month. There are also several other pregnancy and infant groups who have specific memorials and functions that occur this month, but I’m going to focus on this as a general topic.

The beauty of being a Lamaze Certified Childbirth Educator is that I have the joy and pleasure of working with happy pregnant families the vast majority of the time. Though what most people don’t think about when they talk to a Lamaze Childbirth Educator is that we can also be a resource when pregnancy is not going perfectly, and that includes the very devastating death of a baby at any point in pregnancy or as a young baby.

This is not something that most parents-to-be want to hear about. It is something that the vast majority will try to avoid thinking about, even though it is a common fear in pregnancy and beyond. Our job as a Lamaze Childbirth Educator is not to scare them but to give matter of fact, honest information without dwelling on the negative. That said, I know that many childbirth educators do not cover this in childbirth class for a variety of reasons. 

My challenge to you this month is to consider doing any or all of the following, depending on where you are in your journey as an educator, parent, human:

  • Read a Book: There are many good books written about pregnancy loss. The vast majority are written from the view point of the parents involved, but these first hand accounts are extremely poignant and important. It can often be helpful in figuring out how to best help someone who is experiencing the death of their baby. You can also create a reading list of books for parents and one for children. If you can, consider donating a book to your local hospital or library.
  • Take a Class: Often you can find classes available, offered often by hospitals, hospice, or perinatal loss groups, during the month of October. They may be focused on birth workers, or be an in general offering. This is a great way to help build your resource list. One geared towards those who work in birth are going to be your best bet.
  • Take a Tour: Call your local hospital and ask to talk to the Labor & Delivery Nurse Manager. Tell her that you are a Lamaze Certified Childbirth Educator in the area and that you are trying to learn more about how they handle pregnancy loss and stillbirth. Ask if they will share their protocols, and talk to you about local resources. They often support groups that you may not see listed when looking locally.
  • Host a Circle: This can be a very touching but difficult thing to do. I would recommend that you find a local chaplain or counselor to co-host this with you unless you are qualified to handle various issues that may arise. Sometimes this might just be with local birth workers who need to talk about their own losses or the losses within their students or clients.
  • Host a Training: If you have a special talent, consider sharing it with others. For example, many years ago, I learned how to make foot molds and then casts from these molds. I’m the only person in town who does this and that means I go whenever someone asks me to go. There may be times I’m not available, but if I pass that information on to others, then it makes it more available to the community. You could also host a training of other sorts, like having someone come talk to a birth network about how to deal with grief and grieving in class or with your clients.
  • Host a Craft Night: This is something we are trying this year as a way to connect with the labor and delivery nurses on the front lines. A group of local doulas and childbirth educators are meeting at the hospital for a night of knitting and crocheting tiny baby hats to be given to the families who have experienced the death of their baby. It is a way for use to share and work together to make a really horrible experience a bit more personal. We are offering patterns for baby hats from very small gestation sizes through infant sizes, some basic instruction on crochet and knitting, and the hospital is providing a room and snacks.
  • Create Your Own Hats: If you need something to do that is tangible but can’t commit to being with others, you can use the patterns below to create your own stash of hats to donate to your local hospital.

I would invite you to share in the comments what’s on your reading list, other ideas you have for this month or even ideas you have that I may have missed.

Useful Links and Resources

 

 

Babies, Childbirth Education, Guest Posts, Newborns , , , , ,

Black Infant Mortality and the Role of the Childbirth Educator and Doula

September 16th, 2014 by avatar

By Sherry L. Payne, MSN, RN, CNE, IBCLC, CD(DONA)

September is National Infant Mortality Month and today, Sherry L. Payne, MSN, RN, CNE, IBCLC, CD(DONA) shares what she and her organization, Uzazi Village, are doing to help reduce infant mortality in the Black community, where Black babies are disproportionately affected.  You are invited to join Sherry and her team at a reception for Doulas of Color and Allies on Friday.  See below for more information.  I plan to be there and look forward to seeing many of our conference attendees there as well. – Sharon Muza, Community Manager, Science & Sensibility.

© NationalHealthyStart.org

© NationalHealthyStart.org

 

I am fresh off the trail, the Missouri Katy Trail, that is. From September 1-12th, I organized the Black Infant Mortality Awareness Walk. My goal was to walk across the midsection of Missouri talking to clinicians, academics, legislators, and policy makers along the way about the high infant mortality rates in the Black community. I chose to walk during the month of September because it is National Infant Mortality Month. I started off in Kansas City, MO and ended in St. Louis MO, walking along the Katy Trail and driving between towns. Now that the walk is behind me and the DONA/Lamaze Confluence ahead of me, its time to think about the message that doulas and childbirth educators need to hear about Black infant mortality. Black infant mortality is a silent epidemic, that is killing our babies and ravaging our communities.

If we don’t all experience equity in health care, than none of us really does.  Sherry Payne

What is infant mortality? It is a statistical term that refers to the number of infant deaths (from birth to age one) for every 1,000 live births. Infant mortality rates are used as a sensitive indicator of community health. Counties, cities, even countries depend on their infant mortality rates and their rankings to tell them how they are doing in protecting the health and wellbeing of their most vulnerable citizens. The United States currently ranks 55th in the world for infant mortality at about 6 deaths per 1,000 live births.  (CIA Factbook) That doesn’t sound too bad until you compare the US to other industrialized nations like Japan with an infant mortality rate of 2 deaths per 1,000 live births, or Canada with a rate of 4 deaths per 1,000 live births. (CIA Factbook). In fact, compared to other industrialized nations, the US does rather poorly on its infant mortality statistics.

© Jordan Wade

© Jordan Wade

What’s behind the high rates of infant deaths in the US? Well, if you look closely, you’ll see that the high numbers come from within communities of color, particularly the African-American community. In Missouri, for example, if you examine the data by race, you will find that infants in the African-American community are 2-4 times more likely to die prior to their first birthday than their Caucasian counterparts. (Missouri Foundation for Health, 2013.) According to the CDC, infant mortality rates have been dropping among all racial groups, but the difference between death rates among Whites and Blacks persist.  Audiences I spoke to all across Missouri were shocked to learn that the African-American community experiences so much more infant death. Of course, its not just Missouri, these disparities are present throughout the United States.

What are the causes of infant deaths in the Black community?  The March of Dimes lists the frequent causes of infant mortality as prematurity, and complications of prematurity.  Other causes listed in the Kansas City Fetal Infant Mortality Review Report include; low birth weight, lack of access to prenatal care, delayed prenatal care, and poor quality of prenatal care, SIDs and unsafe sleep environments.  These problems are often exacerbated by overarching systemic and structural racism that unfairly targets and penalizes African-American women.  Here in Missouri, low income women can wait up to six months or more to be approved for Medicaid, and often may not be able to start prenatal care until they are approved.  

What can doulas and childbirth educators do about Black infant mortality? Well plenty, actually. Doulas have already been shown to be effective in lowering induction and prematurity rates. (Hodnett, Gates, Hofmeyr, & Sakala, 2013.)  Doulas and childbirth educators by the very nature of their work, assist healthcare consumers in being better informed about their childbearing options. Doulas provide the one on one support that is needed by any woman to boost her confidence in her ability to endure the rigors of childbirth without excessive use of interventions that can place a mother and her baby at greater risk. Childbirth educators can ensure that women understand informed consent and know how to advocate for it. They can both prepare a woman for successful breastfeeding which is protective for sick and vulnerable infants.

But aren’t low income African-American women, the women most likely to be affected by poor birth outcomes, the least likely to interface with doulas and childbirth educators? Yes, that is true. One of the ways to solve that problem is to recruit, promote, and support candidates of color into these fields. There are plenty of women of color who want to do this work, but they often lack the resources. They need the help of allies to provide resources, scholarships, internships, discounts, etc. to assist in getting through expensive trainings. Not all women of color need financial assistance, but for those who do, it can be a formidable barrier. They also need accessible pathways into the profession. If your organization is hosting a training, communicate that within your local communities of color, so that others have a possibility of sharing in the educational opportunities. Do you have women of color as clients in your practice? Invite them to consider becoming doulas or childbirth educators when the time is right for them. They may not consider it a possibility until someone else brings it up as an option.

To learn more about how doulas and childbirth educators can positively impact infant mortality in the Black community, attend my session at the upcoming conference, “Doulas in the Hood: Improving Outcomes Among Low Income Women.” You’ll learn about programs in Missouri and other states that have created successful models that link doulas with low income women. You’ll hear what we are doing here in Kansas City to bridge the needs gap for low income African-American women, for breastfeeding support, for culture specific childbirth education, and for peer model doulas.

Do Black women need Black doulas and childbirth educators?  In a perfect world, my answer would be yes.  It is important for a woman to have a doula or childbirth educator that shares her cultural/world view and understanding of birth and parenting.  However, while there simply are not enough African-American doulas, and childbirth educators out there, those who do serve African-American clients have a responsibility to educate themselves about the issues that impact communities of color.  Examine your own internal biases (everyone has them).  Take a look at your practice.  Would it be inviting to other women of other cultures, races, and ethnicities?  Refer to Science & Sensibility’s Welcoming All Families: Working with Women of Color post from earlier this year.

Until we begin to see the problem of Black infant mortality as a problem for ALL of us, the problems will persist. If we don’t all experience equity in health care, than none of us really does.

I would like to invite any and all of the confluence attendees to join the Board of Directors of both Lamaze International and DONA International and my Uzazi team at our Uzazi Village Reception for Doulas of Color and Allies, on Friday evening, September 19th, 2014 at 7 PM.  Uzazi Village is located at 3647 Troost Ave, Kansas City, MO, 64109.  Hear about programs that are working to lower the infant mortality rate among black infants in our community and connect with others who share your concern and desire to affect change.

References

Amnesty International. (2010). Deadly Delivery: The maternal health care crisis in the USA. Published by Amnesty International.

Beal, A., Kuhlthau, K., and Perrin, J. (2003). Breastfeeding Advice Given to African American and White Women by Physicians and WIC Counselors. Public Health Reports. Vol. 118. p. 368-376.

CIA World Factbook https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

Cricco-Lizza R., (2006)., Black Non-Hispanic mother’s perception about the promotion of infant feeding methods by nurses and physicians. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, Mar-Apr; 35 (2): 173-80.

Fetal Infant Mortality Review 2013. A Program Report of the Mother and Child Health Coalition. Kansas City, Missouri.

Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2013). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews. In: The Cochrane Library, (9).

Kozhimannil K, Hardeman R, Attanasio L, Blauer-Petersen C. (2013). Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries.
Am J Public Health 2013;103(4):e113-e121.

Lee, H., Rubio, M.R., Elo,T., McCollum, F., Chung, K., Culhane, F. (2005). Factors associated with intention to breastfeed among low-income, inner-city women. Maternal & Child Health Journal Sep; 9 (3): 253-61

Missouri Foundation for Health (2013) Health Equity Series: African American Health Disparities in Missouri. Missouri Department of Health and Senior Services, Section for Epidemiology and Public Health Practice, St. Louis, MO.

MMWR Morbidity and Mortality Weekly Report. (2002). Infant mortality and low birth weight among black and white infants–United States, 1980-2000. Centers for Disease Control and Prevention (CDC). Jul 12;51(27):589-92.

Morbidity and Mortality Weekly Review (2013). Progress in Increasing Breastfeeding and Reducing Racial/Ethnic Differences — United States, 2000–2008 Births 62(05);77-80 Retrieved from CDC: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6205a1.htm?s_cid=mm6205a1_w

National Center for Health Statistics. National Vital Statistics Reports (NVSR). Deaths: Final Data for 2011

Newborn loss. (n.d.). Neonatal death. Retrieved September 15, 2014, from http://www.marchofdimes.org/loss/neonatal-death.aspx

Van Ryn, M. (2002). Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care. Medical Care. Vol. 40, No. 1 pp. 140-151.

About Sherry L. Payne

© Sherry Payne

© Sherry Payne

Sherry L. Payne, MSN RN CNE IBCLC CD(DONA), holds a BSN in nursing and an MSN in nursing education from Research College of Nursing/Rockhurst University in Kansas City, MO. She is a certified nurse educator and an Internationally Board Certified Lactation Consultant. She presents nationally on topics related to perinatal health and breastfeeding among African-American women. Ms. Payne founded Uzazi Village, a nonprofit dedicated to decreasing health inequities in the urban core. She is an editor for the Clinical Lactation journal, and participates in her local Fetal Infant Mortality Review Board (FIMR) Board, where she reviews cases and makes recommendations for improvements. Her career goals include opening an urban prenatal clinic and birth center. She would also like to work towards increasing the number of community-based midwives of color and improving lactation rates in the African-American community through published investigative research, the application of evidence-based clinical practice and innovation in healthcare delivery models. Ms. Payne resides in Overland Park, KS with her husband , where they have nine children, six of whom were home-birthed and breastfed.  Contact Sherry for more information about her programs.

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Series: Welcoming All Families; Working with Women Pregnant after Infertility

September 9th, 2014 by avatar

Continuing the Science & Sensibility occasional  series: Welcoming All Families, Certified Nurse Midwife Emalee Danforth examines the research on perinatal and postpartum mental health on the family who arrives in your classroom or office with a history of infertility.  As the childbirth educator, you (and the rest of the class) most likely will not be aware of the families with this specific history, unless the family chooses to share privately or in the class group.  The educator needs to understand and recognize the increased risk of perinatal and postpartum mood disorders these families face.  Childbirth educators should evaluate their language and stories to be sure that they are providing sensitive and appropriate language and examples that welcome and apply to those whose path to parenthood might not be the same as other families in your class. – Sharon Muza, Community Manager, Science & Sensibility.

By Emalee Danforth, CNM

© Wikipedia

© Wikipedia

Infertility, defined as the inability to conceive after 12 months of timed intercourse or donor insemination (Practice Committee for the American Society of Reproductive Medicine, 2013), is a common experience. While estimates range, approximately 6-15% of the United States population will experience infertility (Chandra, Copen & Stephen, 2013) with higher rates possible when viewed from the global perspective (Mascarenhas, Flaxman, Boerma, Vanderpoel & Stevens, 2012).

The majority of research on the experience of pregnancy and parenting following infertility examines only those who have conceived using IVF (in vitro fertilization, also referred to as ART, assisted reproductive technology). This group of patients is easy to identify and therefore study, but represents only a portion of those who have experienced infertility. Additionally, study designs have often excluded those with multiple gestations, those with same sex partners, and those who have utilized donor gametes. In everyday life, all of these types of clients will cross the path of a care provider or childbirth educator and each has a unique experience. The available research can outline some of the known characteristics of persons who have conceived via IVF after infertility but caution should be applied to generalizations.

The Psychology of Pregnancy after Infertility

There is a particular psychology of infertility that can transfer to pregnancy, childbirth and postpartum. The emotional hallmark of infertility is anxiety (Bell, 2013). Once pregnant, this worry does tend to persist through the pregnancy and heighten as the due date approaches. The level of general anxiety appears similar to those who have conceived spontaneously, but pregnancy-focused anxieties are heightened in previously infertile women, especially those who experienced prolonged treatment failure and high infertility-related distress (Hammarberg, Fisher & Wynter, 2008). McMahon et al. (2011) points out that “the relatively low correlation between pregnancy-focused anxiety and state anxiety…confirms that pregnancy-focused anxiety needs to be considered as a separate construct from more generalized anxiety” (p. 1394) and that this phenomena may be due to a particular reproductive history rather than individual personality factors.

Infertility is also known to be associated with elevated rates of depression (Cousineau & Domar, 2007). However, evidence is consistent that once pregnant, ART women and men experience lower levels of depressive symptoms than those that have spontaneously conceived (Hammarberg et al., 2008). This may be related to higher rates of psychosocial factors that are protective for perinatal mood disturbance in ART expecting women and men including higher socioeconomic status, higher education, higher quality and longer lasting intimate relationships, being older than average and having a planned conception (Fisher, Hammarberg & Baker, 2008). This same study posits that “it is possible that this low rate of distress is reflecting an almost elated mood, in which the pregnant state and family formation achieved after a long period of anticipation and via intrusive and disruptive interventions are somewhat idealized”(p.1110). Indeed, Hjelmstedt, Widstrom, Wramsby & Collins (2003) found that ART women experienced pregnancy in a less negative way and were also less worried about possible “loss of freedom” in their future lives as parent compared to the spontaneous conception control group.

It is therefore surprising that after birth, ART women experience postpartum depression at similar rates to the rest of the childbearing population (Hammarberg et al., 2008). Fisher et al. (2008) found significantly higher rates of admission for ART women in Australia for postpartum mood disturbances despite their more elevated mental state antepartum. This may be because after a long struggle with infertility and undergoing invasive and costly procedures, ART women feel “a low sense of entitlement to complain or to express any doubts, uncertainty, or mixed feelings about the realities of motherhood (Fisher et al., 2008, p. 1111).” However, once the baby or babies are born, ART women must adjust to motherhood and cope with the demands of a newborn just as any other mother. The combination of idealization of motherhood and lack of preparation for the experience of ambivalence can cause mental distress postpartum. In addition, the higher frequency of birth complications among ART women including preterm birth, cesarean section, low birth weight and multiple gestation (Hammarberg et al., 2008) all can have an additive effect on the stresses of motherhood.

There is evidence that ART women experience the process of emotional attachment to the fetus differently from those with spontaneous conception. Fisher et al. (2008) found that ART women thought about their fetus as much in early pregnancy as the general population of mothers did in advanced pregnancy. In late pregnancy, ART women had significantly more intense and protective emotional attachments to the fetus than women who spontaneously conceived. McMahon et al. (2011) found that with age taken into account, there was a strong association between ART conception and more intense maternal-fetal attachment. This is likely the result of extended anticipation of parenthood, investment in the process of conception and intimate awareness of the biology and timing of conception.

© infertile.com

© infertile.com

There remains a dearth of information on the experiences of ART women during childbirth. There exists one recent prospective multicenter study out of Finland on this topic (Poikkeus et al., 2014) which finds that dissatisfaction with childbirth was similar between ART women and controls with singleton pregnancies. The factors that have been previously found to be related to risk for a negative childbirth experience still remained true for both groups: low educational level, inadequate social support, dissatisfaction with her partner or spouse, untreated fear of childbirth and antenatal depression. Also recalled intolerable pain in birth and giving birth by emergency cesarean section increased dissatisfaction with birth. The authors’ conclusion was that dissatisfaction with childbirth was not related to mode of conception but rather lay with the underlying individual psychosocial and obstetric factors of each patient.

Recommendations for Care

While the body of research on the experience of women pregnant after infertility remains emergent, we can use what we know to help guide the most optimal and sensitive care for this population. Firstly, it is important to remember that this group is often invisible, particularly in the childbirth education classroom. The question “how many months did it take you to conceive?” or the unwitting quote from Ina May Gaskin “What got the baby in is what will get the baby out” will land quite differently on the ears of a woman who has gone through ART. In the clinical setting most if not all patients will share their mode of conception, but in the setting of CBE it may be kept private and language usage should be sensitive to this.

The within-group differences in an ART population can also be significant. A woman who needed help getting pregnant due to a very low sperm count in her male partner and conceived on her first round of IVF will likely have a different experience and outlook than a woman who has gone through multiple rounds of failed IVF for unexplained infertility and a miscarriage before having a term pregnancy with an egg donor. Each woman will be having her own unique experience.

The combination of early and intense attachment to the fetus as well as increased levels of pregnancy specific anxiety for ART women points to the need for frequent reassurance and quite possibly increased frequency of care, particularly in the first trimester and prior to quickening. Sensitive care during pregnancy can help transition a client, if appropriate, from a sense of herself as “high risk” and under specialty care to generalist obstetric or “low risk” midwifery care. Bell (2013) suggests that this reassurance will help women “slowly grow to trust in the process which is pregnancy, and … gain a sense of accomplishment and fulfillment as they continue to gestate” (p.51).

Promoting physiologic birth is the goal for all women including ART women. ART women are more likely to have protective social factors such as greater age, income, education and more stable relationships that can help increase satisfaction with childbirth but concurrently more likely to have characteristics such as older age, multiple gestation and preterm birth that lead to higher rates of obstetric intervention, which leads to a decreased satisfaction with childbirth. Working with each client’s individual strengths and limitations will help best prepare her for birth. For many women, feeling like they are active participants in their childbirth care and decision making is critical to their feeling of satisfaction. Involvement in this process may help a client regain a sense of control that may have been eroded during invasive and intensive infertility treatments.

While baby blues and postpartum depression and anxiety should be discussed with every client, understanding more about the psychology of ART women can help guide a practitioner to have a nuanced and sensitive discussion with these clients. A skilled provider or childbirth educator will be able to recognize and honor the joy and gratefulness that an expecting woman or couple feels after conceiving through ART, but also understand that this is likely layered with pregnancy-specific anxiety, a desire to regain some sense of control over one’s body or birth, and a vulnerability to postpartum mood disturbances. Anticipatory counseling including statements such as “some women who give birth after successful IVF treatments are surprised by the many ups and downs of caring for a newborn and may not have anticipated any negative feelings” or “no matter how glad you are to become a mother, it is normal to experience fatigue and feelings of ambivalence.” can help new parents allow their full range of feelings to surface. When mothers feel safe to share their feelings, more prompt identification and treatment of depression and anxiety is possible.

Understanding the prevalence of infertility and its psychological effects can help the childbirth educator, nurse, clinician or other birth professional provide sensitive and optimal care to the often invisible population of women or couples who are pregnant following infertility treatment.

Have you had families with a history of infertility in your childbirth classes?  As clients? What if anything did you do different to be sure to meet the needs of these families?  Can you share how you have handled this in your classroom environment?  Did your families choose to let you know?  Your thoughts and comments are valued in our discussion section below. – SM

References

Bell, K.M. (2013). Supporting childbearing families through infertility. International Journal of Childbirth Education, 28(3), 48-53.

Cousineau, T.M. & Domar, A.D. (2007). Psychological impact of infertility. Best Practice & Research Clinical Obstetrics and Gynaecology, 21(2), 293-308. doi: 10.1016/j.bpobgyn.2006.12.003

Chandra, A., Copen, E.E. & Stephen, E.H (2013). Infertility and impaired fecundity in the United States, 1982-2010: Data from the National Survey of Family Growth. National Health Statistics Report, 67, 1-18.

Fisher, J., Hammarberg, K. & Baker, G.(2008). Antenatal mood and fetal attachment after assisted conception. Fertility and Sterility, 89(5), 1103-1112. doi: 10.1016/j.fertnstert.2007.05.022

Hammarberg, K., Fisher, J. & Wynter, K. (2008). Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: A systematic review. Human Reproduction Update, 14(5), 395-414. doi: 10.1093/humupd/dmn030

Hjelmstedt, A., Widstrom, A-M., Wramsby, H. & Collins, A. (2003). Patterns of emotional responses to pregnancy, experience of pregnancy and attitudes to parenthood among IVF couples: A longitudinal study. J Psychosom Obstet Gynecol, 24, 153-162.

Mascarenhas, M.N., Flaxman, S.R., Boerma, T., Vanderpoel, S. & Stevens, G.A. (2012). National, regional, and global trends in infertility prevalence since 1990: A systematic analysis of 277 health surveys. PLOS Medicine, 9(12), 1-12. doi: 10.1371/journal.pmed.1001356

McMahon, C.A., Boivin, J., Gibson, F.L., Hammarberg, K., Wynter, K., Saunders, D. & Fisher, J. (2011). Age at first birth, mode of conception and psychological wellbeing in pregnancy: Findings from the parental age and transition to parenthood Australia (PAPTA) study. Human Reproduction, 25(6), 1389-1398. doi: 10.1093/humrep/der076

Poikkeus, P., Saisto, T., Punamaki, R., Unkila-Kallio, L., Flykt, M., Vilska, S., Repokari, L. … (2014). Birth experience of women conceiving with assisted reproduction: A prospective multicenter study. Acta Obstet Gynecol Scand 2014; doi: 10.1111/aogs.12440
Practice Committee for the American Society of Reproductive Medicine (2013). Definitions of infertility and recurrent pregnancy loss: A committee opinion. Fertility and Sterility, 99(1), 63. doi: 10.1016/j.fertnstert.2012.09.023

Toscano, S.E. & Montgomery R.M. (2009). The lived experience of women pregnant (including preconception) post in vitro fertilization through the lens of virtual communities. Health Care for Women International, 30:11, 1014-1036. doi:10.1080/07399330903159700

About Emalee Danforth

Danforth Emalee head shotEmalee Danforth is a Certified Nurse-Midwife working in Seattle, WA. She practices at University Reproductive Care, the University of Washington’s infertility and reproductive endocrinology clinic. Previously she spent 5 busy years practicing full-scope midwifery in the hospital setting. She holds a BSN from the University of Michigan and an MSN from the University of Washington. She is also a co-facilitator of Maybe Baby, a resource and support group for LGBT persons on the path to parenthood.

Childbirth Education, Guest Posts, Perinatal Mood Disorders, Postpartum Depression, Series: Welcoming All Families , , , , , , ,

Breastfeeding & Racial Disparities in Infant Mortality: Celebrating Successes & Overcoming Barriers

August 28th, 2014 by avatar
© mochamanual.com

© mochamanual.com

August has been designated as World Breastfeeding Month, and Science & Sensibility was happy to recognize this with a post earlier this month that included a fun quiz to test your knowledge of current breastfeeding information.  Today, we continue on this topic and celebrate Black Breastfeeding Week 2014 with a post from regular contributor, Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA sharing information about the increased breastfeeding rates rates among African American women.  Kathleen also discusses some of the areas where improvements can help this rate to continue to increase. 

Celebrating Successes

Many exciting changes occurred in 2013 in the breastfeeding world. One of the best trends was the increase in breastfeeding rates in the African American community. The CDC indicated that increased breastfeeding rate in African American women narrowed the gap in infant mortality rates.  As the CDC noted:

From 2000 to 2008, breastfeeding initiation increased…from 47.4% to 58.9% among blacks. Breastfeeding duration at 6 months increased from…16.9% to 30.1% among blacks. Breastfeeding duration at 12 months increased from… 6.3% to 12.5% among blacks.

Much of this wonderful increase in breastfeeding rates among African Americans has come from efforts within that community. In 2013, we saw the first Black Breastfeeding Week become part of World Breastfeeding Week in the U.S. Programs, such as A More Excellent Way, Reaching Our Sisters Everywhere (ROSE), and Free to Breastfeed, offer peer-counselor programs for African American women.


We can celebrate these successes. But there is still more to do. Although the rates of infant mortality have dropped, African Americans babies are still twice as likely to die. In addition, although rates of breastfeeding have increased among African Americans, they are still lower than they are other ethnic groups.

For each of the 2000–2008 birth years, breastfeeding initiation and duration prevalences were significantly lower among black infants compared with white and Hispanic infants. However, the gap between black and white breastfeeding initiation narrowed from 24.4 percentage points in 2000 to 16.3 percentage points in 2008.

Barriers to Overcome

In order to continue this wonderful upward trend in breastfeeding rates, we need to acknowledge possible barriers to breastfeeding among African American women. Here are a couple I’ve observed. They are not the only ones, surely. But they are ones I’ve consistently encountered. They will not be quick fixes, but they can be overcome if we recognize them and take appropriate action.

1) Pathways for IBCLCs of Color

In their book, Birth Ambassadors: Doulas and the Re-Emergence of Women-Supported Birth in America, Christine Morton and Elayne Clift highlight a problem in the doula world that also has relevance for the lactation world: most doulas (and IBCLCs) are white, middle-class women. And there is a very practical reason for this. This is the only demographic of women that can afford to become doulas (or IBCLCs). The low pay, or lack of job opportunities for IBCLCs who are not also nurses, means that there are limited opportunities for women without other sources of income to be in this profession. Also, as we limit tracks for peer-counselors to become IBCLCs, we also limit the opportunities for women of color to join our field. I recently met a young African American woman who told me that she would love to become an IBCLC, but couldn’t get the contact hours needed to sit for the exam. That’s a shame. (I did refer her to someone I knew could help.)

2) We need to have some dialogue about how we can bring along the next generation of IBCLCs. We need to recognize the structural barriers that make it difficult for young women of color to enter our field. ILCA has started this dialogue and held its first Lactation Summit in July to begin addressing these issues.

These discussions can start with you. Sherry Payne, in her recent webinar, Welcoming African American Women into Your Practice, recommends that professionals who work in communities of color find their replacement from the communities they serve.  Even if you only mentor one woman to become an IBCLC, you can have a tremendous impact in your community. If we all do the same, we can change the face of our field. (Note, here is a wonderful interview with Sherry as she discusses “Fighting Breastfeeding Disparities with Support.”)

3) Bedsharing and Breastfeeding

 This is an issue that I expect will become more heated over the next couple of years. But it is a reality. As we encourage more women to breastfeed, a higher percentage of women will bedshare. As recent studies have repeatedly found, bedsharing increases breastfeeding duration. This is particularly true for exclusive breastfeeding.

Bedsharing is a particular concern when we are talking about breastfeeding in the African American community. Of all ethnic groups studied, bedsharing is most common in African Americans. It is unrealistic to think that we are going to simultaneously increase breastfeeding rates while decreasing bedsharing rates in this community. The likely scenario is that breastfeeding would falter. It’s interesting that another recent CDC report, Public Health Approaches to Reducing U.S. Infant Mortality, talks quite a bit about safe-sleep messaging, with barely a mention of breastfeeding in decreasing infant mortality.  A more constructive approach might be to talk about being safe while bedsharing. But as long as the message is simply “never bedshare,” there is likely to be little progress, and it could potentially become a barrier to breastfeeding.


Reason to Hope

BBW-Logo-AugustDates3Even with these barriers, and others I haven’t listed, Baby-Friendly Hospitals are having a positive effect. When hospitals have Baby-Friendly policies in place, racial disparities in breastfeeding rates seem to disappear. For example, a study of 32 U.S. Baby-Friendly hospitals revealed breastfeeding initiation rates of 83.8% compared to the national average of 69.5%. In-hospital exclusive breastfeeding rates were 78.4% compared with a national rate of 46.3%. Rates were similar even for hospitals with high proportions of black or low-income patients (Merewood, Mehta, Chamberlain, Phillipp, & Bauchner, 2005). This is a very hopeful sign, especially as more hospitals in the U.S. go Baby-Friendly.

http://kcur.org/post/kc-group-fights-breast-feeding-disparities-education-support

In summary, we have made significant strides in reducing the high rates of infant mortality, particularly among African Americans. I am encouraged by the large interest in this topic and the number of different groups working towards this goal. Keep up the good work. I think we are reaching critical mass.

Additional resource: Office of Women’s Health, U.S. Department of Health & Human Services Breastfeeding Campaign for African American families.

References

Merewood, A., Mehta, S. D., Chamberlain, L. B., Phillipp, B. L., & Bauchner, H. (2005). Breastfeeding rates in U.S. Baby-Friendly hospitals: Results of a national survey. Pediatrics, 116(3), 628-634.

Reprinted with permission from Clinical Lactation, Vol. 5-1. http://dx.doi.org/10.1891/2158-0782.5.1.7

About Kathleen Kendall-Tackett

kendall-tackett 2014-smallKathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist, International Board Certified Lactation Consultant and Fellow of the American Psychologial Association in both the divisions of Health and Trauma Psychology. Dr. Kendall-Tackett is President-Elect of the Division of Trauma Psychology, Editor-in-Chief of Clinical Lactation, clinical associate professor of pediatrics at Texas Tech University Health Sciences Center, and Owner/Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett has authored more than 310 articles or chapters and is the author or editor of 22 books on women’s health, maternal depression, family violence and breastfeeding. Dr. Kendall-Tackett and Dr. Tom Hale received the 2011 John Kennell and Marshall Klaus Award for Research Excellence from DONA International. You can find more from her at Uppity Science Chick

 

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