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Safe at Home? New Home Vs. Hospital Birth Study Reviewed by Henci Goer

November 26th, 2013 by avatar

 Regular contributor Henci Goer examines the most recent study on the safety of home birth in the United States.  When taking a closer look at the data analysis done by the authors, there are concerns not addressed in the study, that raise issues that cause the study’s conclusions to be questioned. Henci shares some other studies that do not reach the same results about the safety of home birth. Have you read this study?  If you had read this study too, did you find more questions than answers when you were done? – Sharon Muza, Community Manager, Science & Sensibility.

“Researchers have already cast much darkness on the subject, and if they continue their investigation, we shall soon know nothing at all.” – Mark Twain

flickr.com/photos/vestfamily/2591899412/

The latest contender in the long list of studies attempting to compare the safety of home and hospital birth, “Selected perinatal outcomes associated with planned home births in the United States,” was published last month (Cheng 2013). Let’s start by summarizing the study:

Using data compiled from the U.S. birth certificate, Cheng and colleagues compared outcomes between 12,039 women “planning” home births with 2,081,753 women having hospital births. All women were at term (between 37 and 43 weeks) and carrying one head-down baby. Women with prior cesarean were not excluded. After adjustment for numerous factors including number of prior births, medical conditions (hypertension, diabetes), risk factors (smoking), and social and demographic factors (race/ethnicity, age, marital status), women having home births were much less likely to have an instrumental vaginal delivery (0.1% vs. 6.2%; odds ratio 0.1), induced labor (1.4% vs. 25.7%; odds ratio 0.2), or labor augmentation (2.1% vs. 22.2%; odds ratio 0.3). They were also, however, twice as likely to have a baby with a 5-minute Apgar less than 4 (0.24% vs. 0.37%; odds ratio 1.9), three times as likely to have a baby experience neonatal seizure (0.06% vs. 0.02%; odds ratio 3.1), and more than twice as likely to have a baby with 5-minute Apgar less than 7 (2.42% vs. 1.17%; odds ratio 2.4). On the other hand, similar percentages of babies needed more than 6 hours of ventilator support, and babies born at home were much less likely to be admitted to intensive care (0.57% vs. 3.03%; odds ratio 0.2). In the discussion, the investigators note that removing the 489 women with previous cesareans who had planned home birth and women with medical or obstetric conditions did not alter that infants of women with prior births who planned home birth were more likely to have a low Apgar score. They don’t specify whether this was 5-minute Apgar less than 4 or less than 7 nor do they report the occurrence rate in this higher-risk subgroup.

There is more. To evaluate the effect of birth attendant qualifications, the investigators excluded births attended by doctors or unknown birth attendant and stratified the remaining home birth population into those attended by professional midwives and those attended by “other midwives.” (Confusingly, study authors state that Certified Professional Midwives [CPMs] were categorized as Certified Nurse-Midwives in the birth certificate data yet go on to refer solely to “CNMs” in the rest of the analysis.) In the subset attended by professional midwives, newborn outcomes were similar except that hospital-born infants were more likely to be admitted to intensive care (0.37% vs. 3.03%; odds ratio 0.1).

Cheng and colleagues conclude that while women planning home births are less likely to experience obstetric intervention, their babies are more likely to be born in poor condition. Do their data warrant that conclusion?

To begin with, the relevant question isn’t the tradeoffs between planned home birth per se and hospital birth. It is: “What are the excess risks for healthy women at low risk of urgent complications who plan home birth with qualified home birth attendants compared with similar women planning hospital birth?” This study can’t answer that question. Here’s why:

The study only includes women actually delivering at home, but you can’t make a meaningful comparison unless you have the outcomes of women transferred to hospital. “Planning” in this study meant only that birth at home wasn’t accidental, not the more usual meaning that birth may be planned at home but problems during labor may alter that plan. I discovered this when I wrote the lead author to request cesarean rates, which, oddly, to me, were not reported in the study. She responded that this was because cesareans aren’t performed at home. Puzzled by this explanation, I wrote back that neither are instrumental vaginal delivery, induction, nor labor augmentation, which were reported. She responded that birth certificate data don’t state how labor was induced or augmented but that perhaps at home births it was by rupturing membranes and that “apparently some midwives or birth attendants do perform vacuum extraction at home,” but it is rare since only 10 were reported.

Not all women planning home birth were low-risk. For one thing, women with prior cesareans were included. For another, the methods section states that the analysis adjusted for medical risk, and the discussion notes that women with prior children in the home birth group were more likely to have babies with low Apgar scores even after removing women with medical risk, which implies that some of them had medical problems.

Not all women in the home birth group had qualified home birth attendants. Outcome data on the overall population came from women recorded as being attended by MDs, DOs, “other midwife,” “others,” and “unknown/not stated” as well as by professional midwives.

Rates of neonatal seizure and 5-minute Apgar less than 4 were very low, and the study doesn’t report on perinatal death or permanent disability. As concerning as an excess in low Apgar scores and seizures may be, the real question is excess incidence of permanent harm. Even without limiting the population to low-risk women with qualified care providers, only 1 more baby per 1000 born at home experienced very low 5-minute Apgar, and only 4 more babies per 10,000 experienced neonatal seizure, and while babies born in poor condition are more likely to incur permanent neurologic damage or die, most will recover. Also, as we saw, differences in rates of these adverse outcomes disappeared with a qualified provider.

The proof of the pudding lies in studies free of these weaknesses. A study of 530,000 low-risk Dutch women found no difference in deaths during labor or newborn death rates between women planning, but not necessarily having, home birth and those planning hospital birth (de Jonge 2009). A Canadian study comparing outcomes of 2900 women eligible for home birth with women equally eligible but planning hospital birth reported worse newborn outcomes (more required resuscitation at birth or oxygen for more than 24 hrs and more birth injuries), worse maternal outcomes (more anal sphincter tears and postpartum hemorrhage), and more use of instrumental and cesarean delivery in the hospital population (Janssen 2009).

What can we take away from Cheng and colleagues analysis? First, care provider qualifications matter. Women desiring home birth should have access to professional midwifery care, which argues for making CPMs legal in all 50 states. Second, less than optimal candidates are birthing at home, and some women may be continuing labor at home who shouldn’t. Why might that be? Women may choose home birth because they want control over what happens to them, they have had a prior negative hospital experience, or they want to avoid unnecessary medical intervention (Boucher 2009), the last of which will include women denied hospital VBAC. Women may resist hospital transfer for the same reasons or because they know that at best, hospital transfer means losing the care and advice of the care provider they trust and at worst, they will be treated badly by disapproving hospital staff. If we want to reduce their numbers, hospital-based practitioners need to address the behaviors, practices, and policies that drive women away from hospital birth. This would have the added benefit of improving care for the 99% of American women who would never consider birthing at home.

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126. http://www.ncbi.nlm.nih.gov/pubmed/?term=boucher+2009+home+birth

Cheng, Y. W., Snowden, J. M., King, T. L., & Caughey, A. B. (2013). Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol, 209(4), 325 e321-328. doi: 10.1016/j.ajog.2013.06.022 http://www.ncbi.nlm.nih.gov/pubmed/23791564

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 116(9), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed/?term=de+jonge+2009+planned+home

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6-7), 377-383. http://www.ncbi.nlm.nih.gov/pubmed/19720688

 

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Lamaze International Releases Valuable Cesarean Infographic For You To Share!

October 10th, 2013 by avatar

Lamaze International has long been a leader in providing resources for both parents and birth professionals that promote safe and healthy birth for women and babies.  Evidence based information, appealing handouts, useful webinars for both parents and professionals, continuing education opportunities and more can all be found within the Lamaze International structure.  In May, 2012, Lamaze International released  (and later went on to be a co-winner for the 2013 Nonprofit PR Award for Digital PR and Marketing) the Push For Your Baby campaign, which encouraged families to “push for better” and “spot the best care,” providing resources to help parents wade through the overabundance of often inaccurate information swimming past them, and make choices that support a healthy pregnancy, a healthy birth and a healthy mother and baby.

Today, as I make my way to New Orleans, to join other professionals at the 2013 Annual Lamaze International Conference, “Let the Good Times Roll for Safe and Healthy Birth,” Lamaze International is pleased to announce the release of a useful and appealing infographic titled “What’s the Deal with Cesareans?” In the USA today, 1 in 3 mothers will give birth by cesarean section.  While, many cesareans are necessary, others are often a result of interventions performed at the end of pregnancy or during labor for no medical reason.  For many families, easy to understand, accurate information is hard to find and they feel pressure to follow their health care provider’s suggestions, even if it is not evidence based or following best practice guidelines.

Families taking Lamaze classes are learning about the Six Healthy Birth Practices, which can help them to avoid unnecessary interventions. Now, Lamaze childbirth educators and others can share (and post in their classrooms) this attractive infographic that highlights the situation of too many unneeded cesareans in our country.  Parents and educators alike can easily see what the risks of cesarean surgery to mother and baby are, and learn how to reduce the likelihood of having a cesarean in the absence of medical need.

In this infographic, women are encouraged to take Lamaze childbirth classes, work with a doula, select a provider with a low rate of cesarean births, advocate for vaginal birth after cesarean and follow the Six Healthy Care Practices, to set themselves up for the best birth possible.  This infographic clearly states the problem of unneeded cesareans, the risks to mother and baby, and provides do-able actions steps.

It is time for women to become the best advocate possible for their birth and their baby.  With this appealing, useful and informative infographic poster, families can and will make better choices and know to seek out additional information and resources.

Educators and other birth professionals, you can find a high resolution infographic to download and print here.

Send your families to the Lamaze International site for parents, to find the infographic and other useful information on cesarean surgery.

For Lamaze members, log in to our professional site to access this infographic and a whole slew of other useful classroom activities, handouts and information sheets.

I am proud to say that I am a Lamaze Certified Childbirth Educator, and that my organization, Lamaze International, is leading the way in advocating for healthier births for mothers and babies through sources such as the “What’s the Deal with Cesareans?” infographic and other evidence based information and resources.  Thank you Lamaze!

What do you think of this infographic?  How are you going to use it with the families you work with?  Can you think of how you might incorporate this into your childbirth classes or discuss with clients and patients?  Let us know in the comments section, we would love your feedback!  And, see you at the conference!

 

 

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Maternity Care On the National Agenda – New Opportunities for Educators and Advocates

January 17th, 2013 by avatar

Today, Amy Romano, CNM, MSN, Associate Director of Programs for Childbirth Connection (and former Community Manager for this blog) follows up last Thursday’s post, Have You Made the Connection with Childbirth Connection? Three Reports You Don’t Want to Miss with her professional suggestions for educators and advocates to consider using the data and information contained in these reports and offering your students, clients and patients the consumer materials that accompany them.- Sharon Muza, Community Manager.

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As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.

One area of maternity care that has garnered increasing attention is the overuse of cesarean section, especially in low-risk women. Last year, the multi-stakeholder Maternity Action Team at the National Priorities Partnership set goals for the U.S. health care system and identified promising strategies to reach these goals. One of the goals was to reduce the cesarean section rate in low-risk women to 15% or less. This work served as the impetus for Childbirth Connection to revisit and update our Cesarean Alert Initiative. We undertook a best evidence review to compare outcomes of cesarean delivery with those of vaginal birth. Based on the results, we also updated and redesigned our consumer booklet, What Every Pregnant Woman Needs to Know About Cesarean Section. These are powerful new tools to help educators and advocates push for safer care, support shared decision making, and inform and empower women.

Two of the biggest obstacles to change have been persistent liability concerns and the current payment system that rewards care that is fragmented and procedure-intensive. Efforts to make maternity care more evidence-based or woman-centered often run up against policies and attitudes rooted in fear of lawsuits or increasing malpractice premiums, or against the reality that clinicians can not get easily reimbursed for doing the right thing. But these barriers are shifting, 

Recently the literature has provided example after example of programs that reduced harm and saw rapid and dramatic drops in liability costs as a result. That’s right – one of the best ways to decrease liability costs is to provide safer care. Rigorous quality and safety programs are the most effective prevention strategy among the ten substantive solutions identified in Childbirth Connections new report, Maternity Care and Liability. The report pulls together the best available evidence and holds potential liability solutions up to a framework that addresses the diverse aims of a high-functioning liability system that serves childbearing women and newborns, maternity care clinicians, and payers.  

The evidence and analysis show that some of the most widely advocated reforms do not stand up to the framework, while quality improvement programs, shared decision making, and medication safety programs, among other interventions, all have potential to be win-win-win solutions for women and newborns, clinicians, and payers. If we are to find our way out of the intractable situation where liability concerns block progress, we must learn to effectively advocate for such win-win-win solutions.  Advocates and educators can better understand these solutions by accessing the 10 fact sheets and other related resources on our Maternity Care and Liability page.

Evidence also shows that improving the quality of care reduces costs to payers. As payment reforms roll out, there will be many more opportunities to realize these cost savings. To predict potential cost savings, however, it is necessary to know how much payers are currently paying for maternity care. Surprising, this information has been largely unavailable, and as a result we have had to settle for using facility charges as a proxy. This is a poor proxy because payers negotiate large discounts, and because charges data do not capture professional fees, lab and ultrasound costs, and other services. Childbirth Connection, along with our partners at Catalyst for Payment Reform and the Center for Healthcare Quality and Payment Reform, recently commissioned the most comprehensive available analysis of maternity care costs. The report, The Cost of Having a Baby in the United States shows wide variation across states, high costs for cesarean deliveries, and rapid growth in costs in the last decade. It also shows the sky-high costs uninsured women must pay – costs that can easily bankrupt a growing family. Even insured women face significant out-of-pocket costs that have increased nearly four-fold over six years. Fortunately, health care reform legislation has made out-of-pocket costs for maternity care more transparent by requiring a simple cost sample to each person choosing an individual or employer-sponsored health plan.

Educators and advocates have to be able to help women be savvy consumers of health care. That means being informed about their options and also being able to identify and work around barriers to high quality, safe, affordable care. Childbirth Connection produced this trio of reports to provide a well of data and analysis to help all stakeholders work toward a high-quality, high-value maternity care system.

How Childbirth Educators and Consumer Advocates Can Help

 What is the first thing that you are going to do to join this maternity care transformation? Can you share your ideas for using this information in your classroom or with clients or patients.  Can you bring others on board to help with this much needed transformation?- SM

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Happy 20th Anniversary to the Cochrane Collaboration!

January 15th, 2013 by avatar

As I wrote about in my January 3rd, 2012 post on the top 10 reasons to join Lamaze International, one of the great benefits of being a Lamaze member is complete access to the Cochrane Collaboration.  The Cochrane Collaboration is an international organization whose purpose is to make available information on the effects of healthcare interventions.  Reports in the form of Cochrane Reviews are current, accurate and made available electronically on the internet and by DVD, and updated monthly.  Systematic reviews are conducted and published on a wide variety of healthcare interventions so that people can make informed decisions. This is stored in the Cochrane Library.

Archie Cochrane, photo credit: Cardiff University. Library, Cochrane Archive, University. Hospital Llandough

The Cochrane Collaboration was founded by Archie Cochrane, who was a British medical researcher.  Mr. Cochrane is best known for his article Effectiveness and Efficiency: Random Reflections on Health Services written in 1972.  

The creation of a systematic review of randomised controlled trials (RCT’s) of care during pregnancy and childbirth is “a real milestone in the history of randomised trials and in the evaluation of care.” Professor Archibald Leman Cochrane, CBE FRCP FFCM, (1909 – 1988)

The Cochrane Collaboration is celebrating their 20th anniversary this year, 2013 and will be sharing a series of 24 short videos over the course of the anniversary year, focusing on the ideas, achievements and people that have been part of the history of this international and well-respected organization.  I am sharing the first in this series, so you can learn a bit more about how this organization came to be recognized as the gold standard in evidence-based health care.

The United States Cochrane Center has created and made available free of charge, an online tutorial, “Understanding Evidence-based Healthcare: A Foundation for Action, that can help you to learn how to best navigate and understand the resources contained in the Cochrane Library.

Lamaze International’s Healthy Birth Practice Tools is completely based on evidence based information and was created so that consumers could understand and advocate for the best care for themselves and their babies.  Lamaze recognizes the importance of educators and others having access to up to date information and therefore is pleased to offer access to the Cochrane Library as a member benefit.   To access the Cochrane Library as a Lamaze member, first login to Lamaze International’s Member Center and then follow the drop down box to the Cochrane Library. You will be redirected to the library, with full access.

I rely on and use this member benefit constantly, and appreciate it being made available to me by Lamaze.  Won’t you share in the comments section how you use the Cochrane Library?  How has it helped you?  Do you find what you need?  Do you share information and studies with your students, clients and patients?  Let us know, please.

References 

Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972. (Reprinted in 1989 in association with the BMJ, Reprinted in 1999 for Nuffield Trust by the Royal Society of Medicine Press, London (ISBN 1-85315-394-X)

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Pelvic Exams Near Term: Benefit or Risk? Talking to Mothers About Informed Consent and Refusal

November 2nd, 2012 by avatar

Today, S&S contributor Jackie Levine discusses the potential risks of routine cervical checks near term and how to help your clients and students be prepared to have a discussion with their health care provider about the necessity of such exams. – SM

There are some studies that show a link between routine weekly pelvic exams in the last month or so of pregnancy and an increase in rupture of membranes (ROM) that occur well before labor was meant begin, meaning the membranes have ruptured prematurely, (adding a P to ROM, for premature rupture).   The natural onset of labor may be a week or perhaps only days away, but everything is not quite ready, and if effective labor does not begin induction frequently follows.  And when induction fails, as often it will, since the rupture was premature, and the body and the baby are not ready, cesarean is often the outcome.

photo credit: flickr (link below)

Many women find that their health care providers may start doing pelvic exams at about 37 weeks gestation.  Women should consider asking their doctor or midwife whether these exams are necessary to insure the health and safety of herself and her baby, before providing consent for this invasive procedure.  When I discuss these near term cervical exams with my childbirth class students and look at the studies, mothers-to-be have to ask themselves whether the benefits of weekly exams outweigh the other risks; potential PROM, induction and the increased possibility of cesarean section.

“How do I tell my health care provider that I don’t want an exam, and not have those uncomfortable moments when my doctor or midwife thinks I’m defying him or her and not letting them do what they always do?”  That’s the common and sensible worry, that our students may have, but if we provide an opportunity to role-play with our students and clients and also provide the studies, they will feel confident about having this discussion. They will know the facts and are informed health consumers who could consider saying “Oh, I just don’t want that exam today, so can we do it next week?” They might also share that they’ve researched this topic, mention the studies and ask how routine exams week after week will help insure good health.

An older study examining the relationship between late term pelvic exams and the incidence of PROM stated:

 In the 174 patients on whom pelvic examinations were done weekly starting at 37 weeks gestation, the incidence of PROM was 18%,   which was a significant increase (P=.001).  The primary cesarean section rate was comparable in both groups with PROM; however, the overall primary cesarean rate when PROM occurred was found to be twice that of the remaining population. The study suggests that routine pelvic examinations may be (sic) a significant contributing factor to the incidence of PROM. Women with uncomplicated pregnancies were randomly assigned to one of two groups. The author theorizes that the probing finger carries up and deposits on the cervix bacteria and acidic vaginal secretions capable of penetrating the mucous plug and causing sufficient low-grade inflammation or sub-clinical infection to rupture membranes.“  “It would therefore seem prudent to recommend that no pelvic examinations be done routinely in the third trimester unless a valid medical indication [sic] exists to examine the cervix … especially since the information gained from these routine examinations is often of little or no benefit to either the physician or the patient.” (Lenahan, 1984.)

We have all been subtly bullied at one time or another by those in positions of authority, and it’s easy to understand the courage and confidence needed to question a caregiver. It’s a mother’s right and responsibility first to know and then to question, but confidence is the key.  We must make an effort to give real meaning to a women’s right to choose, and to the principle of informed refusal.  The American Congress of Obstetrics and Gynecology (ACOG) has addressed informed refusal several times with its membership since at least 19921, speaking powerfully  about the autonomy of the individual.  Although these writings and bulletins are aimed mainly at assuring legal protection for caregivers, they are a resounding affirmation of the legal and moral right of the patient to decide for herself.

Since the studies assert that routine exams are neither predictive nor probative, the doctor or midwife must be able to say something medically strong to counter the available studies.  When mothers have asked their providers for the reasons to do an exam, they bring a myriad of interesting answers back to class for discussion, but rarely any facts or science.  Remember, ACOG  itself published a study last year examining the basis for its care guidelines and found that “One third of the recommendations put forth by the Congress in its practice bulletins are based on good and consistent scientific evidence” ACOG, 2011) meaning Level A, and that gives us pause to consider the 70% of practices represented by Levels B and C . Care providers will often reconsider when an informed mother-to-be can ask politely and tactfully, about the science that recommends a weekly routine cervical assessment.

Again, women should be able to weigh the risks of routine exams against the possibility of that cascade of interventions that follow on with PROM, interventions that will, at the least, lead to an uncomfortable and harder-to-manage induction, and at worst, put our students and clients on that gurney ride into the operating room.

When a mother is motivated to discuss routine pelvic exams with her caregiver, it may be the first test of the mutual trust and respect she hopes for in that relationship.  Until that point in her pregnancy, she may not have had the opportunity, or the necessity to assert her rights as a maternity patient.  She may have refused to have a routine sonogram or two because her insurance policy would not cover extra routine assessments, but refusing pelvic exams unless there is a valid medical reason will tell her how little or much her HCP is willing to act on best evidence, give her individuated care and show respect for her informed refusal.

The first time she refuses the exam may not be an accurate opportunity for her to judge; many caregivers will let refusal ride that once, but as pregnancy nears term, most docs begin to be insistent about cervical assessment, even without medical indication. A mother-to-be can begin to learn her caregiver’s view of best-evidence care and his or her willingness to listen to her so that she will have an idea, going forward, of how best to assert her rights, with knowledge and confidence in herself, and can get support she may need in our classes.

In a Science & Sensibility post in May 2011, I talked about the importance of giving mothers the same studies that caregivers have access to.  What I said then about giving our classes the actual studies, along with discussion, still applies:

“…perhaps we need to give women a different kind of “evidence”, by giving them a look into the medical community.  If women can know more of what goes on inside the profession, if they know a bit of what the docs know, they feel a different level of empowerment.  They feel a gravitas….Not only do they know that the evidence exists somewhere out there…they see it; they own copies of the studies. They feel trusted with special information that they would never otherwise have access to. In addition to learning to trust their bodies, in addition to knowing how birth works, in addition to practicing comfort measures, they learn about what goes on behind the scenes.  It expands their sense of control and choice. “  

Refusing to have routine pelvic exams in those last weeks of pregnancy is a real opportunity for our students and clients to learn how to ask for, even insist on, best-evidence care for themselves and their babies.  It’s certainly worth a try, and we can support them in the last weeks in a positive way with lots of opportunity for role-play and discussion as they report back to class and share their experiences with informed refusal.

How do you bring up the topic of regular cervical exams for women who are not in labor?  Do you talk about this with your clients and students?  What are your favorite resources for presenting this and facilitating discussions?  Have your students shared stories about their experiences.?  Are you a health care provider?  What are your feelings on routine pelvic exams at the end of pregnancy?  Share your thoughts in our comment section. – SM

References:

ACOG: Ethical dimensions of informed consent: a compendium of selected publications, ACOG Committee Opinion 108. Washington DC, 1992.

ACOG Committee opinion. Informed refusal. Number 166, December 1995. Committee on Professional Liability. American College of Obstetricians and Gynecologists. et al. Int J Gynaecol Obstet. (1996).

ACOG Committee Opinion No. 306. Informed refusal. ACOG Committee on Professional Liability, Obstet Gynecol. 2004 Dec;104(6):1465-6.

Lenahan, JP Jr., Relationship of antepartum pelvic examinations to premature rupture of the membranes. Journal Obstetrics Gynecology 1984, Jan:63(1):33-37.

Levine, J. (May 31, 2011) A Lamaze Story. Retrieved from http://www.scienceandsensibility.org/?p=2954

Vayssière, C. Contre le toucher vaginal systématique en obstétrique Gynécologie Obstétrique & Fertilité, 2005, Volume 33, Issue 1, Pages 69-74.

Wright JD, Pawar N, Gonzalez JS, Lewin SN, Burke WM, Simpson LL, Charles AS, D’Alton ME, Herzog TJ, Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins, Obstet Gynecol. 2011 Sep;118(3):505-12.

photo credit: www.flickr.com/photos/nathansnostalgia/498100786/

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